COUN 5106 Assignment 1 Review and Assessment

Sample Answer for COUN 5106 Assignment 1 Review and Assessment Included After Question

Write a 3-4-page proposal for billing changes, and explain how the proposed changes will benefit the organization, the physicians, and the patients. Note: The assessments in this course build upon each other, so you are strongly encouraged to complete them in sequence. Show Less By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: •Competency 1: Develop financial strategies to address dynamic environmental forces. (L24.2, L24.5, L17.2) ◦Develop a step-by-step process for a revenue cycle. ◦Recommend a pricing structure method. •Competency 2: Analyze the cost and revenue implications for organizational changes due to environmental forces. (L18.2, L12.1) ◦Explain the factors to consider for insurance contract negotiations. ◦Explain a process for handling private pay and charity care. ◦Recommend a billing software system. ◦Explain how billing process changes benefit physicians, clinics, and patients. •Competency 4: Communicate in a manner that is scholarly, professional, and consistent with expectations for professionals in health care administration. (L6.1, L6.2, L6.3, L6.4) ◦Write content clearly and logically with the correct use of grammar, punctuation, and mechanics. ◦

Format citations and references using the APA style. Suggested Resources The resources provided here are optional and support the assessment. They provide helpful information about the topics. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. MHA-FP5006: Health Care Finance and Reimbursement Library Guide can help direct your research. The Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you. The chapter in the following book contains information on revenue cycle management: •Harrison, C., & Harrison, W. P. (2013). Introduction to health care finance and accounting. Clifton Park, NY: Cengage Learning/Delmar. Available in the courseroom via the VitalSource Bookshelf link. â—¦Chapter 11, \”Revenue Cycle Management,\” pages 197–212. The chapters in the following textbook contain information on billing and coding for health services, the financial, legal, and regulatory environment for health care organizations, revenue determination, and managed care: •Cleverley, W., & Cleverley, J. (2018).

The clinic is a conglomeration of physicians who offer specialized care. Each group of physicians tried to manage their own billing process but it quickly became obvious that one billing office would be more efficient. You realize that there has been a lack of consistency in the clinic and that you will need to update the billing policies and procedures immediately. You also realize that there is always resistance to change, and you will need to provide evidence supporting the changes you plan to make. Prepare a proposal for billing changes that you would present to the physicians. You will need to support each proposed change with relevant evidence to assure buy-in from the physicians. There is no specific format you must follow for this assessment, but be sure that your proposal is clear, logical, and succinct. Follow APA guidelines for any in-text citations and references. Include a title page and reference page.

A Sample Answer For the Assignment: COUN 5106 Assignment 1 Review and Assessment

Title: COUN 5106 Assignment 1 Review and Assessment

The success of any healthcare institution is dependent on various aspects of systems working together. The revenue cycle management, which encompasses the billing system, depicts a crucial department that cannot be given a blind eye. Essentially, proper management of the financials of any healthcare organization determines whether or not it remains afloat. This essay, therefore, proposes a step by step account of the billing process, determination of the pricing structure, negotiating the insurance contracts, and handling of private pay and charity care.

The Revenue Cycle

To have the cycle functioning optimally, there should be an understanding that there is a need for system integration, which essentially combines all the electronic health records for the patient, billing, accounting, and collections. The cycle begins with sourcing for the appropriate RCM software. The software can be installed in the organization servers then managed by competent members from IT (Magray, 2016). On the other hand, it would be worthwhile to hire third-party experts to run the system if the organization expands the capacity to bring on board satellite affiliates to the institution.

Patient pre-authorization is then put in place, which in this case, efforts are made to ascertain if there are any doubts about the coverage. The necessity of the prescription, procedure, or service is determined in this step. In the next step, the eligibility and verification of the benefits are done, for instance, through secure channels with the help of a dedicated RCM software. Claims are then submitted in the next step, which is done automatically by using appropriate software. 

Subsequently, payments are posted after successfully submitting the claim. The billing in this respect is done through the Electronic Data Interchange (EDI). Putting in place the appropriate denial management strategies is essential to keeping track of any claims that the insurer has turned down. The denial management helps to determine possible reasons for denial of honoring claims and therefore address them. Finally, working without reports would render operations futile. The software thus helps generate customized reports, detailing the management of information and the key performance indicators to determine whether or not the team is meeting targets.

