Question

Unit 7 assignment- Regulations Fact Sheet

Introducing to healthcare professionals I have to identify a topic involving regulatory requirements for reimbursement and collections.

while using medical claims processing manual and picking any topic between Section 50 - Filing a Request for Payment with a Carrier on FI through Section 100 - Medicare as a Secondary Payer.

I'm having a hard time Providing a minimum of three facts about the regulation and explain the context of the regulation, how it applies to health care professionals.

Answer & Explanation
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Healthcare reimbursement is often a month's long process that requires multiple steps, each of which can go wrong at any moment, further delaying payment to the provider and potentially saddling patients with bills they don't understand and therefore don't pay. Ultimately, healthcare reimbursement in full isn't even a guarantee. 

Step-by-step explanation

In most industries, paying for a service or item is straightforward. You see the price, make the payment, and receive the item or service. The entire transaction takes a matter of seconds. Healthcare reimbursement is far more convoluted. The biggest difference between healthcare and other industries is that providers are paid after services are rendered. Healthcare reimbursement is often a month's long process that requires multiple steps, each of which can go wrong at any moment, further delaying payment to the provider and potentially saddling patients with bills they don't understand and therefore don't pay. Ultimately, healthcare reimbursement in full isn't even a guarantee. 

When billing insurance, consider the following five steps that providers must take to receive and retain healthcare reimbursement:

 

Step 1. Document the details necessary for payment. 

All of this information goes directly into the patient's medical record where it's stored securely and becomes the foundation for medical necessity of the services provided.

Step 2. Assign medical codes. Providers or certified medical coders assign medical codes in the electronic health record (EHR), or the EHR may suggest codes through automation. These codes translate narrative documentation into concise terms that payers use to understand what services physicians or other healthcare professionals perform and why. Each service or procedure has an associated payment rate based on the work that's required to perform the job.

Step 3. Submit the claim electronically. Providers may submit claims directly to payers, or they may choose to submit electronically and use a clearinghouse that serves as an intermediary, reviewing claims to identify potential errors. In many instances, when errors occur, the clearinghouse rejects the claim allowing providers to make corrections and submit a 'clean claim' to the payer. These clearinghouses also translate claims into a standard format so they're compatible with a payer's software to enable healthcare reimbursement.

Step 4. Interpret the payer's response. After a claim passes successfully through the clearinghouse, a payer reviews the claim and either adjudicates fully towards the allowable amount or rejects all or a portion of the claim. Payers communicate healthcare reimbursement rejections to providers using remittance advice codes that include brief explanations. Providers must review these codes to determine whether and how they can correct and resubmit the claim or bill the patient.

Step 5. Prepare for post-payment audits. 

If documentation doesn't support the services billed, providers may need to repay the healthcare reimbursement they received.  

Each of these steps takes time and resources, two of the most limited commodities in today's provider settings. As the industry continues to pivot toward value-based payments, health information technology will play a critical role in streamlining processes and increasing efficiencies related to healthcare reimbursement.