MHA5006 Capella University Revenue and Reimbursement Summary

Write a 3–4-page proposal for billing changes and explain how the proposed changes will benefit the organization, the physicians, and the patients.

Note: The assessments in this course build upon each other, so you are strongly encouraged to complete them in sequence.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Develop financial strategies to address dynamic environmental forces. (L24.2, L24.5, L17.2)
  • Competency 2: Analyze the cost and revenue implications for organizational changes due to environmental forces. (L18.2, L12.1)
  • Competency 4: Communicate in a manner that is scholarly, professional, and consistent with expectations for professionals in health care administration. (L6.1, L6.2, L6.3, L6.4)
  • Develop a step-by-step process for a revenue cycle.
  • Recommend a pricing structure method.
  • Explain the factors to consider for insurance contract negotiations.
  • Explain a process for handling private pay and charity care.
  • Recommend a billing software system.
  • Explain how billing process changes benefit physicians, clinics, and patients.
  • Write content clearly and logically with the correct use of grammar, punctuation, and mechanics.
  • Format citations and references using the APA style.

Expert Solution Preview

The medical field is constantly evolving, and healthcare organizations must be adaptable to ensure that they thrive in a dynamic environment. One critical aspect of healthcare administration is billing and revenue cycle management. As a medical professor, it is essential to teach students how to develop financial strategies that address environmental forces and analyze the cost and revenue implications of organizational changes. In this proposal, we will recommend several billing changes that will benefit the healthcare organization, physicians, and patients.

Step-by-Step Process for a Revenue Cycle:
To ensure an efficient revenue cycle, healthcare organizations must implement a step-by-step process. The revenue cycle includes registration, insurance verification, charge capture, coding, billing, and denial management. Each step of the process should be carefully monitored to avoid errors and ensure that claims are submitted accurately and promptly.

Recommendation for a Pricing Structure Method:
One effective pricing structure method is the resource-based relative value scale (RBRVS). This method assigns values to procedures based on the time required, technical skill and difficulty, and the intensity and effort required to perform each service. By using the RBRVS method, healthcare organizations can set prices that are fair and competitive while also ensuring that physicians are adequately compensated for their services.

Factors to Consider for Insurance Contract Negotiations:
When negotiating insurance contracts, healthcare organizations must consider several factors, including payment rates, contract length, and network participation requirements. Negotiating payment rates that are fair and reasonable is critical, as this will affect revenue generation. The contract length should be negotiated to ensure that the organization has sufficient time to evaluate the contract’s effectiveness and make changes as needed. Additionally, contracts should be evaluated for network participation requirements to determine if they align with the organization’s strategic goals.

Handling Private Pay and Charity Care:
To manage private pay and charity care, healthcare organizations should implement clear policies and procedures. The private pay policy should clearly outline payment requirements, including payment methods, payment schedules, and consequences for non-payment. For charity care, organizations should establish eligibility criteria and require patients to apply for financial assistance. A clear and concise policy for handling these types of care will promote transparency and ensure that patients are treated equitably.

Recommendation for a Billing Software System:
A robust billing software system is critical for an efficient revenue cycle. A good system should have an intuitive user interface, automated claims processing and scrubbing, and strong security features. Additionally, the system should be integrated with the EHR system to enable efficient data transfer and avoid errors.

Benefits of Billing Process Changes:
The proposed billing process changes will benefit physicians, clinics, and patients. By implementing an efficient revenue cycle, healthcare organizations will reduce costs, improve cash flow, and have better control over the billing process. Physicians will benefit from having accurate and timely payments, and clinics will be able to track expenses and revenue more effectively. Patients will benefit from fewer billing errors, faster claim processing times, and more transparent billing practices.

Healthcare organizations must be adaptable to keep up with the dynamic environment of the medical field. Efficient billing and revenue cycle management are critical for ensuring the financial health of organizations. Through the proposed billing changes, healthcare organizations will be able to increase revenue, reduce costs, and benefit physicians, clinics, and patients. By teaching students these critical skills, we are preparing them to be effective healthcare administrators who will be able to thrive in a dynamic and constantly evolving field.

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