DEPARTMENTAL IMPACT ON REIMBURSEMENT 2

Departmental Impact on Reimbursement

Impact of the departments at the healthcare organization that utilize reimbursement data
Reimbursement from insurance companies is the main source of revenue for healthcare
providers. Proper management of reimbursement process is, therefore, important for maintaining
the financial health of a healthcare facility. If the departments that manage reimbursement data
are not effective, the healthcare facility risks experiencing a drop in revenue collection which
may have negative effects on its ability to fund its operations such as staff remuneration and
purchase of hospital equipment and drugs (Britton, 2015).
Type of audit to determine whether reimbursement impact is reached fully by the
departments
The type of audit required to determine whether reimbursement impact is fully reached
by the departments is internal audit. Such an audit will provide the organization with information
required to evaluate, and if need be, change its financial operations with the goal of maximizing
revenue it gets from reimbursement. An internal audit will check both account receivables and
accounts payable and look out for any discrepancies (Harrington, 2019). If there are
discrepancies, it will look out for possible causes such as level of compliance with policies and
procedures meant to ensure that the organization receives maximum reimbursement possible. If
there is compliance but there are still problems, then the auditors may recommend changes to the
facility’s policies and procedures related to reimbursement process.
Measuring impact of these departments on pay-for-performance incentives

DEPARTMENTAL IMPACT ON REIMBURSEMENT 3
With healthcare now focused on quality of care that patients receive rather than just
number of services, incentives have been established to encourage healthcare providers to
provide quality care that leads to better outcomes for patients. These incentives are provided
based on certain measures that reveal the quality of care that patients receive at a given facility.
These measures are structural, process and outcome.
Structural measure includes information that reveals preparation of a healthcare facility to
provide quality patient care. The measure evaluates information such as the ratio of physicians
and nurses to patients and the effectiveness and efficiency of the hospital’s IT system
(Mendelson et al., 2017).
Another measure is process measure. This measure evaluates how the healthcare facility
plans patient care from the time a patient arrives at the hospital to the time that they leave
(Mendelson et al., 2017). It includes an analysis of its tests and diagnosis procedures, and the
different treatment methods that it employs to bring the patient to health (Mendelson et al.,
2017).
The last measure is outcome measure. This is a measure of how effective the hospital’s
intervention measures are in restoring the health of the patient (Mandelson et al., 2017). This
measure includes evaluation of records such as hospital acquired infections, surgical
complications, and surgical mortality rates. A hospital whose data shows a drop of figures such
as surgical mortality rates and hospital acquired infections may be deemed to be providing
quality care and, therefore, may qualify for pay-for-performance incentives.
Departmental activities and how they impact reimbursement

DEPARTMENTAL IMPACT ON REIMBURSEMENT 4
Healthcare facilities provide a wide range of services to patients. Insurance providers of
the patients then pay for these services. For healthcare facilities to receive these payments they
need to have accurate documentation. This documentation is done in all the departments whose
activities affect reimbursements. These departments include clinical department, patient account
department, and healthcare information department.
It is in the clinical department that the patient receives the care that brings them to the
healthcare facility in the first place. Activities that occur in this department include verification
of the patient’s insurance details and documentation of the patient’s condition and the type of care
that they receive (Harrington, 2019). If documentation in this department is not done accurately,
the hospital risks having some of the services that it provides to patients going unpaid.
In the patient account department, the staff collect data from the patient’s records. They
then produce a patient bill using the hospital’s charge master system (Harrington, 2019). The bill
is then sent to the patient’s insurance provider for payment of services that have been provided.
Thus, if this department is slow in processing of patient bills there may be delays in receiving
reimbursement payments.
Lastly, the department of healthcare information management codes medical records of
patients. Staff at this department review charts and then assign a proper code for the services
received by the patient (Harrington, 2019). It is important that all codes are accurate because
errors at this department may result in delaying or even non-payment by the patient’s healthcare
insurance provider.
Department responsible for ensuring compliance with billing and coding policies

DEPARTMENTAL IMPACT ON REIMBURSEMENT 5
The department that is responsible for billing and coding policies is health information
management department. Patients have records that show the level of care that the hospital
provided them with. The health information management department assigns codes to this care
that the patients receive at the healthcare facility (Harrington, 2019). Staff at this department
make sure that these codes are an accurate reflection of the level and type of care that the patient
received while at the facility (Harrington, 2019). This process is important because it enables the
healthcare facility to receive full reimbursement on time.

DEPARTMENTAL IMPACT ON REIMBURSEMENT 6

References

Britton, J. R. (2015). Healthcare Reimbursement and Quality Improvement: Integration Using
the Electronic Medical Record: Comment on” Fee-for-Service Payment-an Evil Practice
That Must Be Stamped Out?”. International journal of health policy and
management, 4(8), 549.
Harrington, M. K. (2019). Health Care Finance and the Mechanics of Insurance and
Reimbursement. Jones & Bartlett Publishers.
Mendelson, A., Kondo, K., Damberg, C., Low, A., Motúapuaka, M., Freeman, M., & Kansagara,
D. (2017). The effects of pay-for-performance programs on health, health care use, and
processes of care: a systematic review. Annals of Internal Medicine, 166(5), 341-353.