Reimbursement keeps changing in the sector of healthcare. Even before elements of the Affordable Care Act started to go into effect, an increasing concentration on value- based care versus volume has led many healthcare agencies and contributors to consider accountable and patient-centered care models in which they consider a greater share of risk.
In this changing atmosphere, revenue must be handled differently to make sure that the value delivered to sufferers is paid for suitably both in terms of precision and timeliness.
For hospitals and physician practices to make sure that their claims are paid, they must 1st comprehend how the different sections of claims management impact reimbursement.
The negative affect poor claims management can have on reimbursement is primarily more pronounced in clinical environments where resources committed solely to the revenue cycle are mostly lacking.
In accordance to Jain, those healthcare agencies and contributors succeeding at reimbursement take into account and deal how each of the several components of the patient-provider interaction fit into the revenue cycle and could introduce spaces leading to loss or threat:
Victorious claims processing operation contains skilled personnel and well-monitored procedures. The revenue cycle, of which claims processing are but one part, will vary in accordance to the makeup of a healthcare agency as well as the billing model being utilized by that health network, hospital, or physician practices.
No matter the size of a key stakeholders and tasks in claims processing from the front to the back should be managed in a proper way.
A move from fee-for-service to pay-for-performance has healthcare agencies reconsidering how their clinical practices will affect their bottom lines heading forward as contributors assume higher and higher accountability.
With most health networks, hospitals, and physician practices yet depending on encounter-based, reimbursement issues over next various years could become “exponential,” states John Dugan, CPA, Partner at PricewaterhouseCoopers (PwC) who oversees its healthcare contributor practice.
“Those that are getting it are making contributions in various places as well as attempting to comprehend how well they are following evidence-based medicine across the agency,” he elaborates. “Having those standardized stages of care that are encouraged by data analytics for them to comprehend what the outliers are in the cost to treat, that is where you are analyzing the savings driven out of the network.”
Healthcare agencies of entire sizes find themselves in a specifically challenging spot when it comes to reimbursement. However, reimbursement is starting to shift away from volume to value; much of their revenue today still relies on the fee-for- service payment network. How then do healthcare agencies — from health networks to physician practices — make sure that best practices are in place to succeed in both reimbursement settings?
The answer to that query includes taking a step back and searching at various key considerations affecting the professional revenue cycle and ways to execute organizational models that reinforce efficiencies in billing operations and claims management.
Since the approval of the Health Information Technology for Clinical and Economic Health (HITECH) Act, the healthcare industry has spent most of its period and resources on selecting, executing, and optimizing EHR networks.
While EHR adoption surely will play a significant to clinical quality improvements, what about the IT systems and services essential for making sure that a healthcare agency’s care is being accurately billed and paid?
In accordance to industry insider, that is a query being inquired by members of the finance departments at healthcare agencies. “You are at an interesting time where meaningful use has made the government investment into wiring up electronic health data and at the similar time running parallel are executives stating, ‘Are we making the similar in- vestments on the revenue side of those applications?’” states John Dugan.
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