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Background: HealthCare Solutions is a mid - sized healthcare organization providing a range of medical services. Despite having a decent patient volume, the organization faces
Background: HealthCare Solutions is a midsized healthcare organization providing a range of medical services. Despite having a decent patient volume, the organization faces significant challenges in managing its revenue cycle effectively. Perceived Problems: The orderentry system, charging system, charge description master, and billing software do not communicate with each other which sometimes prevents accurate information from being shared from one system to another. One situation that keeps reoccurring is that registration clerks update patient demographics and insurance information but this information sometimes makes its way to the billing system and sometimes does not. Also, some of the charges for laboratory tests are not being correctly captured in the billing system. Patients have been calling repeatedly about incorrect bills and are not getting satisfactory explanations about how to read their bills, what the insurance companies are responsible for, and what the patients are responsible for about their financial responsibilities and insurance coverage adequately. This lack of transparency contributes to confusion among patients, leading to delayed or missed payments. Patients often receive bills without clear explanations, causing frustration and disputes. The diagnostic and procedure codes are frequently incorrect on the bills. The Chief Financial Officer does not know why the claims are being rejected by the insurance company. Are the coders doing a poor job or is the documentation not available in the patients medical records? When the claims are denied, they pile up in the Revenue Cycle Managers office and frequently dont get rebilled within the allowed Medicare and insurance timeframes.
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