Reimbursement is changing in healthcare. Even before elements of the Affordable Care Act began to go into effect, a growing focus on value versus volume has led many healthcare organizations and providers to consider accountable and patient-centered care models in which they assume a greater share of risk.
A successful claims processing operation comprises skilled personnel and well-monitored processes.
The revenue cycle which claims processing is but a part will vary according to the makeup of a healthcare organization as well as the billing model being used by that health system, hospital, or physician practices.
Here is a breakdown of personnel and activities within a hybrid billing model that marries both a decentralized and centralized billing models:*
• Capture insurance data
• Verify Insurance and eligibility
• Conduct prior authorizations and obtain referrals
• Collect co-pays and deductibles at time of service
• Clinical staff
• Obtain patient consents and waivers
• Capture charges accurately
• Conduct timely completion of clinical documentation (affects charge lag)
• Track and resolve billing edits
• Conduct timely submission of claims to payors
• Follow up on outstanding A/R balances
• Post denials and resolve
• Engage in accurate payment posting
• Provide education and feedback to front-end staff and providers
• Ensure communication and feedback across all stakeholders
• Monitor staff performance
• Review revenue cycle metrics and analyze trends on a regular basis
In order that the revenue cycle functions smoothly and that opportunities for improvement in reimbursement are addressed in a timely fashion, leaders from the various departments in a healthcare organization must communicate in a scheduled way with certain meetings occurring more frequently than others.
For instance, whereas the business office manager and financial counselors and members eligibility/authorization team might on a biweekly basis to review trends in patient access, the group administrator, business office manager and business office staff might meet on a monthly basis to discuss underpayment trends, cash balancing, and claims-related problems or concerns.
No matter the size of an organized, key stakeholders and activities in claims processing from the front to the back should be organized in a standardized way.