The medical billing cycle is a series of steps in a hospital or other healthcare organization when billing for services. After a patient gets treated, the healthcare facility claims from the insurance firm, thus the billing process. The medical billing process begins when a patient undergoes a procedure or is admitted to a hospital, say for urgent care. The first thing the hospital will do is assign a code for that specific service or procedure. A code could be an ICD-10, CPT-4, HCPCS Level II, or another coding system depending on their jurisdiction and what they’re paid by third-party payers such as Medicare (Semprini et al., 2022). In any case, the code will be entered into an EMR or CPOE system and then sent to an account representative for verification. Thus, this paper analyses the billing cycle and the challenges created by the ever-changing technological and regulatory environment.
The first step done in this billing cycle process is the coding. Depending on the preferred coding method, the code is sent for confirmation by the account owner. If the account representative verifies the code, then it is a positive confirmation; otherwise, it is a negative confirmation that can stall the process (Ho et al., 2017). The account representative also verifies if other codes associated with that service or procedure have not been validated previously.
Further, the second step in the billing process involves dealing with Medicare and other third-party payers of healthcare. This is where the hospital or healthcare organization sends all billing information to both Medicare and third-party payers. Every month, the hospital or healthcare organization will send the reimbursement amount of Medicare information and any other payment they may receive (Semprini et al., 2022). Once this step is complete, the medical billing cycle has begun. This happens before a patient walks out of a hospital, so by this time, it’s pretty clear what services a patient has received and what services have been provided on that visit.
While discussing billing in the ever-changing environment, a question for this paper would be, “What are billable services?” There are many billable procedures, but what is a billable procedure? A billable procedure one can write up in an electronic record can be an EMR or CPOE system, and if a hospital uses a paper chart, it’s still considered a billable procedure. However, this research takes note of the challenges and the possible discrepancies and exclusions that can arise on reliance on paper records.
The Impact of the Affordable Care Act
The Affordable Care Act is one of the most disruptive pieces of legislation regarding healthcare in the US. The Affordable Care Act is one of the most disruptive pieces of legislation regarding healthcare in the US. Passed in March 2010, this act has prompted major changes to healthcare delivery in the US. The most significant difference is that health care insurance will now be provided for all Americans. This means that no one can be denied coverage due to preexisting conditions; all adults are required by law to purchase health insurance or face a tax penalty, and subsidies are available for lower-income individuals.
As of October 2013, over 8 million people had enrolled in state exchanges (representing about 3% of the US population) (Semprini et al., 2022). The law provides subsidies for those who do not receive full-time employment, cannot access employer-based coverage, or purchase insurance on their own. Subsidies range from $100 for individuals making up to 138% of the poverty line, to $700 per month in income (Semprini et al., 2022). In addition, any insurance company that wishes to remain in the state must accept all applicants regardless of preexisting conditions or whether an individual has paid for coverage in the past three months. Other features include bans on insurers from refusing to cover a customer even if they have had a lapse in coverage; caps on the amount an insurance company can charge per enrollee; elimination of lifetime caps on coverage for those with preexisting conditions; and free preventive care.
In line with this discussion, the ACA causes some uncertainty regarding billing, and its ambition adds to the dark cloud of what forms billable service or procedure. Thus, some companies take advantage of denying payments to deserving Americans. Since doctors and hospitals are independent service providers, they are not considered essential service providers; thus, they do not have the protection that utilities or other important industries have. This means that they must collect payments from patients to stay operational.
One of the essential factors in healthcare, while one of the most overlooked, is compliance. Compliance is unique to every healthcare organization and can vary depending on the state, hospital, or even type of medical facility that is being operated. Hospitals must comply with regulations because it will significantly impact their payment rates and the release of funds by both Medicare and Medicaid. As stated in the article “A Hospital Compliance Checklist,” Healthcare organizations need to be aware of patients’ civil rights, regulation laws, and government regulations (Ho et al., 2017). Moreover, specific and routine performance improvement activities need to be taken to remain compliant with the government and current medical regulations.
The Joint Commission (TJC) is an organization that focuses on healthcare compliance, safety, and accreditation. This organization must accredit hospitals to receive Medicare funding for clinical care. This certification is vital for healthcare organizations hoping to receive Medicare funding. A health care organization will not have its claims paid by Medicare or Medicaid if it is not accredited (Semprini et al., 2022). The Joint Commission also issues safety alerts and compliance alerts to healthcare organizations. The Joint Commission has created several standards that need to be adhered to for an organization to be accredited. Disclosures are another form of compliance essential for hospitals with Medicare funding. When a patient receives treatment or services, the hospital must inform them about all the benefits of being treated at that particular medical facility. Non-disclosure of specific payment terms can result in Medicare funding and liability claims. Overall, the challenges highlighted above in urgent care (and in milestone one) can only be addressed through joint efforts of the players in the health sector and strict standards by the concerned authorities.
Ho, V., Metcalfe, L., Dark, C., Vu, L., Weber, E., Shelton, G., Jr, & Underwood, H. R. (2017). Comparing utilization and costs of care in freestanding emergency departments, hospital emergency departments, and urgent care centers. Annals of Emergency Medicine, 70(6), 846–857.e3. https://doi.org/10.1016/j.annemergmed.2016.12.006
Semprini, J., Lyu, W., Shane, D. M., & Wehby, G. L. (2022). The effects of ACA medicaid expansions on health after 5 years. Medical Care Research and Review: MCRR, 79(1), 28–35. https://doi.org/10.1177/1077558720972592
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