Revenue and Reimbursement

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Write a 3-4 page proposal for billing changes, and explain how the proposed changes will benefit the organization, the physicians, and the patients.

Introduction

Note: The assessments in this course build upon each other, so you are strongly encouraged to complete them in sequence.

Regardless of the corporate structure, health care organizations must remain financially viable. Income must be forecasted according to existing contracts with stakeholders, such as insurers and private payers and state and federal payers.

Health care leaders must also deal with the reality of finite resources, including caring for patients with limited or no resources. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires triage and emergency care for patients in need (Social Security Administration, n.d.). Health care executives are responsible to support emergency care, and they must manage finite resources to achieve this legal imperative

To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community.

  • What resources are available to help patients with no insurance and no financial means to pay for health care?
  • How can an organization be financially prepared to handle uninsured patients?

Reference

Social Security Administration. (n.d.). Compilation of the social security laws. http://www.ssa.gov/OP_Home/ssact/title18/1867.htm

Preparation

Use the Capella University Library and the Internet to locate resources and information on health care revenue cycles and billing processes.

Imagine that you have just stepped into a new role as the office manager for a very successful clinic. The clinic is a conglomeration of physicians who offer specialized care. Each group of physicians tried to manage their own billing process but it quickly became obvious that one billing office would be more efficient. You realize that there has been a lack of consistency in the clinic and that you will need to update the billing policies and procedures immediately. You also realize that there is always resistance to change, and you will need to provide evidence supporting the changes you plan to make.

Prepare a proposal for billing changes that you would present to the physicians. You will need to support each proposed change with relevant evidence to assure buy-in from the physicians.

There is no specific format you must follow for this assessment, but be sure that your proposal is clear, logical, and succinct. Follow APA guidelines for any in-text citations and references. Include a title page and reference page.

Requirements

Write a proposal for changes you would like to make to the billing policies and procedures in a successful physicians clinic. Include the following in your proposal:

  • Develop a step-by-step process for the entire revenue cycle from pre-verification of insurance to accounts receivable management.
  • Recommend a method for determining a pricing structure. What factors can influence pricing?
  • Explain the factors that must be considered while negotiating insurance contracts. What major payer categories are appropriate for this practice?
  • Explain how the clinic will handle private pay and charity care.
  • Recommend either an installed or a web-based billing software system. (Please note that you should not recommend a specific brand of software; just the type of software.)
  • Explain how the changes will benefit the physicians, the clinic, and patients.

Additional Requirements

  • Include a title page and reference page.
  • Number of pages: 3–4.
  • At least three current scholarly or professional resources.
  • APA format for in-text citations and references.
  • Times New Roman font, 12 point.
  • Double-spaced.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Develop financial strategies to address dynamic environmental forces. (L24.2, L24.5, L17.2)
    • Develop a step-by-step process for a revenue cycle.
    • Recommend a pricing structure method.
  • Competency 2: Analyze the cost and revenue implications for organizational changes due to environmental forces. (L18.2, L12.1)
    • Explain the factors to consider for insurance contract negotiations.
    • Explain a process for handling private pay and charity care.
    • Recommend a billing software system.
    • Explain how billing process changes benefit physicians, clinics, and patients.
  • Competency 4: Communicate in a manner that is scholarly, professional, and consistent with expectations for professionals in health care administration. (L6.1, L6.2, L6.3, L6.4)
    • Write content clearly and logically with the correct use of grammar, punctuation, and mechanics.
    • Format citations and references using the APA style.
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