A hospital billing process begins when an individual comes in for diagnosis and treatment for an injury and is admitted for more than 24hours. The admitting clerk first obtains a person’s demographic such as age, gender, address, symptoms, and insurance information which is entered into a computer system. Once everything is verified by insurance verifier, admitting clerk collects co-payment and assign a patient an account number, which is associated with all charges and payment related to the duties of care. Once a patient is admitted the attending physician dictates history, which includes admitting diagnosis. Then the nurse enters the patient’s medical records and inputs physician orders in a computer. After attending physician supply documentation …show more content…
Outpatient services can be a laboratory, Emergency department, ambulatory surgery center, urgent care and rehabilitation center. When an individual is seen in the emergency department a patient is considered an outpatient unless he/or she is admitted. Physicians visits the patients, perform surgeries, discharge patients from the hospital the same day. Once a patient is discharge the patients’ medical record is sent to the biller who uses the CMS-1500(02-12) insurance claim form for services provided by the physician not by the hospital, then uses CMS 1450 (UB-04) to bill for hospital services. Outpatient billing process requires the CDM to use book volume 1 and 2 ICD-9CM and HCPCS in order to report patient’s condition and services provided. Once that is done the claim is double checked and submitted with the EOB, and the patient receives the remaining …show more content…
DRG groups all discharge cases into one of 25 Major Diagnostic Categories (MDCs) by age, sex and gender it combines diseases and treatment into a code, which then produces a relative weight for reimbursement. DRG was developed by Professors John D. Thompson and Robert B. Fetter in 1977 to help with classification to be used in UR. UR is a utilization review department that certifies a patient’s complaints and meets hospital guidelines to warrant admittance to a hospital. In 2008 DRG was renamed to Medicare Severity Diagnosis-related Group (MS-DRG) which is a more complexed three tiered system, which split payments based on patient severity as determined by major complication/comorbidity (MCC), a complication/comorbidity (CC) or no CC. example of DRG is when a patient has congestive heart failure for several years and is admitted with admitting diagnosis of chest pain, while hospitalized the patient experience atrial fibrillation using the DRG system the biller would use code 121.09 acute transmural myocardial infarction of anterior wall with code 150.9 for congestive heart failure and CC 148.0 atrial
The expense per discharge and the expense per adjusted discharge are both higher than average. The positive trend in outpatient profitability has been in an increase in profit per visit and net revenue per visit. Outpatients profit has influenced the hospitals in expanding their outpatients and shrinking its inpatient services. Inpatient charges increased the net revenue per discharge shown in the quartile information. The Riverview Community Hospital is known to provide high-quality services to its patients. It provides an adequate amount of revenue to cover its expenses. Moreover, it allows provides charity care without affecting its stability. Also, the Riverview community hospital has joint reimbursement from the government. The length of hospital stays has been below average with allowing doctors and nurses with effective resources. The average length is below average it is quite beneficial to both patients and the hospital because it is less costly, and opens up resources for other nurses and doctors not only does it help out the workers, but allows the patient to be taken care of with accessible facilities. Therefore, it
Computerized Physician Order Entry (CPOE), is also known as Computerized Provider Order Management (CPOM). CPOE is a process of automated or electronic entry record of health care physician on different types of instructions on how to treat patients, especially patients that are hospitalized under a physician’s care. CPOE is one of the most remarkable system that is being used in the healthcare system to effectively reduce the amount of medication errors. The University of Health Care System might be in the process of rolling out the CPOE portion out of the EMR project, however, they did not do a thorough investigation on what CPOE is and whether or not it would have a positive impact on the EMR project. They should have not taken the step to start the project without already knowing the basics of CPOE. They might have had thought that since it is a computerized system everything would turn out okay and there would not be any problems. However, they fall short to recognize that the user’s knowledge and experience with using the CPOE system would have a significant influence on the effectiveness and productivity of the actual system.
The medical supplies that is sourced by Kaiser Permanente headquarters is handled by an governmental agency DME (Durable Medical Equipment) department which handles equipment and supplies that are for repeated use and it may also provide crutches, oxygen equipment, wheelchairs or blood testing strips for diabetics. The rest of the supplies are handled locally by hospitals. Clinical engineering department is responsible for handling the medical supply inventory. They can distinguish which equipment needs to be included in the inventory after following guidelines of some government
The IPPS or the inpatient prospective payment system refers to a system of payment which includes the diagnosis-related groups’ cases as acute care hospital inpatients. This system is based on resources which are utilized when treating Medicare recipients belonging to these groups. Each diagnosis-related group (DRG) comprise of a payment weight. The IPPS serves an integral role when it comes to deciding the overall hospital costs of all the devices used to treat the patient in within a specific inpatient stay.
