Analysis of Healthcare Reimbursement Report and Strategies

This report analyzes the healthcare reimbursement process, emphasizing its critical role in organizational financial health. It highlights the impact of effective reimbursement management on profitability, detailing how proper coding, such as the use of HCPCS/CPT codes and the resulting APC groups, is essential. The report also covers the significance of pay-for-performance strategies, including structural, outcome, and process measures, and their role in evaluating and improving care quality. Furthermore, it outlines the reimbursement process across departments, from front-end insurance verification to back-end billing edits, and emphasizes the importance of staff training and accurate performance procedures. By managing reimbursement effectively, healthcare organizations can improve their overall performance and financial margins. The report references key sources such as Cleverley & Cleverley (2017), Harrington (2019), Kliethermes (2017), and Movva & Jani (2018) to support its analysis.

Reimbursement
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In healthcare, each department affects the process of reimbursement. According to
Harrington (2019), the profitability of an institution is significantly impacted by the management
of reimbursement. Poor management of reimbursement leads to an increase in the billing cost
and drop in the rates of the collection, which results in the rise of accounts receivable. The
acquisition value thus becomes unholdable. Effective management within the departments
establishes a healthy relationship between the healthcare staffs and the patients as well as
ensuring a site-level control.
The billing of reimbursement is determined by the proper and timely use HCPCS/CPT codes
that produce Ambulatory Payment Classification (APC) groups (Cleverley, & Cleverley, 2017).
APC reimbursement for the organization is achieved by making sure that the departments have a
complete and accurate coding system in place. Audit check should, therefore, be conducted
regularly to check for the same. Movva, & Jani (2018), highlighted three strategies to capture
pay-for-performance rewards which are structural strategies, outcome measures and process
strategies. Structural strategies gauge the attributes of care like human resources, material
resources and the structure of the organization. It entails the involvement of information
technology (IT) to aid care in the clinical area. The process measure takes into consideration the
procedures such as test, surgeries, involved in providing care. The CMS, private payers and third
parties routinely receive these measures in order to aid in report cards preparation. This measure
also gauges the accuracy, timeliness, appropriateness and the complications of therapy given.
Outcome strategies measure the results of the whole process of care and are also used to follow
up patient's satisfaction with their care (Harrington 2019)
The reimbursement process is the same across all the departments. It involves finding the
insurance data and verifying the patient eligibility at the front-end as well as collecting the co-

pays and deductible obtained during referrals and initial authorization. The back-end departments
deal with the resolution of billing edits, submission of the payor’s claims on time and follow up
on the debts. The clinical department only receives patient waivers and consent, while the
management communicates and provides feedback on time to all the parties involved in the
process of reimbursement. Management also tracks performance and evaluate trends in regard to
reimbursement. The billing and coding departments should understand the patient role in
payment and also analyze the insurance coverage, medical charges, and make accurate billing
forms (Kliethermes, 2017). Moreover, it collects payments from the patients or insurance
companies.
Proper administration of the coding and process and evaluation of the revenue cycle aids the
facility to find out areas that need improvement and also reduction of cost. The staff should,
therefore, be continually trained in order to promote professional fee billing, accountability,
proper coordination between the back-end departments and front-end departments. Furthermore,
a consistent, accurate and proper communicated performance procedure and expectations will be
achieved. This will increase the profit margin of the facility. Therefore, reimbursement should be
managed properly in order to improve the overall performance of the organization.

Reference
Cleverley, W. O., & Cleverley, J. O. (2017). Essentials of health care finance. Jones & Bartlett
Learning.
Harrington, M. K. (2019). Health Care Finance and the Mechanics of Insurance and
Reimbursement. Jones & Bartlett Learning.
Kliethermes, M. A. (2017). Understanding health care billing basics. Pharmacy Today, 23(7),
57-68.
Movva, N., & Jani, A. J. (2018). The value of pay-for-performance in England: An evaluation of
NHS England's Quality Outcomes Framework.