MHA FPX 5006 Assessment 2 Revenue and Reimbursement

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Healthcare Insurance Management

MHA FPX 5006 Assessment 2 Attempt 2 Revenue and Reimbursement

In health care organizations, focus of the management must be given to the financial aspects as income must be forecasted according to existing contracts with stakeholders. Healthcareprocessionals are responsible for supporting viable emergency care and they must manage finite resources to achieve legal imperatives (Gupta, 2020). A healthcare organization can earn money in different ways. As a role of an office manager, it is my duty to help the physicians to try to manage their own billing processes efficient. I observed that this proactive is not followed by the clinic consistently and the billing policies need an upgrade, therefore, I need to develop financial strategies that help the organization to address dynamic environmental forces and revenue cycle and recommend a new pricing strategy. 

Process Developed for a Revenue Cycle 

According to Kamble (2018), healthcare organizations can conduct several steps for revenue cycles such as preregistration, registration, charge capture, claim submission to name a few. The first step is preregistration that allows medical centers to gather demographic data and insurance information as well as eligibility datathrough a clearinghouse. This data then transfers the two-insurance carrier of the patient and flows through the provider’s practice management system (). This helps the provider to know more about the coverage of the patients. The second process in revenue cycle is registration that ensures 100% accuracy of patients’ data from start to finish and also helps providers to collect and save vital information such as phone number, date of birth, guarantors, and insurance information of their patties. The Charge Capture is the next step that allows for the information to automaticallyflow into the practice management billing side based on what the provider puts in their documentation.

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The next step is the Claim Submission that allows for sending information to the insurance carrier when the charges are stored in the system. The teams can observe the charges and the CPT code and ask questions related to the matching of the procedure with the diagnosis. The next step is claim submission that includes sending information to the insurance carrier after the charges have been entered (Mohamed, 2021). In the last two steps, the first thing to do is the remittance process that includes getting the remittances back and explaining the benefits to the practice. The calculation of allowable is done here that allows providers to know their contract with the insuranceproviders. Insurance follow-up is the last stage that allows medical experts to view what is paid and not paid? For instance, they can observe the Accounts Receivable report that facilitates the insurance follow-up after knowing what is sitting in the insurance. That allows for Patients Collections that involves getting money from the pateints while they are in the clinic. This requires creating a standard policy for collecting copayments.  Therefore, each step of revenue collection is important to help the providers and the pateints get along with each other well. 

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Pricing Structure Method to Support Financial Structure Strategies 

Pricing strategies provide vital signal to healthcare organization leaders to determine their right resources for an accurate delivery of services. Health care industry is not a classic marketplace for goods and services. Customers are often referred to as “health insurers” or purchasers who possess lesser information that makes them less sensitive to prices (Sousa et al., 2019). Provider payment systems are based on specific payment methods and supporting mechanisms. The price shows that the cost of delivering services is covered and it also offers vital incentives to medical centers and hospitals. For instance, our hospital serves a number of low-income patients to ensure coverage and quality. The prices are often adjusted to achieve the set objectives of this healthcare organization.  In the US, the prices are determined though the method of individual negotiations. This means that the prices are agreed upon through negotiations between patients who pay and the healthcare insurers. The price negotiations are also popular in the United States due to recent pressures to increasing consumer sensitivity to prices (Senthilkumar et al., 2018). This means that the providers and the customers will have higher bargaining powers. Therefore, in such type of a system, under such a system, the healthcare organization agrees to accept lower rates from the insurer to meet the goals of hospital to improve their revenues and facilitate pateints. This helps to build good reputation and there is a price discrimination factor that is discussed in the next section. Moreover, administrative costs are also increasing due to health insurance marketing expenses and billing tasks. This is indeed a drawback to the organization in terms of promoting welfare. Therefore, it is vital to understand that in the US, private insurers use Medicare rates for individual price negotiations. This shows that government-bases Medicare system has greater impact or an influence over the prices paid by the private insurers. In our organization, prices are negotiated individually for various healthcare services provided to the patients.  In terms of selecting a pricing system, the healthcare organization can select the system in which the organization agrees to accept lower rates from the insurer to meet the goals of hospital to improve their revenues and facilitate pateints. This is because the other pricing systems focus less on the needs of hospital and the costs associated with the functions. This system ensures that the hospital will help the patients with affordable price structures and they will benefit the most from the insurance companies while giving the organization a chance to gain maximum profits. 

Factors to Consider for Insurance Contract Negotiations

In the US, the pricing system is different than Australia where practitioners are paid by fee-for-service based on Medicare benefits. This means that our organization does not provide rebates to the patients. In the US system, Medicare severity diagnosis related groups are observed and we create a list of those groups of patients suffering from diabetes or other similar diseases. This shows that each patient has a relative weight which helps to reflect their overall expected cost of interventions (Osoro, n.d). For instance, renegotiating contracts are vital according to circumstances.The following factors are vital to consider: 

MHA FPX 5006 Assessment 2 Attempt 2 Revenue and Reimbursement

  1. Scarcity of healthcare services should be taken advantage of that allows insurance organizations to work with us. 
  2. We have specialty value in providing mental healthcare services and PSTD and hypertension psychotherapy services that distinguishes us from others in the same area. This way, insurance organizations can make more money from our specialists’ skills. 
  3. We must also care for the direction of insurance companies and knowing their interests are vital. This means that if the insurance organizations are pursuing other practices, they may use our reference to build a mutually beneficial contract. 
  4. Moreover, if the negotiations are not going to work well or have risks, then our management must decide when to take the South route and discontinue in the long-run by hiring experienced attorneys (Mohamed, 2021). 

