Introduction to Reimbursement and the Revenue Cycle

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Reimbursement and the Revenue Cycle
Healthcare reimbursement refers to the payment that the healthcare service provider, such as hospitals and diagnostic facilities, receives for providing the service. In most instances, the healthcare insurer pays for either all or part of healthcare costs (Felman, 2021). The amount offset by the insurer depends on the specific plan that the patient belongs to. The patient may be responsible for some of the costs in some plans as the insurer covers the rest. If the patient does not have any insurance coverage at all, they may be responsible for reimbursing the healthcare providers for the whole services they receive.
In most cases, the patient reimburses the institution after receiving the medical services. After the patient receives the services, they send the bill to their insurer to offset the costs. The amount charged on the system depends on the services that the patient has agreed with the service provider. Private insurers usually negotiate their own reimbursement rates with their providers and the hospitals. Certain private insurance companies do not reimburse the service providers enough, unless in emergency cases. Therefore, the service provider needs to understand the type of insurer they are dealing with before rendering the services.
Once a doctor accepts the patient's insurance services, the payer's reimbursement for that said service has been agreed upon. The doctor will accept it and provide the services without any extra costs beyond what the patient is insured for and willing to pay. Balance billing occurs when the healthcare service provider opts to bill for an additional amount unless they were informed before time about the additional services. Therefore, under normal circumstances, balance billing is illegal. When the patient requires additional services not included in the insurance, they may have to pay out of their pockets. In such cases, the healthcare service provider is allowed to make such deductions.
If the services are provided to the patient, but the payments are not remitted, the payer should communicate the reason for the reimbursement rejections through the remittance advice codes. These codes include a brief explanation of why the payment was not remitted. The provider is then expected to review the codes and assess whether they can correct and resubmit the claim or bill the patient. For example, in some cases, payers may reject services that are not supposed to be billed together during a single visit. In other instances, they may reject the request for reimbursement because of lack of medical necessity or because the said services occur in a specific timeframe after a specific procedure. Other rejections could be linked to non-coverage or many other reasons. Therefore, the healthcare service provider should follow up with the insurer to understand why the claim was not reimbursed or bill the client.
The revenue cycle is as follows:
19240506985Customer Service Department00Customer Service Department
26289001339850
19335757620Accounting and Finance Department00Accounting and Finance Department
center1422400
1943100219710Receipt of Healthcare Services00Receipt of...