Revenue and Reimbursement

Introduction and Overview

Billing refers to the process ofcreating an invoice for the goods or services. The process involvesboth front office employees such as receptionists as well as backoffice employees including the medical biller. In healthcare, billingprocess includes reviewing and analyzing insurance reports as well asorganizing billing forms. Organizations keep on conducting a periodicaudit to ensure consistency of the office billing policies. Hence, anoffice manager is responsible for setting up measures destined todetermine the eligibility of financial reports. In return, it helpsin the achievement of the organization’s primary goal that isconsistency. The paper aims at suggesting ways that ensure thebilling policies and procedures are up to date.

Revenue cycle

Revenuecycle involves the following phases:

• Stage one: Patientregistration

The revenue cycle begins withpatient registration, which involves a phone call for an appointmentrequest. The front-office staffs then conduct a telephone interviewwith the patient to compile a billing and insurance information.Then, they request the patient to participate in online registrationdone via the company’s website. (Bragg, 2013). The patient`sinsurance coverage is examined in the process.

• Stage two: Chargecapture

It involves transferring patientcharges to the practice management (PM) system. An electronic systemis utilized to avoid redundancy and inconsistency.

• Stage three:Computerized payment posting

Automated payment posting reducespaperwork in the organization. In addition, it regularly involvespayers, clearinghouses, and software vendors regarding new onlineservices as well as incorporating new payer in the form of electronicdelivery and automatic posting.

• Stage four: Insuranceeligibility assessment.

It entails assessing andintegrating automatic insurance coverage verifications intoworkflows. Clearinghouse services are used to develop the appointmentschedule in advance during the batch process. In the case of walk-inpatients, utilization of verification via the PM structure isrecommended. Additionally, incorporating a verification frameworkestablishes a history within the patient`s record that upholdsfollow-up collection activities in case of any discrepanciesexperienced by the payer.

What is a pricing structure?

Pricing structure refers to aconsistent and designed approach to pricing goods and services toattain business and market objectives. Pricing structure determineshow a firm progresses and perceived by the clients. In this case, asan office manager, I may opt for economy pricing. This type ofpricing minimizes the expenses related to marketing and production tomaintain low prices. It helps to attract a particular section of themarket that is responsive to prices. Moreover, economy pricingenables the firm to compete favorably in the industry.

Methodology to pricingstructure

While deciding on the type ofprice structure a firm should adopt, there are some of therecommended methodologies to be taken into consideration as discussedbelow:

• Cost-based pricing itrefers to pricing techniques whereby some amount of targeted profitmargins is included to the cost of the goods or services to get thefinal price.

• Markup pricing it thepricing procedural whereby the fixed percentage cost of the goods isincorporated into the price of the goods or services to obtains theselling price.

• Demand –based pricinghere, the price of a good is decided upon by taking consideration itsdemand.

Some factors determine prices ofgoods and services in the market as illustrated below:

• Competitive pricing, thisis the price that is being used by the competitors to charge theirgoods and services. For instance, if all the rivals are charging $10for a particular good or services, then that the price the firmshould charge to enable it to compete favorably in the market.

• Market forces, theseforces dictate the type of prices to be adopted in the market. Forinstance, if demand is high exceeding supply, price increases.Likewise, if supply exceeds demand, prices decrease (Santerre,&amp Neun, 2012).

• Business objectives: thegoals of a particular organization influences the kinds of prices tobe charged on goods and products. For instance, if a particularcompany wants to gain a competitive advantage in the industry, it mayconsider charging its products lowly compared to its competitors(Feinschreiber &amp Kent, 2012).

Considerations for negotiatinginsurance contracts

The first step in negotiatinginsurance contracts is undertaking the necessary homework. In thiscase, it is important to check up those contracts that requirerenegotiated through calculating the revenue per visit. The next stepafter doing your homework is looking for the culprits. After havingcalculated the revenue per visit, here the manager will concentrateon identifying that insurance corporation that is causing theorganization most financial grief. The third and the fourth steps arereading the contracts and arranging for meeting respectively. In thethird step, the principal activity is going through all the insurancecontracts and identifying the one based on healthcare (Marburger,2012). There is a need tofamiliarize with the contents of this insurance. In the fourth step,the manager needs to arrange for a meeting with the respectiverepresentatives from the healthcare. In this stage, the terms andconditions of the contract are discussed. After having held ameeting, the next step would be to wait for the response from therepresentatives. The last step is making follow-ups to ensure alldetails are taken into consideration and regulations are adhered.

Considerations for private andcharity care

While considering for private payand charity care, the following aspects ought to be taken intoconsideration: Set Goals for the Relationship, it involves comparingthe organization’s goals with those of the charity careorganizations. Secondly, organizations should go beyond the rates,the main objective of the any managed care concession are to obtainfair reimbursement for services. Nonetheless, it should not be thecompany’s major goal. Instead, it should focus on the value ofservices given by the managed care. (Bragg, 2013). Thirdly,establishing a Payer strategy before engaging in a negotiationforum, policymakers should aim at establishing a payer strategy.Additionally, reaching out to your contracting counterpart thisentails engaging in a conversation with the individual’s from payerside. It entails collecting critical information including thepayer’s objectives as well as new services or products offered bythe managed care.


In summary, the above-discussedaspects enhance the updating of billing policies and procedures.Consequently, it fosters consistency as well as efficiency enablingthe organization’s achievement of its targeted objectives alongwith facilitating satisfactions of consumers’ wants.


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Feinschreiber,&nbspR.,&amp Kent,&nbspM. (2012).Asia-Pacifictransfer pricing handbook.Singapore: John

Wiley&amp Sons.

Marburger,&nbspD.,&amp Business Expert Press.(2012). Innovativepricing strategies to increase profits.

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Santerre,&nbspR.&nbspE.,&ampNeun,&nbspS.&nbspP. (2012).Healtheconomics. Mason, OH:South-Western.