Discuss when or where the revenue cycle process begins for inpatient and outpatient/ambulatory services.
Revenue cycle in a health care is a complex web that starts when a patient visits a health facility for medication and ends when the payer settles the bill. This process can take a long time than one could think. Revenue cycle starts at admission desk where the patient data are captured. These data define who the patient is, reason for visiting the facility and who will fund the services provided. If the patient data is not corrected captured the reimbursement claim may be declined due to incorrect details. Also, insurance providers want to know which services the patient who to them is the policy holder received. The service providers can decline reimbursement if the policy does not cover what was provided. This may make patients to shoulder huge medical bills (Hawkins, 2021).
Describe how inpatient charges are captured in an inpatient setting.
Inpatient charges are charges imposed on admitted patients. These charges are captured immediately the services are given. The specialist giving the care need to record the codes for the services given as they occur. The same happens for all the supplies the patient uses. For example, a doctor can spend 20 minutes assessing the patient and then later diagnose the patient with a given medical condition like hypertension. In this case the doctor need to record two different things; the time for consultation and diagnosis (ZAMOSKY, 2015).
If the charges are not captured as they occur some may miss to be counted when calculating the total bill. Also, failure to capture the charges as they occur may result to incorrect codes being used during final calculation. This may make the patient dispute the charges.
Describe how ambulatory charges are captured in an ambulatory setting.
Ambulatory charges are records of cost of care given to a patient who is not admitted. These charges include use of the facilities, surgery procedures and care given by the medical professionals. These charges are captured from the time the patient visits the facility. All the facilities the patient uses are recorded, the procedures performed and care given. These charges are a bit lower than inpatient charges. This is because the patient does not spend the night in the facility (Galarraga, 2015).
Describe the importance of the information in the physician office encounter form.
Encounter form is the form that capture the information of the patients visit to a health facility that include patient information, visit information, payment method and diagnosis and procedures codes. This information is important when submitting reimbursement claims. The information on this form acts as the basis of billing (Harris, 2009). Therefore, the encounter form is important as without it there is no reimbursement claim that can be submitted.
Analyze the similarities and differences between the UB-04 and the CMS-1500.
UB-04 form is the standard claim form used by institutional provides to bill inpatient and outpatient medical claims. While, CMS-1500 is the standard form used to submit medical claims by non-institutional providers like doctor’s office. The two forms were developed by CMS and can be used to submit claim to both Medicare and Medicaid, and health insurance providers (Michigan.gov, n.d.). The major difference between these two forms is that CMS-1500 is used by physicians to submit claims, while, the hospital uses UB-04.
Discuss one reason a medical claim would be denied?
One reason for medical claim being denied is the requested service being not included as a cover benefit. For example, cosmetic therapy and some elective surgery are not included in many policy covers. Also, state definitions of essential health services make some services not to be included in the Affordable Care Act (Davis, 2022).
Revenue cycle in a health care is a complex web that starts when a patient visits a health facility for medication and ends when the payer settles the bill. This process can take a long time than one could think. Revenue cycle starts at admission desk where the patient data are captured. These data define who the patient is, reason for visiting the facility and who will fund the services provided. If the patient data is not corrected captured the reimbursement claim may be declined due to incorrect details. Also, insurance providers want to know which services the patient who to them is the policy holder received. The service providers can decline reimbursement if the policy does not cover what was provided. This may make patients to shoulder huge medical bills (Hawkins, 2021).
Describe how inpatient charges are captured in an inpatient setting.
Inpatient charges are charges imposed on admitted patients. These charges are captured immediately the services are given. The specialist giving the care need to record the codes for the services given as they occur. The same happens for all the supplies the patient uses. For example, a doctor can spend 20 minutes assessing the patient and then later diagnose the patient with a given medical condition like hypertension. In this case the doctor need to record two different things; the time for consultation and diagnosis (ZAMOSKY, 2015).
If the charges are not captured as they occur some may miss to be counted when calculating the total bill. Also, failure to capture the charges as they occur may result to incorrect codes being used during final calculation. This may make the patient dispute the charges.
Describe how ambulatory charges are captured in an ambulatory setting.
Ambulatory charges are records of cost of care given to a patient who is not admitted. These charges include use of the facilities, surgery procedures and care given by the medical professionals. These charges are captured from the time the patient visits the facility. All the facilities the patient uses are recorded, the procedures performed and care given. These charges are a bit lower than inpatient charges. This is because the patient does not spend the night in the facility (Galarraga, 2015).
Describe the importance of the information in the physician office encounter form.
Encounter form is the form that capture the information of the patients visit to a health facility that include patient information, visit information, payment method and diagnosis and procedures codes. This information is important when submitting reimbursement claims. The information on this form acts as the basis of billing (Harris, 2009). Therefore, the encounter form is important as without it there is no reimbursement claim that can be submitted.
Analyze the similarities and differences between the UB-04 and the CMS-1500.
UB-04 form is the standard claim form used by institutional provides to bill inpatient and outpatient medical claims. While, CMS-1500 is the standard form used to submit medical claims by non-institutional providers like doctor’s office. The two forms were developed by CMS and can be used to submit claim to both Medicare and Medicaid, and health insurance providers (Michigan.gov, n.d.). The major difference between these two forms is that CMS-1500 is used by physicians to submit claims, while, the hospital uses UB-04.
Discuss one reason a medical claim would be denied?
One reason for medical claim being denied is the requested service being not included as a cover benefit. For example, cosmetic therapy and some elective surgery are not included in many policy covers. Also, state definitions of essential health services make some services not to be included in the Affordable Care Act (Davis, 2022).
