Managing Healthcare Costs and Revenues

With these types of organizations they have different methods of payments and reimbursements. They have guidelines through the government that they will have to abide by. The government sponsored payers are Medicaid and Medicare. The majority of patients that are treated are on Medicare or Medicaid. With patients not insured each type of organization handles reimbursement differently. For- Profit hospitals it is bad debt, which is when charges of patient are written off. With not –for –profit organizations it is considered charity care. This type of care has to be documented and reported on tax status.

The private insurers are patients with other insurances. Under Medicare and Medicaid, services that are provided by the hospitals are paid by a prospective reimbursement. Prospective reimbursement is established before the services are provided. They have a defined dollar amount per day and per diagnosis. They also use a fee scheduled by CPT code or procedure code which is usually used for physicians. Since these types of insured patients only are billed a certain amount, most procedures are not fully reimbursed. Retrospective reimbursement is determined after the services have been delivered. This is one of the reasons organizations are struggling. Along with less reimbursement, the CPT codes or procedure codes have to be correct according to the procedure ordered. “If an organization wants to get paid, its better off taking the time to make sure all its codes are accurate, timely , and meet all payers’ requirements ”(Kapsambelis, 2004, p. 3).

When good claims go bad, “ beneficiaries who aren’t covered; services that payers say aren’t reasonable and necessary; provided services that weren’t covered; duplicate bills ...

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...ations to be successful they must keep up with the new technology.

Works Cited

Bigalke, J. T. (2009, February). Healthcare Financial Management [Managing Uncertainty to succeed in the new health economy]. , (), . doi: Retrieved from

Buchbinder, S. B., & Shanks, N. A. (2007). Managing Costs and Revenues. In (Ed.), Introduction to Healthcare Management ( ed., p. pp. -). : . []. doi: Retrieved from

CBO Projects Total Healthcare Spending to Hit 26 Percent of GDP by 2035 [Healthcare Financial Management Association]. (2010, August). , 9. Retrieved from

Journal of Healthcare Finance. (2008). A Framework for Cost Mnanagment and Decision Support Across Health Care Organizations of Varying Size and Scope. Journal of Healthcare Finance, 63-75.

Kapsambelis, N. (2004, October). Getting Paid In Behavioral Healthcare [Team spirit]. , 9(10), 1-4. Retrieved from