Like most businesses, hospitals must be able to catalog, appropriately charge, and reconcile all services provided to its customers. In a hospital’s case, however, the patient is the “customer” and each patient that passes through the doors of a hospital will experience a different encounter. Imagine the monumental task of making sure that each patient is charged comprehensively and compliantly for all services rendered and supplies and pharmaceuticals used. In a hospital, this task is monumental in that it is also further complicated by the fact that each patient may have unique insurance coverage and billing requirements that make the seemingly straightforward, but yet time consuming, act of patient charge capture an intricate and inefficient event which often leads to lost revenue. Patient charge capture in a hospital setting consists of complex and disjointed systems, operational activities, and clinical processes.
Relative to these complexities, the hospital charge capture process is often difficult and subject to a variety of breakdowns. After patient services are rendered, it is commonly the responsibility of clinical staff to precisely document the five Ws: “who”, “what”, “when”, “where”, and “why” of that patient encounter and then accurately translate the complete patient encounter to charges. While it is often clinically clear what patient services have been rendered, specific payer billing requirements and government regulation frequently drive “how” services should be documented in the patient record and subsequently reported on the patient bill (claim) in order to be paid. The ability to satisfy payer documentation and coding requirements necessary to receive appropriate payment is difficult to administer. It is these intricacies related to charge capture and billing processes that create a plethora of opportunities for breakdowns in the revenue cycle which often result in the loss of reimbursement.
This document specifically addresses some of the common contributing factors for lost charges in the middle revenue cycle and how some organizations are mitigating this risk.
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