Patient access
Scheduling / pre-registration;
This step allows for collection of client’s data and admission to the correct department.
Insurance verification/authorization;
This step allows the hospital staff gauge the client’s ability to pay for the medical services they are seeking
Time of service registration;
This step evaluates the time and type of service a client is seeking; these factors play a role in determining the cost of medical care.
POS collection: Point of service collections feature allows for the identification and billing of all billable services even at their point of care, but in a clinically friendly manner.
Financial counseling
It is paramount to let the client understand the different options they have to finance their medical care, and how each option will influence the rest if their care.
Revenue integrity
Charge capture: through coding, this feature allows for the identification of very billable service.
Clinical documentation: this feature allows for the computation of all clinical data that contributed to medical billing.
Coding: this feature allows for the identification of very billable service
HIM throughput: this tool helps in the management and analysis of medical drugs.
Charge master management: charge master is a library of all chargeable services, as well as all past medical charges from different clients.
Claims management
Billing: this features allows for the collection of revenue from clients for every billable service.
AR follow-up & Management: this is a management office that takes care of conflicts between the client and the hospital or the hospital and insurers.
Payment Posting: this feature allows clients or their associates submit their bills efficiently.
Customer service: Customer service is at the heart of the billing department; it allows for the identification of queries and a timely intervention.
Collections/Agency Management: Again, this is a management office that foresees the operations of third parties and revenue collections.
Reimbursement
3rd party contracting: This feature allows for efficient and accountable identification of third part service providers.
Denials management: In some circumstances, some client’s or insurers might deny or fail to pay medical bills because of one reason or another; this tool helps the billing department in dealing with these cases amicably.
Contract management: In some instances, the hospital might seek third party services, thus this feature helps in the management of contracts.
Pricing strategy/ fee schedules: This tool provides all the policies required in the establishment of the coding system.
Revenue recognition: This tools for the analysis of all revenues generated from the clinical departments billings.
As much as a hospital is geared towards providing care to its clients, it has to generate revenue for its continuous existence. Malhotra (2009) argues that, a hospital is an organization that recruits the skills and efforts of a wide variety of professionals, semiprofessionals and non-professionals in order to provide exceptionally personalized services to clients. Malhotra (2009) indicates that, just like other organizations, hospitals are designed to pursue certain goals through a collaborative activity. In addition to the principal goal of providing healthcare, a hospital may have other objectives such as its own maintenance and survival, financial longevity and the championship of nursing education and research. However, under these circumstances, the focus is on the provision of healthcare, and financial longevity.
In the MAD model highlighted above, which is part of the integrated billing model, caution has been taken to enhance the financial longevity of the hospital in question. In other words, revenue has to be generated in order to foresee the financial hospitality of this hospital. In order to attain this goal, automation was necessary. Automation within the clinical departments is essential because these departments are the primary revenue generators in the hospital. While the goal the hospital seeks to enhance its financial longevity, caution is taken not to compromise the primary goal of providing healthcare. Griffin (2011) argues that licensed hospitals must have a compliance and performance improvement program in place. Automated billing systems are the heart of compliance and performance improvement programs because they allow for counterchecking of system flaws.
In the MAD model highlighted above, the initial pre-registration step plays a vital role; it helps the hospital’s billing department to understand the needs of the client prior to admission. When a client is finally admitted, focus is then geared towards the provision of quality healthcare with confidence that the patient will pay for the services. The pre-registration stage ensures that the patient is admitted only after providing a well-defined plan on how they are going to cover their medical costs. In other words, once admitted, there is no point where medical care can be stopped because of finances. Besides, revenue integrity and claims management take care of that aspect as the patient receives the necessary medical attention.
On the other hand, the patient access stage has been made possible through enhancement of front-end services as illustrated in figure 2. Scheduling has been boosted in order to minimize registration errors. Front-end operations have been made easier through the establishment of a coding system that ensures every service that is provided is billed accordingly. Scheduling allows for billing of future services that would otherwise be unaccounted for.
Front-End Processes
Scheduling/Registration errors: This step allows for collection of client’s data and admission to the correct department.
Front-end edits: At the front end, it is essential to ensure that no errors are made during scheduling or pre-registration.
Coding assignment: coding allows for identification of every service and its associated cost.
Charge Lags: this feature eliminates the delay in service delivery due to delayed billing.
Time of Service Collection: It is important to bill every service in a timely manner, and this feature takes care of this aspect.
Percentage of Patients Cashiered: This tool assists the billing department to compute the number of clients who have been billed; the computation can be used for accounting purposes.
