In current healthcare webinars, reimbursement module has undergone a change as it has been observed prior to Affordable Care Act was introduced. There was a growing pursuit of quality based care against quantity due to which the healthcare facilities, hospitals, and the providers began to implement new models to make their facilities more focused on patient care and created a responsible & answerable environment. In this ever-changing industry landscape of new care models, revenue collection was handled with a unique approach to assure quality given to the client is being compensated in accordance with precision and on time services.

To assure claim reimbursement in revenue cycle the healthcare organizations, providers, and physician practices should grasp the numerous elements of claims management for successful reimbursement. The success rate of the reimbursement is based on corrections in your system as these small enhancements streamline the process is stated by Nalin Jain, Delivery Director of Advisory Services for CTG Health Solutions in one of his statements.

The inadequate support entirely devoted to revenue cycle or reimbursement process adversely affect the claims management which one common trait in numerous healthcare facilities or clinics. Mr. Jain also tells that physicians are caregivers but they need to run their practice as a business “claims processing was the sand in the gears of practice management.” There are few providers and healthcare facilities who realize the numerous parts of the patient-provider communication are relevant for the revenue cycle and could recognize the holes heading to damage or uncertainty. Such elements are as follows pre-service, pre-registration, pre-authorization; the process of care; process integrity practices such aschargemaster, coding compliance, clinical documentation; billing services such as customer support, collections, follow-up; and Administrative services such as contract management, fee schedules, debt collections, managed care contracts, denial management.

Reimbursements start with evaluating the prevailing process by paying particular consideration to three large operative sections such as operational, technical, and financial. The financial section supervises the accounts receivable such as dismissals, management of disapproval and collection rates. The technical section looks into the applications, processes, and systems and is involved in whole patient-provider communication. The operational section looks into workflows, vendor relationships, and account the staffing.

The evaluation will persist for numerous months revolving around the basis of the size of the healthcare facility and scope of methods are examined. It is only finished when the healthcare facility or the provider is able to construct the wireframe connecting to one another along with the standards through which they can calculate their effort in comparison. In enhancing claims management and reimbursement rate, technology also plays an essential part.

The process of claim can be successful when the system is streamlined & trackable with a proficient staff. Claim processing is a part of the revenue cycle which differs on various aspects of healthcare facilities such as its composition and billing process. Below is a pictographic representation of claim management roles:

For the revenue cycle to operate easily along with possibilities for advancement in claims management in a managed way the heads of every department should interact with each other simultaneously in a healthcare facility in a timely fashion with a frequent meeting to ascertain the process in an orderly way. In claims process irrelevant of the size of planned, chief stakeholders, and actions in all the departments from front to back should be prepared in a regulated manner.

Reimbursement policies are also influenced by federal policies as a slight variation from the service fee to the performance fee has got the healthcare facilities to rethink their clinical practice to achieve the aimed objective as the providers are owning up to more and more responsibility. According to many experts, current practice in reimbursement objections for mostly every healthcare organization, hospital, provider, and physician depends on the confrontation, however, after many years it is expected to be rapid. Broadly there are two categories in which healthcare falls one is based on regulations and the other is focus on the patient. The very first category was prominent in the past months with CMS (Centers for Medicare & Medicare Services) coming up with many changes and regulation in the admissions process which providers didn't have a welcoming attitude and many were in rejection. As the second category is strictly based on the patient experience and their experience during the healthcare duration. This phase had more impact than the first as majorly people opted for more care-oriented facilities. The chief reason for the denial from healthcare facilities was due to the medical requirement for inpatient admissions and Medicare came up with the regulation in 2015 of the two-midnight rule which caused the clients to rush.

The reason responsible for such regulations is to transform the hospital use from inpatient to outpatient. The healthcare sector has begun to deal their practice as a business and their patients as consumers marking the start of patient-focused care. This culture of placing the needs of patients on a high priority is making the major difference in healthcare providers.

Reimbursement is the one point where all the healthcare facilities find themselves difficult as reimbursement now has changed from volume to value. Let's take a look to understand the complete revenue cycle below:

In professional revenue cycle, there are numerous chief concerns affecting it and methods to execute facilities standards to sustain effectiveness. The answer to that question involves taking a step back and looking at billing operations and claims management. Nonetheless, if the revenue cycle is not regulated or handled properly the collection flow can fall, billing charges can increase, and the A/R will grow to the point that the price of the takeover is lost. It is an imperative perception especially at the time of providers stabilization whereas huge healthcare facilities like hospitals and health systems are getting with autonomous practices. The present industry landscape the healthcare facilities are transforming the revenue cycle process to reduce the loss.

The healthcare organizations who are flourishing in handling the revenue cycle are able to view the larger picture and own the capability to interact with the team members who are not able to perform well and affecting adversely the reimbursement process. In the end, it matters to organize, run a successful revenue cycle, able to point out the flaw in the system, pluck the flaws out and recognize the possibilities for cash improvement. Claim Management is a part of the revenue cycle but has great relevance.