Revenue and Reimbursement Essay

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.

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: Revenue and Reimbursement Essay

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.


Although the medical facility is concerned with treating patients and saving lives, there is a need to develop a more successful revenue and reimbursement policies and processes. This is intended to ensure that the facility stays financially healthy. It is this awareness that creates the present need for a revenue management cycle as a financial process to help the facility in managing the clinical and administrative functions liked to revenue generation, payment and claims processing. This is intended to help the facility in identifying, managing and collecting patient service revenue while facilitating the payment of bills. It is notable that without this financial process, the facility would be unable to keep operating (Cherry & Jacob, 2016). The present paper explores changes to the revenue cycle management strategy while noting its effects on the facility’s capacity to continue operating and paying its bills.

Develops a step-by-step process for a revenue cycle and explains the function or importance of each step.

A revenue cycle is a financial process that is intended to aid the management of the clinical and administrative functions linked to revenue generation, payment and claims processing, as well as identifying, managing and collecting patient service revenue (Getzen, 2013). The cycle begins with the patient making an appointment to seek health care services and ends when the facility collects all the payments for the services. The first step is the pre-registration that involves the patient making an appointment with an administrative staff who establishes an account for the patient while scheduling the appointment and verifying the patient’s eligibility for insurance. This is considered an important step since it determines the patient’s capacity to pay for services through collecting information on insurance coverage and medical histories. The second step entails the patient receiving the required medical care as scheduled in the appointment. The third step involves creating a claim. This entails identifying the treatment received and matching them to the most appropriate ICD-10 code that signify the expected reimbursement from each treatment. The step also entails completing the charge capture duties that document the services provided in terms of billable feels. The final step involves submitting the claims by sending it to the government or private payer for reimbursement. At this point, the common tasks would include posting the payment, processing statements, collections, and claims denial handling. Reimbursements are made on the basis of payer contracts and coverage for the patient. Denials would typically be caused by the patient accounts being incomplete, items missing from the chart and improper coding. For any service that is not covered by insurance, the facility would have to notify the patient who would then make a direct payment. Overall, the revenue cycle helps the facility to get fully paid for its services in a timely manner (Moiso, 2013; Munro, 2016). Revenue and Reimbursement Essay

Recommends a pricing structure method, and explains how the pricing structure method supports the financial strategies of the organization.

An appropriate pricing structure should be negotiated between medical personnel, medical facilities, and insurers. In this case, medical personnel and facilities would try to negotiate for higher payments to allow them present good services and leverage their position in the medical care plan, while the insurers negotiate for lower costs to leverage their customer base. This pricing structure supports the facility’s financial strategies by allowing them to consultatively present prices that are acceptable to customers while also addressing their financial needs with comfortable profit margins. Although a medical facility can negotiate prices with some insurers, this is not true for some federal insurance schemes such as Medicare where the government sets lower price rates for medical procedures and does not negotiate with the facilities or medical personnel with the intention of keeping health care costs down (Emanuel, 2014).

Explains the factors to consider for insurance contract negotiations, and identifies the major payer categories appropriate for the practice.

There are four factors to consider for insurance contract negotiations. Firstly, evaluate the contract in terms of expiration dates and terms, as well as notice for rate adjustment. Secondly, collect and offer accurate data on expenses, revenue and utilization. This allows the insurer to offer a fee schedule for the services offered at the facility thus organizing the negotiations and making it easier to address contentious issues. Thirdly, gain a good awareness of the legal implications. Finally, determine the market share to help in leveraging insurance contract negotiations in terms of feedback from patients and competition from other facilities (Patel & Rushefsky, 2015).