Takeda, Taylor, Khan, Krum, & Underwood. (2012) states ‘(1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the ‘usual care’ comparator provided in different trials’. (P. 2).
The chargemaster or charge description master (CDM) is a basically a financial tool or an electronic system that housed detailed description/information about service charges to patients. The chargemaster can be a manual list or a file that is located in the organization’s account receivable billing system that contains hospital’s services, item, and their charges. Furthermore, the chargemaster is a very crucial aspect of the reimbursement cycle and must contain vital information necessary to produce an itemized statement and claim form. Key components of the chargemaster include, chargemaster line-item numbers, line-item descriptions, revenue codes, CPT codes or healthcare common procedure coding system (HCPCS) codes,
Medical billing transforms health care services into billing claims. The responsibility of the biller is to follow that claim to ensure the physicians, hospitals, third party billing companies, as well as federal and state governments receive reimbursement for the work that is provided. An experienced biller can boost revenue performance for the facility while keeping the business running smoothly.
According to Accuracy at Every Step: The Challenge of Medication Reconciliation (n.d.), the most challenge is called medication reconciliation, which is a formal steps of gathering information related to the patient’s medication with accurate current medication list and compared to the doctor’s admission, transfer and discharge orders. Its aim is to prevent medication errors. There are three steps process- Verification (gather medication history), Clarification (confirm the medication with doses, properly) and Reconciliation (documenting with medication information). This challenge is important to obtain accurate information on all patients entering the hospital. Information technology may play an important role in improving
Langenbrunner, J., Cashin, C. & Dougherty, S. (2009). Designing and implementing health care provider payment systems how-to manuals. Washington, D.C: World Bank.
Gong, Y. (2010). Case-based Medical reasoning. HMI 8571 Decision Support Systems in Healthcare. Feb 22, 2010. Retrieved on 2/22/10 https://hmi.missouri.edu/moodle/mod/resource/view.php?id=11201
reimbursement determinations. As a result, the camaraderie among physicians has developed into a more aggressive approach to impede competition (Shi & Singh, 2012). Little information is shared with patients in regards to procedures or disease control. The subjects are forced to rely on the internet for enlightenment on the scope of their illnesses (Shi & Singh, 2012). Furthermore, the U.S. health care system fails to provide adequate knowledge on billing strategies for operations and other medical practices. The cost in a free system is based on supply and demand and is known in advance of hospital admission (Shi & Singh, 2012). The need for new technology is another characteristic that is of interest when considering the health care system. Technology is often v...
I had the opportunity to meet with Dee Laguerra for a few hours and learned so much about the Medical records side of our facility and its impact on healthcare organization. As Director of Health Information Management (HIM) she is responsible for many aspects of managing the medical record; which is a legal document. I did not realize how complex this department is and how vital this department is to the legal and financial position of the organization. Dee’s position as director is the responsibility for the collection, organizing, scanning, and completions of the medical records in a timely matter after the patient is discharged. The reason for the timeliness of scanning the medical records is for the preparation for the coders to review all the charts to code for insurance billing. The time requirement for th...
Admission and discharge dates are used to bill for a patient stay. There are certain rules which apply to the to determining the LOS or ALOS for a patient. Acute care facilities have an ALOS of less than 30 days and long care facilities provide care for long than 30 days. In addition to determining LOS if a patient I readmitted for the same diagnosis within 72 hours “requires all diagnostic or outpatient services rendered during the DRG payment window (the day of and three calendar days prior to the inpatient admission) to be bundled with the inpatient services for Medicare billing ()” Capturing the accurate data and ensuring it flow accurately for coding and billing to process smoothly. Due to the numerous services that are provided through
When scheduling a patient for a diagnostic procedure or laboratory test, it is often easier for the physician’s office to schedule the appointment than to have the patient schedule it. Before scheduling a procedure for a patient, the medical assistant needs to compile the information that needs to be relayed to the outside facility. The critical information needed for scheduling a patient procedure includes:
This working document provides a summary of the Case Coordination Group (CCG) Review’s initial assessment of the CCG operations and a ‘first cut’ of draft proposals for change or modification to those operations.