Institutional Affiliation Reimbursement and the Revenue Cycle (Research Paper Sample)

Reimbursement and the Revenue Cycle
Name
Institutional affiliation Reimbursement and the Revenue Cycle
Introduction
Reimbursement is one of the most complex frameworks regarding services payment in the health care industry. The complexity is observed due to the tendency of rules that governs healthcare reimbursement to change frequently (Herbert, 2012). This is highly observed, especially in the government paid systems due to the frequency of changing of government policies. In simple terms, reimbursement refers to an act where an individual is repaid for any expenses incurred while in the line of duties while offering services on behalf of another party. Due to the complexity of the process, reimbursement framework differs from one health care to another. This paper examines the issues of reimbursement in Athena health Inc.
Meaning of Reimbursement at Athena Health, Inc
Athenahealth Inc is a San Diego based company which established in 1997 (athenahealth.com, 2016). It provides cloud-based medical services and a point of care mobile apps. At Athena health, reimbursement varies depending on the payers. For instance, the health insurance payers may carry contracts with several practices where such contracts are renegotiated periodically. In this regard, the price for services differs (either contracted by the payer or services occurring outside the system. In the reimbursement process, the ‘maximum allowed payment’ acts as the starting point that determines what an individual will pay. The payer has to adjust maximum allowed payments with the claim edits. The adjustments enable the payers either disqualify or reduce the payments for some services. Determining the obligations of the insurer/payer and the patient regarding the amount charged for a particular service is the hardest part of the reimbursement framework.Numerous packages are put in place to stipulate the refund process at Athena health Inc. for example, a ‘payment rule’ is used to determine the amount to be paid where the data reviewed are the total allowed amount and amount owed by the patient where the difference calculated is paid by the payer or insurer (athenahealth.com, 2016). As comprehending payer rules can be complex sometimes, Athena health Inc prefers using cloud-based medical billing system.
The Revenue Cycle at Athena Health
Revenue cycle refers to a recurring set of activities and processing of information relating to operations associated with the provision of goods or services and collecting cash paid in the process. The primary objective of this cycle is to ensure that the right products/ services are provided at the right place, price, and time (Diamond, 2014). Athena health revenue cycle seeks to ensure that the claim process is more efficient. The efficiency is achieved by providing insight into the system’s supply chain to ensure there is an ease in the revenue management practices. The revenue management cycle starts at physician section. At this point, the doctors attending the patient write down the kind of services required by the patient. At this point, scheduling and pre-registration take place. The next step is insurance certification where clarifications are made regarding payers credentials. This step is closely followed by charge entry submission. At this point, the difference between patients’ obligations and payer’s obligations is determined. The next step is payment posting by the hospital where the payer (third party) is expected to follow up. At this point, claim edit process takes place where elimination or reduction of prices of particular services provided is done. The last step involves clarification of patient statements and collection of payments.


The revenue cycle flowchart
Role of Various Departments in Revenue Cycle at Athena Health
For the management realize the objectives of the period of income, a variety of critical decisions must be made. The decision-making process requires the management to capture and process data from various departments (Diamond, 2014). At Athena health Inc, the revenue cycle involves several departments such as accounting and finance, the ICT department, and the human resource. The HR departments play the role of recruiting, training and evaluating all the personnel’s involved in the revenue management as per the organization’s policies. The staff ensures that the objectives of the revenue cycle are achieved. Another important department in Athena health revenue cycle is the accounting and finance. Th...