There are three payer categories appropriate for the practice. The first category is managed care that entails the payer forming an active network with specific medical facilities so that patients are restricted in the facilities from which they can receive medical care. It includes preferred provider organizations, health maintenance organizations, and point-of-service plans. The second category is indemnity policies where patient are allowed to receive care from any facility that could include those outside the country. This category typically requires that the patient pay a deductive before the payer covers the rest of the cost. The final category is high deductible plans that have high deductible and low premiums. Patients covered using this plan are expected to cover the care cost until a predetermined deductible is reached after which the payer takes over the payment. It includes health savings accounts and health reimbursement arrangement (Patel & Rushefsky, 2015).

Explains a process for handling private pay and charity care, and how the process fits into the financial strategies of the organization.

The process for handling private pay and charity care should follow five steps. The first step is to present an eligibility criteria that identifies the patients eligible for private pay and financial aid. The second step is to use an established basis for calculating the costs each patient is expected to pay. The third step is to describe the application process that each patient would undergo in order to be identified in the category of private pay or charity care. The fourth step is to describe how the financial assistance will be publicized. The final step is to limit the amounts charged to patients eligible for the two groups. The amounts charged should be limited to the amounts billed for insured patients. The process fits with the facility’s financial strategy by ensuring that it controls its incomes and expenditure (Cherry & Jacob, 2016). Revenue and Reimbursement Essay

Recommends a billing software system by comparing the benefits and limitations of each in terms of organizational needs and financial strategies.

The two most appropriate billing software systems for the facility are Kareo Clinical EHR and PrognoCIS by Bizmatics. Kareo Clinical EHR is a web-based tool that facilitates practice management, medical billing and records keeping. It is useful for small and medium medical practices, particularly for customizing reports, stored patient records, managing payment collections, following up on delinquent accounts, confirming insurance, and scheduling payments. It can be set up and become operational within 48 hours and can be used for different practices to include podiatry, chiropractic, cardiology, pediatrics, family medicine and mental health. However, it has technical issues in linking the facility to the insurer (Software Advice, 2018a). PrognoCIS is a cloud-based tool that includes integrated modules for revenue cycle management, patient portal, practice management, and EHR. It is a customizable tool that can work with a wide range of electronic devices to facilitate financial management efforts. However, its major shortcoming is that customers complain about substandard technical support (Software Advice, 2018b). Through comparing the two software systems, it is clear that PrognoCIS is more appropriate.

Explains how billing process changes benefit physicians, clinics, and patients. Provides supporting references and examples.

Changes to the billing process ensures that the physicians and clinics are fairly paid what they are owed in terms of services they process. In fact, it enhances the reimbursement process by ensuring that each provider is paid for services irrespective of having the same designation or addressing the medical needs of the same patient within the same day so that there are no confusions. Also, it improves the billing practice, helps in understanding the rules that govern practice, and helps in scheduling medical benefits. For the patients, the changes helps them in addressing the hustle linked with paying for medical care by correctly identifying the mode of payment (whether personal or through an insurance), as well as the correct amount they should pay (Getzen, 2013). Revenue and Reimbursement Essay


Cherry, B. & Jacob, S. (2016). Contemporary nursing: issues, trends, & management (7th ed.). Amsterdam: Elsevier Health Sciences.

Emanuel, E. (2014). Reinventing american health care: how the Affordable Care Act will improve our terrible complex, blatantly unjust, outrageously expensive, grossly inefficient, error prone system. New York, NY: Public Affairs Publications.

Getzen, T. (2013). Health economics and financing (5th ed.). Hoboken, NJ: John Wiley & Sons.

Moiso, M. A. (2013). A guide to health insurance billing (4th ed). Clifton, NY: Delmar.

Munro, D. (2016). Casino healthcare: the health of a nation: America’s biggest gamble. New York, NY: BookBaby.

Patel, K. & Rushefsky, M. (2015). Healthcare politics and policy in America (4th ed.). New York, NY: Routledge.

Software advice (2018a). Kareo Clinical EHR Software. Retrieved from

Software advice (2018b). PrognoCIS by Bizmatics Software. Retrieved from Revenue and Reimbursement Essay

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