Healthcare Reimbursement - Essay Example

"Healthcare Reimbursement" is a perfect example of a paper on the health system. Reimbursement refers to the payments made to the hospitals, doctors, diagnostic facilities, or any other healthcare providers receive for the services provided (Casto & Forrestal, 2013). In most cases, this payment is made by the insurer or the patient, and the government, in full or partial payment. Unlike other industries, reimbursement in the healthcare industry follows the delivery of services and may take longer due to the processes involved. Healthcare organizations rely on reimbursement to finance the healthcare services provided, compensate the healthcare employees, and develop the healthcare services in a bid to improve the quality. Like any other industry, the healthcare industry's success is based on the balance between the cost and revenues. Reimbursement is the main source of healthcare revenue. If the services are provided without reimbursement, the balance between the expenditure and revenue will be disturbed, thus curtailing the organizations’ ability to deliver healthcare services. Also, the quality of services would be jeopardized. The quality of services is a dependency on the technology adopted and the physician's skills. Healthcare organizations require finances to fund these factors. In general, the operations of healthcare organizations will be jeopardized.

Revenue cycles differ depending on the healthcare facilities. The chosen healthcare center is Florida Hospital Orlando, which is among the largest hospitals in Florida. In this facility, the revenue cycle starts when that patient makes an appointment with the hospital (Wright, 2017). After an appointment is made, preregistration is made, where the hospital officials enter the patient's details into the Revenue cycle software. The following step is preauthorization by the insurer, where the insurer ensures that the medical procedure and the resources used are necessary. This step is not important for patients who are not covered or are in critical condition. After preauthorization, the hospital verifies the benefits and eligibility of the patient. Florida Hospital Orlando uses software to effect this step. At this point, the patient receives healthcare services from the hospitals. The following step on the revenue cycle is claim submission. This entails the submission of the services provided and the resources used in the service delivery. Once the claim is submitted and reviewed, the payment is posted. The final step is reporting, where financial reports are filed. Various departments within the hospital influence the revenue cycle. The admission department is essential in the first three steps of the revenue cycle. Preregistration, preauthorization, and verification are done at these departments. The next department is the emergency/medium care unit. Here, the patient’s condition is assessed and treated or admitted for further observation. Other departments involved in the treatment process include the intensive care department, laboratory department, and wards department. The services and resources used in these departments are necessary for claim submission, payment posting, and reporting stages of the revenue cycle.

Florida Hospital Orlando provides healthcare services to citizens in Florida and other states. The hospital offers a wide range of services from emergency healthcare attention, obstetrics, surgeries, et cetera. The operations in each department are financed by the patient revenues received. This implies that the successful operation at these departments depends on the reimbursement management department (Stockamp, 2005). This department deals with revenue cycle management and reporting financial transactions within the organization, which are essential for organizational decisions.

The hospital needs an internal audit to assess whether its departments fully reach the reimbursement effects. Internal audit provides the organization with information regarding its financial and operational controls. Auditors compare the accounts payable and receivable to evaluate any discrepancies. Also, the organizational policies are assessed in compliance with its demands to establish the need for improvement. A report is provided showing the hospital's effectiveness as far as reimbursement is concerned.
Pay for performance is largely adopted by most healthcare organizations as a compensation approach. The approaches used to effect pay-for-performance include structural measures, process measures, and outcomes measures. The structural measure is focused on the organizational structure of the hospital. Process measure evaluates the care plans adopted by providers for each patient. Finally, the outcome measure addresses the overall health outcomes resulting from the services provided by each provider. All these approaches are designed to assess the performance.

The main departments at Florida Hospital Orlando include the admission department, medium /emergency care department, assessment department (laboratory, x-rays, et cetera), theatres, and wards. The admission department is involved in creating an account for the patient and setting up their health history. This department provides foundation information for reimbursement purposes. At the emergency department, the patient is observed by a doctor, who either treats them or recommends further assessment lab or x-rays. The resources and services offered in these departments form the basis for reimbursement claims. Similarly, the assessment department, theater department, and ward department offer services geared towards patient treatment. All services and resources involved are used to determine the amount payable. The provider performance in each department and the resources utilized are the key drivers to reimbursement reforms (Veletsos, 2003).

The revenue cycle management department is responsible for ensuring compliance with billing and coding policies. This department is involved in tracking the patient's cycle through the hospital and the services received. From the first contact, the department personnel creates an account for each patient and codes the treatments for reimbursement purposes. Billing and coding policies provide the guidelines that should be followed in the whole process of reimbursement.