BHA FPX 4009 Assessment 3
The Revenue Cycle Process
The revenue cycle can be described as the exhaustive range of operations that is to be taken care of by a healthcare organization starting from the appointment of patients to the last process of recovering the amount due. Managing this cycle is imperative for efficiently enhancing and sustaining the organization’s fiscal health, and hence its cash and solvency (Kovner & Knickman, 2019).
According to McLaughlin & McLaughlin (2021), an effective revenue cycle enables payments of the services offered to be paid on time without much exposure to financial risks thus supporting the continuity of the organization’s operations. The specific steps of the revenue cycle process are shown below Revenue cycle is the process by which many important financial efficiencies take place. The following activities include patient registration in which specific demographic and insurance data is obtained.
These pieces of data are crucial when endeavoring to ensure a patient is covered and in the case of filing a claim by said patient (Harris & Raskin, 2020). After this the next process is referred to as rendering services whereby the client is provided with medical services for which documentation is key in determining billing. The next process before it can form part of the value package is the documentation of the services offered of which appropriate records of those services are prepared.
It is essential for charging and for developing accusations or cases as established by researchers (McLaughlin et al., 2021). Setting charges includes the process of ascribing the expenses that will be incurred regarding the services in the documented information proving process which has an element of accuracy to prevent billing complications.
Purpose of Each Step
Patient registration is the first and very important step to the commencement of the revenue cycle. In this process, basic demographic data about the patient and details of his insurance policy that he holds are recorded. It is crucial as it assists in confirming patient’s insurance and his/her eligibility in terms of bill and reimbursement.
For instance, a registration clerk updates patient identification information and insurance details upon a patient’s admission or visit to a healthcare facility and generates a patient record in the healthcare system. This step is relevant to decreasing the occurrence of claim denials and proper billing (Harris and Raskin, 2020).
The following process is rendering of services that involves giving of care or services to the patient for the ailment or condition ailing the patient. This is important at this stage because the kind and quantity of care provided has to be well-documented to substantiate the subsequent charging.
Specifically, when a physician performs a diagnostic test or a surgical operation, such services must be recorded elaborated so that the correct amount can be charged to the patients, or health insurance companies (McLaughlin & McLaughlin, 2021).
Another process is documenting services, in this process services provided are recorded in detail. It is a significant documentation that will help in charging and in the preparation of claims. Documents work to capture all the processes that are involved in the provision of care to patients and this is crucial especially when it comes to billing and coding .
For example, they describe type of service and special factors in their patient’s EHR once a procedure has been completed so as to have grounds for charging appropriately and for preparation of their claims (Kovner & Knickman, 2019).
Key Responsibilities of Individuals
Several related roles exist within the revenue cycle process that help in managing healthcare finances. Every person named has certain roles and tasks to perform in the framework of the organizational financial management. Patient access representatives are a part of the revenue cycle and are responsible for the initial stage of the cycle. Some of the common tasks include patient identification, data entry, and data validation which involves entering and confirming patients’ details like gender, age, and insurance.
This step precedes the billing and reimbursement process because it involves the checking and correcting of the patient data and insurance status. For instance, whenever a patient gets to a certain health care facility, the Patient Access represents gets all the relevant information and confirms his/her insurance details. This is important for avoiding too many claims’ rejects or payment delays, which is crucial for sustaining financial flows.
Medical Coders are involved in converting the particulars of the medical services provided in a health care setting into codified forms that are charged. They are involved in the process of analyzing the paperwork of the services provided by the healthcare practitioners and identifying the appropriate ICD-10, CPT, or HCPCS codes. It is essential that this coding be specific to provide an accurate billing document that reflects the services and comports to the payers’ demands.
For example, after a procedure has been performed, a Medical Coder assigns code that best describes the services offered hence formulating claims. Coding is vital to warrant proper reimbursement, and more especially, coding minimizes cases of claim denial.
Billing Specialists are involved in the charge capture /documentation, coding, and submission of claims to the various payers. Some of their duties are to confirm that all the charges are rightly recorded and to make sure that the claims presented conform to the payer regulations.
Billing Specialists always look into the claims that have been denied or rejected, figure out the causes, and correct them before resubmitting the claims again. For instance, a Billing Specialist sends a claim that has been prepared on the charges that have been provided by Medical Coders electronically. If there is a hitch in executing tasks, they contact the parties involved to fix the problems that affect revenue cycle reception and payment which greatly benefits healthcare facilities (Kovner & Knickman, 2019).
