The purpose of the hospital billing process is to obtain full reimbursement for services and items rendered by the facility. Reimbursement is received under unique payment terms from patients and third party payers including insurance carriers and government programs.
- What percentage of your claims require human intervention to drop to billing?
- Are all claims converted to 837 files and filed electronically?
- Do you have a defined work flow driven by technology?
- Do you have a secondary billing process in place?
- How do you identify high risk areas needing education, QA and Competency Validation?
Despite having served the community with the best health services available, receiving complete reimbursement from a variety of payers operating under unique payment terms is not guaranteed, even when a facility has correctly performed all the steps required to submit an invoice or claim form (registration, posting charges to the patient's account, chart review and coding, etc).
Each facility manages a complex array of agreements with health insurance firms, government-funded programs, and individual payers. Matching authorizations, codings, and certifications to participating provider agreements and various payer guidelines and unique reimbursement systems and timelines introduces meaningful risk to timely cash collection and facility fitness.
The billing process is made more complex by the wide variation in payer guidelines. These guidelines often affect the provision of patient services, the claim submission process, and the amount and/or timeliness of reimbursement. Compliance with these agreements is a condition for reimbursement and may include legal consequence from non-compliance.
Participating Provider Agreements
Most facilities work with various payers that provide coverage to patients including Medicare, Medicaid, TRICARE, worker's compensation, managed care programs, self-insured businesses, automobile insurance, and various heath insurance programs. Matching the services performed by facility staff to unique combinations of "Benefit Plans," "Customary Charges," "Covered Services," and the unique business processes of payers can become an ordeal for even the largest hospital.
Billing requirements too vary between payers regarding documentation, coding, claim for requirements, etc. Even the appeals processes can be very different.