Front-end processes play a crucial role; they are the first point of contact between the client and the hospital. These changes will enhance the admission process; patients’ correct information including demographic and financial backgrounds are computed from the onset. In addition, scheduling of anticipated service is documented. Besides, coding for every billable service is achieved. Furthermore, every statistic, and most importantly, medical billing records of every client are recorded from the onset necessitating efficient accounting.
Business Office Functions
Electronic Claim Submission: This aspect automates the claim submission process thus allowing for a faster claim dispute resolution.
Edit Processing: this feature is essential to ensure that no errors are made during scheduling or pre-registration.
Remittance and Payment posting: This feature must provide various options for payers to submit or post their payments.
Denial Management: In some circumstances, some client’s or insurers might deny or fail to pay medical bills because of one reason or another; this tool helps the billing department in dealing with these cases amicably.
Insurance Follow Up: This feature addresses those with medical care insurance; it allows for the collection of client’s medical bills payments from such insurers.
Payer Analysis: This feature evaluates the manner in which a client or their associated medical financier paid for the medical service; it should be authentic and accountable.
Customer Care Services: Customer service is at the heart of the billing department; it allows for the identification of queries and a timely intervention.
Self-Pay Collections: Self-pay clients have no medical insurance, and have to pay for their medical bills on their own. Appropriate measures must be enacted to allow the collection of revenue from such clients. The fact that they have no medical cover should not delay service delivery.
Third Party Collections: this is a management office that foresees the operations of third parties and revenue collections.
Improvements in the business office functions have a host of benefits. First, these functions allow for the provision of nursing and medical care in an efficient manner without destructions. In other words, as the business office functions follow-up with other auxiliary functions, the nursing and medical processes do not stop. Secondly, these functions allow for amicable settlement of any queries that may arise between the hospital and the patient or the hospital and the medical insurance companies. In other words, these functions necessitate effective remittance and payment positing. These features eliminate cases of missed payments, as well as build a good rapport between the hospital and its associates (clients and medical insurers)
Enhance back office functions.
Charge Submissions and Cashiering: the identification of a coded service and timely billing are of essence. Therefore, points of cashiering should be easily accessible.
Claims Processing: Claims processing allows for identification and management of billing issues that led to overbilling.
Remittance and Payment posting: This feature must provide various options for payers to submit or post their payments.
Denial Management: In some circumstances, some client’s or insurers might deny or fail to pay medical bills because of one reason or another; this tool helps the billing department in dealing with these cases amicably.
Third-Party follow-up: This back office function assists in the identification and collaboration with third parties that are linked to the billing department.
Payer Payment Analysis: This feature evaluates the manner in which a client or their associated medical financier paid for the medical service; it should be authentic and accountable.
Customer Service: Customer services is at the heart of the billing department; it allows for the identification of queries and a timely intervention.
Self-pay Collection: Self-pay clients have no medical insurance, and have to pay for their medical bills on their own. Appropriate measures must be enacted to allow the collection of revenue from such clients. The fact that they have no medical cover should not delay service delivery.
Collection Agencies: These are agencies (third parties) that are involved in the collection of medical bills accrued by their associates. The billing system must be integrated to allow effective communication between it and those agencies.
Results:
- Consumer focused: The objective of any given hospital is to provide quality healthcare; the improvisations in the billing department must be geared towards quality healthcare, and this is shown by high customer satisfaction.
- Improved Claimed Accuracy: This aspect helps address issues of overbilling with high precision.
- Increased collections: The implementation of the above processes will enhance the overall hospital collections.
In addition, figures 3 and 4 highlight other important aspects of the integrated billing model. Business office functions take care of the business part of the hospital, as the nursing departments take care of the patient care role. In other words, as the patient is receiving anticipated care, the business office functions allow for follow-up, claims management, third party operations, and the provision of customer care. The integrated billing model has enhanced back office functions that support the execution of its roles as highlighted in figure four.
Moreover, Diamond (2011) and Magovern and Jurek (2008) contend that in order for billing systems to be efficient, hospital employees must be computer literate and have an understanding of associated computer software. Efficient hospital billing departments have well-defined protocols that help front office user to understand hospital billing flow, data elements and coding systems. On the other hand, DeKaye contends that every department in the hospital that generates charges needs to understand the importance of entering the charges in the hospital’s computer system. Charge capture at every stage closes the holes through which hospital revenue can be lost.
References
Diamond, M. (2011). Understanding Hospital Coding and Billing: A Worktext. London: Cengage.
DeKay, K. (1997). The Patient Accounts Management Handbook. New York: Jones & Bartlett.
Griffin, D. (2011). Hospitals: what they are and how they work. New York: Jones & Bartlett.
Magovern and Jurek (2008). Hospital Billing. New York: McGill-Hill Education.
Malhotra, K. (2009). Hospital Management: and evaluation. New Delhi: Global India Publications.