Consequences to Institution
When certain tasks within the revenue cycle process are not completed properly, there can be serious consequences for either the financial solvency or the efficiency of the health care organization. First of all, patient registration is the crucial step in the process of creating the basis for accurate work of billing.
Thus, mistakes in charge master records and verifying or entering patient details can result in improper billing and insurance rejections. For instance, if a Patient Access Representative does not properly check the eligibility of the payer in the patient’s insurance, the submitted claim may be denied by the payer.
This can prove disadvantageous because the organization may engage in delayed payments whereby certain expenses may not be recovered again, consequently creating an unstable financial base for the organization (Harris & Raskin, 2020). This means that accurate registration is very vital in the process of claiming the amount from the insurance company to avoid cases of denials and long periods of awaiting for reimbursement.
BHA FPX 4009 Assessment 3 The Revenue Cycle Process
In the next stage, medical coding also becomes very relevant in the conversion of documentation into coded froms for billing. Incorrect coding impacts directly on the financial issues such as claims denial and under-reimbursements. When a Medical Coder reports wrong codes for a procedure, then such a claim may be rejected or paid less than the due amount. Not only does such error hold up the payment but it also opens the organization up for an audit and penalty that happens to touch on both revenues and image (McLaughlin & McLaughlin, 2021).
The measures indicate that the situation can result in costly and disruptive effects if coding is not well done. The preparation and submission of the claim is as important as the diagnosis of the disease. Claims that are not prepared and submitted to the insurance companies with great care may prove to be problematic for the Billing Specialists in the following ways;
For instance, in a case where a claim is prepared and submitted for processing with some data missing or incorrect it can lead to rejection and therefore follow the process of being resent and this would take time of processing besides the extra work to be done. Such inefficiency poses a tremendous force in the management cash flow while enhancing the operation costs hence exacerbating economic challenges (Kovner & Knickman, 2019). To summarize, claim preparation and its submission entails a very critical role for any company to keep a healthy check on their revenue cycle.
Additional Steps & Challenges
These extra measures and factors are important since financial risks of the organization have to be controlled in order to guarantee payment for delivered services.
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Financial Counseling and Assistance
This paper identifies that one major drawback of managing uninsured patients is lack of financial advising. In particular, a financial manager undertakes an important segment of evaluating the patient’s capability to make payments and giving details about the different provisos of the payment, inclusive of low-payment options, payment by installment, or application for a grant to encourage payment for the due balance.
These services assist patients in seeking acceptance of other payment plans, for instance, charity care or government programs and clarify the patients’ payment obligations. For instance, an insurance policy advisor might help an uninsured client investigate for emergency Medicaid or similar programs with regard to the state. This step is vital in mitigating the risk of non-payment and explaining to the patient his or her estimated bill (Harris & Raskin, 2020).
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Establishing Payment Plans
For the uninsured individuals, there are always challenges that the health care organizations have to assess structures in order to get paid on other installments that may be for a long time. Payment plans are terms of payment understood between the patient and the service provider enabling the part payments of the service bill without having to make the payment in full for the service given.
This can also assist in improving the chances of acquiring payments from uninsured patients that are financially incapable of paying a tremendous amount of cash upfront. For example, a specific clinician such as a billing specialist will be able to negotiate a payment plan that the patient will be paying in instalments according to his or her capabilities. Implementation of these plans calls for proper analysis and bargaining to create workable terms for both the patient and the health organization (McLaughlin & McLaughlin, 2021).
Conclusion
In conclusion, the revenue cycle process is an important aspect in the functioning of health facilities as it has different steps to provide the proper billing system and achieve the goal of getting the right payments at the right time. Every process, starting from patient registration and ending up with the accounts receivables, provides a crucial function and determines the organization’s financial stability and organizational performance.
The functions of patient registration, medical coding, claim preparation, and account receivables are crucial since they help reduce claim denials, avoid losses, and promote efficient cash flow. Specific roles of people in the revenue cycle such as Patient Access Representatives, Medical Coders, Billing Specialists and Accounts Receivable Specialists are also a vital components of the process.
Their compliance to time and correctness in executing contracts guarantees billing is done appropriately, claims are processed and payments are received on time. Lapses in these responsibilities have Danny’s corporation experiencing some adverse effects such as delayed payments for the raw materials it buys, higher administrative costs and financial stress.
Moreover, the treatment of uninsured patients results in the other issues that are not easy to solve and which need specific techniques like financial consultance, poor patients’ financing or more tendencies towards the uncompensated care. Solving these problems requires the use of certain approaches to control the risks associated with finances, decrease administrative loads, and work with the cases of bad debts.
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