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1. Revenue And Reimbursement Essay Example Paper
Revenue And Reimbursement Essay Example PaperBackgroundAlthough 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 (Britton, 2015; Cherry &
Jacob, 2016)Revenue And Reimbursement Essay Example Paper. 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.ORDER YOUR PAPER
HEREDevelops 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 (Sterling, 2014). 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

2. 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 Example Paper.Recommends a pricing structure method, and
explains how the pricing structure method supports the financial strategies of the
organization.Activity based costing offers the best pricing structure for the facility. The
structure allocates costs based on consumption using a seven step process. Firstly, activity
centers are defined. Secondly, an analysis of the activities within the centers is conducted.
Thirdly, the output is determined for each center. Fourthly, costs are calculated for every
activity in each center. Fifthly, the administrative costs are allocated to each center. Sixthly,
total costs are calculated by adding the administrative costs to the costs for each activity.
Finally, the cost price for the activities based on total costs along with an acceptable profit
margin. This pricing structure supports the facility’s financial strategies by allowing it to
consultatively present prices that are acceptable to customers while also addressing their
financial needs with comfortable profit margins. To be more precise, the structure evaluates
the facility’s actual cost structure by offering useful information about actual amounts
(Kazemi & Zadeh, 2015).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)Revenue And Reimbursement
Essay Example Paper.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)Revenue And Reimbursement Essay Example Paper.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

3. 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 Example Paper.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 (Berger, 2017; Getzen, 2013)Revenue And Reimbursement
Essay Example Paper.ReferencesBerger, E. (2017). Finding a balance on balance billing.
Annals of Emergency Medicine: An International Journal, 70(2), A15-A18. DOI:
10.1016/j.annemergmed.2017.05.024Britton, J. (2015). Healthcare reimbursement and
quality improvement: integration using the electronic medical record. International Journal
of Health Policy and Management, 4(8), 549-551.Cherry, B. & Jacob, S. (2016).
Contemporary nursing: issues, trends, & management (7th ed.). Amsterdam: Elsevier Health
Sciences.Getzen, T. (2013). Health economics and financing (5th ed.). Hoboken, NJ: John
Wiley & Sons.Kazemi, Z. & Zadeh, H. (2015). Activity based costing: a practical model for
cost price calculation in hospitals. Indian Journal of Science & Technology, 8(27), 1-6. DOI:
10.17485/ijst/2015/v8i27/81871. Retrieved from
http://www.indjst.org/index.php/indjst/article/view/81871Moiso, M. A. (2013). A guide to

4. 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 Revenue And Reimbursement Essay Example Paper.Software advice (2018a).
Kareo Clinical EHR Software. Retrieved from
https://www.softwareadvice.com/medical/kareo-software-profile/Software advice
(2018b). PrognoCIS by Bizmatics Software. Retrieved from
https://www.softwareadvice.com/medical/prognocis-bizmatics-profile/Sterling, R. (2014).
Revenue cycle management and EHRs. Retrieved from
https://www.hbma.org/news/public-news/n_revenue-cycle-management-and-ehrsORDER
YOUR PAPER HEREPreparation 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 Revenue And Reimbursement Essay
Example Paper.PROFICIENT DISTINGUISHED Develops a step-by-step process for a
revenue cycle. Develops a step-by-step process for a revenue cycle and explains the
function or importance of each step.Recommends a pricing structure method.
Recommends a pricing structure method, and explains how the pricing structure
method supports the financial strategies of the organization.Explains the factors to consider
for insurance contract negotiations. Explains the factors to consider for insurance
contract negotiations, and identifies the major payer categories appropriate for the

5. practice.Explains a process for handling private pay and charity care.Explains a process for
handling private pay and charity care, and how the process fits into the financial strategies
of the organization.Recommends a billing software system. Recommends a billing
software system by comparing the benefits and limitations of each in terms of
organizational needs and financial strategies.Explains how billing process changes benefit
physicians, clinics, and patients. Explains how billing process changes benefit
physicians, clinics, and patients. Provides supporting references and examples.Writes
content clearly and logically with the correct use of grammar, punctuation, and mechanics.
Writes clearly and logically with the correct use of spelling, grammar, punctuation,
and mechanics; uses relevant evidence to support a central idea.Formats citations and
references using the APA style with few errors. Formats citations and references with
no errors.Revenue And Reimbursement Essay Example Paper