In your response posts to at least two other peers’ initial posts, address the following: Describe how the peers’ responses impact healthcare reimbursement from the organizat

Gayle Discussion:

Good afternoon class,

My name is Gayle, and I am finishing up my final classes for my master’s in healthcare administration.  I received my bachelor’s with SNHU and am excited to be at the home stretch.  I currently work as an office manager in a behavioral health clinic for Catholic Charities.  I work a part time job as well on the weekends and have 2 children 7 & 15 years old.  I am looking forward to eventually having some me time.

Each of the four questions asked by the patient are important because they determine the cost owed by the patient, and what is covered by the insurance company.  Many insurance companies require that a patient meets their deductible which is defined as “a specified amount or capped limit you must pay first before your insurance will begin paying your medical costs.” ( How Do Health Deductibles Work?, 2021).  With some insurance plans patients are still responsible for a percentage of certain procedures.  It is imperative for patients to understand their plan to decide what is affordable. It is also important to make certain that prior authorizations are to be completed prior to treatment being rendered. Failure to do so can lead to insurance companies denying claims.  A prior authorization is asking permission with supporting documentation to perform a service prior to providing said service. Facility charges, physician charges and any other incurred charges are important questions to ask so the patient can make sure that all these charges are covered by their insurance company.

Procedural codes are determined by “costs associated with a specific procedure are assembled into categories and compiled into a base figure with any additional indirect components or overhead costs taken into account. The resulting figure is then corrected for the institution's collection rate to assure complete recovery of all costs.” (Anderson, 1985) Although the article is out of date, it still represents an accurate description.

Because all insurance plans are very different and the patient scheduling department may not have the answers, I always advise patients to call their insurance company directly to find out what they are responsible for.  I will also provide them with the proper procedure and diagnosis codes to ensure they are receiving the most accurate information.  With the patients having the correct information and charges for the treatment they receive; they will make sure they are able to afford the procedure and provide payment prior to having services rendered.

 

References

Anderson, D. J. (1985). Procedural cost accounting: a survival tactic.  Radiology Management,  7(3), 19–24. https://pubmed.ncbi.nlm.nih.gov/10272541/#:~:text=The%20costs%20associated%20with%20a%20specific%20procedure%20are

  How Do Health Deductibles Work? (2021, April 20). Healthline. https://www.healthline.com/health/consumer-healthcare-guide/how-do-health-insurance-deductibles-work#definition

Dustin Discussion:

Hello Class,

My name is Dustin Chang and I’m 24 years old and residing in Aurora, Colorado. I currently work as a part-time registrar at HCA in Colorado. I am currently pursuing my master's in science in Healthcare Administration in the business side of healthcare such as being a manager, health specialist, or human resource in healthcare. As a register, I deal with patients who come to the ER with their health insurance and use a system that can upload which health insurance they have. 

All four questions are very important when explaining to patients the cost of procedures and how much their health insurance will cover, other medical costs, and how much the patients could pay out of pocket. Pre-authorization is key because “healthcare providers get approval from your insurance plan before prescribing medication or medical procedure” (Bihari, 2023).” failing this authorization could affect insurance companies denying claims which will cause many issues. 

As for detectables, many health providers would prefer seeking medical procedures for patients towards the end of the year which resets at the beginning of the new year. “Once you’ve met your plan’s deductible, you may or may not face copays or coinsurance depending on the plan’s out-of-pocket maximum” (O’Brien, 2022). Explaining to patients that deductibles would work best at the end of the year which could have them paying less. 

One of the hardest parts for patients when discussing insurance coverage is does their insurance covers provider expenses or even facility expenses without knowing any of that information. The physician's charge depends on which medical procedure will be used and how the patient's health insurance will cover the medical expenses. Most insurances do cover medical procedures and it’s important that the medical provider explain to patients the need for the medical procedure and the cost will be. Working as a registrar and checking in patients with prepared MRI or other medical procedures, the insurance is usually covered but most patients tell me they had to pay some sort of out-of-pocket cost. The facility charges are at most healthcare facilities and explaining to patients that facility charges are used for the “cost of running the facility, such as supplies, equipment, exam rooms, and other services not related to physician bills' (CHI Franciscan Health 2024). Explaining to patients about facility charges is important because there is a difference between physician costs and facility costs. 

Patient perception towards payment can affect the revenue cycle for a healthcare organization is crucial because not explaining all the health information such as insurance for medical procedures to patients could cost the hospital money. Patients can choose which medical facility to go to get their procedure done. The one key element is how much insurance will cover a medical procedure prescribed by their medical provider. There are many different medical bills that are often sent to patients and if the healthcare organization explains well which insurance covers which cost, whether they have met their deductible, and how much they have to pay out of pocket are all important decisions for patients. Not explaining to patients payment towards their medical procedures could impact revenue for healthcare organizations which could mean debt. Working as a registrar, so many patients tell me the importance of their financial plan when getting a medical procedure and how the hospital explains all medical costs that will be included which makes the patients less stressful. Explaining insurance coverage to patients is important when delivering the best health care and decreasing high medical expenses that patients don’t want to see. 

Reference 

Bihari, M. (2023). Prior Authorization: Overview, Purpose, Process. Verywell Health. Retrieved from:  https://www.verywellhealth.com/prior-authorization-1738770

O’Brien, S. (2022). Here are 4 ways to take advantage of your health-care expenses before the end of the year.  CNBC. Personal Finance. Retrieved from:  https://www.cnbc.com/2022/11/13/4-ways-to-take-advantage-of-your-health-care-expenses-before-year-end.html

CHI Franciscan Health. (2023). Understanding Facility Charges. Retrieved from:  https://www.vmfh.org/content/dam/vmfhorg/pdf/legacy-chi/website-files/locations/st-michael-medical-center/pdf/Harrison_UnderstandingFacilityChargesFAQs.pdf