This means that the insurance businesses are complex and there are social factors which must be considered. Since most patients avail insurance benefits out of feat that they may lost their money on healthcare, insurance providers must also show genuine interest in the needs of patients. The client would rather like to be safe than risking financial resources earned in limited amount. Insurance benefits should be explained to the customers to make them visible and dynamic because many people cannot understand specialized insurance policies. 

The major payer categories in the US are of three types such as the government payers, private insurances, and commercial payers. Regarding medical billing training and education, it is vital for the organization to know about each of these payers. These organizations can offer plans such as indemnity, managed care, and consumer driven plans. The most major payer is Medicare that is federal government payer for patients over 65 and with disabilities. It also provides health insurance for retirement age. Another government payer is Medicaid that facilitates low income and disabled people and is administered by the state government (Kamble, 2018). Each state has own rules regarding coverage benefits. It covers military persons and retired military professionals too. 

Process for handling private pay and charity care

In order to suit the financial strategies of the organization, it is vital to consider the operations of private and charity pay insurance organizations in the US. Private care insurance option provides more choices to help customers in private as well as public hospitals. It makes treatment faster that allows customers to respond well to government taxes (Gupta, 2020). This means that our team must know their financial goals, risk and financial quality metrics to improve relations with payers that will make a difference in our overall success. These private and charity payers collect a premium from employers and pay for services regarding their policies. Medicare is the largest payer in the US with MA (Medicare advantage) continues to enhance. For instance, we need to find common grounds with these payers. Every clinic can start with reimbursement and we need to reduce administrative hassles. This means that knowing the needs of complex patients by analyzing data is crucial. The insurancecompanies know a lot about us from medication, equipment, treatment, specialty to emergency visits. Therefore, it is vital for treating the payers with respect and come prepared in all meetings with them. These tactics will fit better into the financial strategies of the organization in terms of creating better relationships with the endurance organiziatons. Private pay or charity care process is made simple when more focus is given to the needs of customers suffering from financial issues and also to the costs of the organization. 

Billing software system recommendation

There are several benefits of an integrated medical billing system. Many healthcare providers in the United States use medical billing software which serve as automation tools to record billing tasks, patient insurance, and claims and processing information. The two best billing software are Azalea Health and Kario tools compared for consideration for our use. For instance, we have analyzed the benefits and limitations of each of these tools. Azalea Health tool is becoming more popular because it is transformation IT health platforms to connect with providers in the community and patients as well. This is a full-fledged cloud-based system that delivers electronic health record which is integrated with our telehealth facilities (Abu-Eliz et al., 2020). Whereas, Kario is good software that is more suitable for undependably running clinics that offers a web-based practice management tool. It also integrates with core functions of a healthcare organization, but has a higher price compared to Azalea to suit our financial needs ($589.00). 

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How Billing Process Changes Benefit for Physicians

The medical billing automation system is a vital part of our continued successful operations. Our organization is hugely relying on translating patient visits into real-time reimbursements using this software system (Gupta 2020). It improves efficiency and provides several benefits to providers as well as the pateints: 

  • The integrated EMR billing medical software is vital for reducing time and it only needs a nurse to input data in one place. 
  • It saves money for the organization by reducing paper work and also reduces administrative workload (Mohamed, 2021). 
  • It allows us to keep our billing conventions updated
  • It provides power to nurses to reduce human errors and provide accurate prescriptions of medications. 
  • It allows for better reporting procedures across departments with more information to close financial gaps. 
  • It helps to reduce pateints’ dissatisfaction with more patient-focused approach. 


Abu-Eliz, I., Hassan, A., Nazimuddin, A., House, M., & Abd-Alazar, A. (2020). The benefits and threats of blockchain technology in healthcare: A scoping review. International Journal of Medical Informatics142, 104246.

MHA FPX 5006 Assessment 2 Attempt 2 Revenue and Reimbursement

Gupta, A., &Niranjan, A. (2020). Hospital management and control system. European Journal of Molecular & Clinical Medicine7(06), 1079-1085.

Kamble, S. S., Gunasekaran, A., Goswami, M., & Manda, J. (2018). A systematic perspective on the applications of big data analytics in healthcare management. International Journal of Healthcare Management.

Mohamed, A. A., El-Bendery, N., & Abdo, A. (2021, October). An Essential Intelligent Framework for Regulatory Compliance Management in the Public Sector: The Case of Healthcare Insurance in Egypt. In Proceedings of the Computational Methods in Systems and Software (pp. 397-409). Springer, Cham.

Osoro, G., & Wairimu, K. L. Analysis of the relationship between information communication strategy and financial performance of healthcare insurance companies in Nairobi County, Kenya.Journal of medical systems43(9), 1-10.

 Senthilkumar, S. A., Rai, B. K., Meshram, A. A., Gunasekaran, A., &Bendery, S. (2018). Big data in healthcare management: a review of literature. American Journal of Theoretical and Applied Business4(2), 57-69.

Sousa, M. J., Pesqueira, A. M., Lemos, C., Sousa, M., & Rocha, Á. (2019). Decision-making based on big data analytics for people management in healthcare organizations. Journal of medical systems43(9), 1-10.