HCM 345, Final Project - White Paper.docx - REIMBURSEMENT 1 HCM 345 Final Project Reimbursement and Revenue Cycle Ambur Felker Southern New Hampshire

HCM 345, Final Project - White Paper.docx - REIMBURSEMENT 1...

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REIMBURSEMENT 1 HCM 345: Final Project Reimbursement and Revenue Cycle Ambur Felker Southern New Hampshire University
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REIMBURSEMENT 2 Table of Contents Introduction 3 Reimbursement 3 Revenue Cycle 5 Prioritization of Departments 6 Department Impact Reimbursement 7 Audits and Pay for Performance 8 Departmental Activities 9 Impact of Billing and Coding Compliance 10 Billing and Reimbursement Data Collection 11 Third Party Policies and Key Areas for Review 12 Structure and Development Plan 13 Marketing and Reimbursement Strategies 14 Communication and Contract Reimbursement 15 Billing and Coding Compliance 16
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REIMBURSEMENT 3 Introduction St. Luke’s is a healthcare organization that consists of many hospitals, urgent care facilities, specialty practices, and primary care practices across the Eastern part of Pennsylvania and into the Western part of New Jersey. Understanding the importance of reimbursement and the revenue cycle to the organization is something that is extremely important to make sure St. Luke’s is able to continue to provide care to patients. Different departments within St. Luke’s take part in the revenue cycle and contribute to reimbursement. Therefore, reviewing and monitoring the processes on a regular basis will help with maximizing reimbursement for the organization. Reimbursement at St. Luke’s When a patient receives services from St. Luke's these services need to be billed either to the health insurance or directly to the patient. The payment that St. Luke’s receives for providing the medical care is described as healthcare reimbursement (Torrey, 2018). The majority of their claims reimbursements are from insurances or government payers. Once the payments are received it generates revenue, and this is referred to as a revenue cycle. The revenue cycle is important in order to keep St. Luke’s in good standing. Revenue is needed to pay employees, order supplies, and other costs that come up to run a healthcare facility. To help manage the billing and receive reimbursement, a system has to be in place (LaPointe, 2018). Once a medical service is received, St. Luke’s sends a bill to who ever are responsible for the medical costs. The amount of time and efficiency in which these bills are paid plays a role with determining if the organization will survive (LaPointe, 2018).
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REIMBURSEMENT 4 Based on the services rendered is what determines the amount that is billed, and the amount that is agreed upon with the health insurance due to the contracted rate that St. Luke’s has with the insurance for what to pay for a particular service (Torrey, 2018). The claims management team at St. Luke’s helps with the understanding of how to negotiate payer contracts, but it is also important for them to know the rules of the insurance companies. This knowledge is needed to code, appeal claim denials, and for tracking or monitoring charges like audits. Putting money back into St. Luke’s helps on keeping a continuous flow with performing services. Now, often
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