Determining a Pricing Structure

The pricing structure settled on should be robust and straightforward at the same time. In this case, therefore, the market-oriented pricing structure should be explored. This option offers opportunities to capture a share of the market, create significant loyalty, increase demand through the utilization of economies of scale, and even stifle competitors out of the market. The strategy also confers some advantages in the long run. For instance, it can be combined with other pricing strategies to form a blend of more efficient pricing. It also offers an opportunity to increase the prices while at the same time monitoring competition. Further, this method helps to maintain operations to avoid being faced out by the competitors.

Several factors ought to be considered when determining the pricing structure for the healthcare organization. Competitors rank top as they determine whether the business could set prices independently or dependent on other healthcare organizations. The costs incurred in acquiring equipment and delivering services to the patients should also be factored in when pricing. There should also be a consideration of the state of the economy since people would be unwilling to spend when the economy is unfavorable, thus poor business.

Negotiating Insurance Contracts

Insurance plans are highly negotiable, and when doing so, there is a need to factor in some considerations. First, always consider the other party in the negotiations, determining what the payer is most concerned about, for instance, the ancillary services, then utilize them appropriately. Payers always look for cost controls and predictability, and therefore, the healthcare organization should be able to demonstrate that.

The availability of clinical data is also crucial since payers would need it as proof of compliance with clinical practice and disregard for unnecessary and expensive services. There is also a need to consider the contract language used since some payers demand prices that match public rates like Medicaid. Also, consider the appropriate authorization for the treatment course, the time frame allowed to file an appeal, and the period required to submit it. The relevant payer categories to consider would include both public and private. Important ones include Medicaid, BCBS, and Medicare.

Private Pay and Charity Care

The first undertaking when handling the private pay patients is to ensure the availability of a formal policy that is read to them to facilitate comprehension of obligation. The payment for the services by private option would be handled on a case by case basis. The private pay individuals would discuss with the presiding physician in advance regarding possible adjusted fee schedules. Later, there would be an arrangement for payment plans, like percentage charge, and the physician fee only limited the patient’s ability to pay. Before delivering the services, the patients should then sign promissory notes and make down payment in case of expensive procedures.

Regarding charity care, there ought to be guidelines and criteria definitions. Policies ought to be in place regarding the patients who suit to be considered for charity. Once determined, all medical professionals should be involved equally in rendering their services. Each of the cases should be rotated evenly to all the nurses and physicians assigned in every rotation order. The costs incurred in delivering charitable services are considered bad debts, collected, and then sent to the collection agency.

Web-based Billing Software System

QuickBooks software is appropriate billing software that offers acceptable standards in healthcare practice. It is capable of accepting business payments, carrying out the payroll functions, and managing and paying the bills (Stamper, Hartley, & Morrison, 2019). The software is also able to track the sales and profits, and it is capable of scheduling recurring payments, which saves time.

Benefits of the Changes to Physicians, Clinic, And Patients

When the RCM services provided are efficient, the physician has ample time to focus on improving healthcare services and improving the efficiency of the practice. Further, the physician’s revenue is also sustained since it is unlikely that losses would be imminent. The clinic stands to benefit significantly from streamlined operations since there would be more transparency and control over the financials. There are also reduced costs associated with the in-house operations and hence increasing the profitability of the clinic.

An efficient RCM allows for Account Receivables (A/R) reconciliation and hence follow-ups enabling the care providers to focus on delivering patient care. The clinic would also benefit in the sense that there are reduced billing errors when an appropriate software is in place; this goes a long way to build the reputation of any healthcare institution (Landman, 2016). A useful software impacts the patient because a lot of time is saved when verifying payments, and hence services are rendered fast.

When professional billing agents help in verification of all details like insurance compliance, patient enrolment, diagnosis, and treatment, there is little room for the occurrence of errors, and this increases the level of patient satisfaction. In the case of private patients, an efficient system protects them from incurring unnecessary expenses due to erroneous summations.


Landman, J. H. (2016). The value of behavioral health. Healthcare financial management : Journal of the Healthcare Financial Management Association, 70(12), 68–69.

Magray, N. (2016). SPORT FISHING, AN OPPORTUNITY FOR PROMOTION OF ADVENTURE TOURISM IN JAMMU AND \R\Nkashmir. International Journal in Management and Social Science, 4(11), 12. Retrieved from 4,ISSUE 11,November,2016

Stamper, J., Hartley, P. A., & Morrison, M. (2019). U.S. Patent No. 10,346,587. Washington, DC: U.S. Patent and Trademark Office.