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HCM345 Healthcare Reimbursement

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The billing and reimbursement in health system is complex and it is essential to provide transparency to the patients. It will empower them to make the right decisions and help in seeking the right financial help. The access to the patient will develop the tone towards perception of patent in the care journey. Some of the data needed for the effective patient access are schedules, financial clearance, needful registration, and patient collection (Carlo et al., 2019). The exceptional customer service will include the verification of insurance coverage, development of treatment estimation, authorization on referrals, provision of other financial options and determining any financial obligation associated with the out-of-pocket expenditure of patients.
 
Healthcare settings are dependent on the third-party policies and therefore, any changes or billing process for PFS or administration need to be adhered with their requirement for maximizing the benefits from the reimbursement. The third-party helps in stabilizing the healthcare costs and funds, it also assists in promoting, preventing along with providing the instant resolution for effective payer healthcare services (Hawkins, 2018). The key areas of review will include the effective and accurate amount of information. The adequate information will help both payer and service provider to understand the eligibility criteria, responsibility of patients, verification method, collection of capital along with procedure towards delivering or seeking care services. Such key areas are essential as it helps in better understanding towards the financial obligations. It also helps patients towards gaining the complete knowledge of third-party and reimbursement procedure and seek adequate opportunity for the same.
 
For effective follow-up of the staffs, it is essential to develop and design the follow-up calls that will help in enhancing the clarification and impose the documentation towards medical records (Chung et al., 2018). Therefore, documentation is the most evident element for following up with the staffs and effective monitoring will ensure the structure is followed and successful. For periodic review of procedure, the compliance plans will be effective as it helps in reducing the needful for audits. The planning will help in reducing the number of false claims and assist in preventing the ethical conflicts. The initial step is designing of policies, standards and protocols for conducting the plan and second step include the compliance officer to develop committee for effective provision of oversight program. The third step will be delegation of tasks and authorities and fourth step is educating the employees along with developing the effective communications. The fifth stage will be designing monitoring and evaluation followed by sixth stage of identifying any gap and developing corrective action. Hence, it will be continual compliance plan to ensure the essential compliance (Green, 2018).
 
The new managed care contract will help in enhancing the performance of financial strategy.  To negotiate with newer contract, it is essential to consider the role of payer should be developed for any form of negotiation. When the organization is developing the relationship, it is also essential to identify the needs and interest of the payer. Other stakeholders such as physicians or care providers should also be including within the approach of negotiation.
 
Every associated stakeholder such as care providers, health plans, individuals, plan sponsor and other are invested and considered within the managed care contract. Each operation staff is considered and connected prior to any associated payer negotiation. The implementation of survey that include insurance verification, denial management staffs, medical records along with billing and case management will be considered as major role.
 
The new managed care will have positive impact on the overall reimbursement and revenue. The major and significant reason is its ability to successfully negotiating the contracts and providing the overall ranges of opportunities in the revenue models and products. It is important to note that effective managed care will improve patient satisfaction and amplify the patient engagement. It will help in automatically develop and increase the revenue due to continual gaining of the services and better patient outcome (Palimaru et al., 2021). The regulation along with ethical standards are the key crucial elements that will help in overall and better understanding of the ethical standards. The internal audit is considered as the key element that will help in identifying any gap areas or mistakes that will help in effective billing and coding. The internal audit will also help in monitoring and checking the adherence and requirement needs as per the ethical needs and standards. Improper audit or absence of audit may result in poor monitoring of the compliance that are associated with the ethical needs and standards (Xima, 2016). It will also result in loss of money and the overall procedure of reimbursement may takes longer. Therefore, internal audit will help in effective compliance with the needed regulations and other associated ethical considerations.

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