Coder Interview with a Health Care Provider

Coder Interview with a Health Care Provider Order Instructions: Select a coder/biller for a health care provider or facility and conduct an interview to review the process the coder/biller uses to satisfy reimbursement requirements for billing purposes.

Coder Interview with a Health Care Provider
Coder Interview with a Health Care Provider

Write a paper (750-1,000 words) that describes the processes used in producing a final bill. Answer the following questions in your discussion:
1. How are health care charging and pricing processes different from other industries?
2. How do private and government insurers and payers impact actual reimbursement?
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

1
Unsatisfactory
0.00%

2
Less Than Satisfactory
65.00%

3
Satisfactory
75.00%

4
Good
85.00%

5
Excellent
100.00%

80.0 %Content

65.0 % Essay Report on Interview with a Health Care Coder/Biller with the Difference Between Charging/Pricing Processes in Health Care vs. Other Industries, and Impact of Government and Private Insurers and Payers on Actual Reimbursement

Does not demonstrate an understanding of the business concepts involved in the issue, including the implications. Does not address process differences and reimbursement impacts as specified in the assignment. Does not demonstrate critical thinking and analysis of the situation, and does not develop effective answers to the questions, with rationale.

Demonstrates an only minimal understanding of the business concepts involved in the issue. Only minimally addresses process differences and reimbursement impacts as specified in the assignment. Demonstrates only minimal abilities for critical thinking and analysis of the case study, and develops weak answers to the questions, with the minimal rationale

Demonstrates knowledge of the business concepts involved in the issue, but has some slight misunderstanding of the implications. Satisfactorily addresses process differences and reimbursement impacts as specified in the assignment. Provides a basic idea of critical thinking and analysis for the questions, answers, and rationale. Does not include examples or descriptions.

Demonstrates acceptable knowledge of the business concepts involved in the issue. Satisfactorily develops process differences and reimbursement impacts as specified in the assignment. Develops an acceptable response and rationale for it. Utilizes some examples.

Demonstrates thorough knowledge of the business concepts involved in the issue, and their implications. Thoroughly develops process differences and reimbursement impacts as specified in the assignment. Clearly answers the questions and develops a very strong rationale. Introduces appropriate examples.

15.0 % Integrates Information From Outside Resources into the Body of Paper

Does not use references, examples, or explanations.

Provides some supporting examples, but minimal explanations and no published references.

Supports main points with examples and explanations.

Supports main points with explanations and examples. Application and description are direct, competent, and appropriate of the criteria.

Supports main points with references, examples, and full explanations of how they apply.

17.0 %Organization and Effectiveness

6.0 % Thesis Development and Purpose

Paper lacks any discernible overall purpose or organizing claim.

Thesis and/or main claim are insufficiently developed and/or vague; the purpose is not clear.

Thesis and/or main claim are apparent and appropriate to the purpose.

Thesis and/or main claim are clear and forecast the development of the paper. It is descriptive and reflective of the arguments and appropriate to the purpose.

Thesis and/or main claim are comprehensive; contained within the thesis is the essence of the paper. Thesis statement makes the purpose of the paper clear.

6.0 % Paragraph Development and Transitions

Paragraphs and transitions consistently lack unity and coherence. No apparent connections between paragraphs are established. Transitions are inappropriate to purpose and scope. An organization is disjointed.

Some paragraphs and transitions may lack logical progression of ideas, unity, coherence, and/or cohesiveness. Some degree of organization is evident.

Paragraphs are generally competent, but ideas may show some inconsistency in the organization and/or in their relationships to each other.

A logical progression of ideas between paragraphs is apparent. Paragraphs exhibit a unity, coherence, and cohesiveness. Topic sentences and concluding remarks are appropriate to the purpose.

There is a sophisticated construction of paragraphs and transitions. Ideas progress and relate to each other. Paragraph and transition construction guide the reader. Paragraph structure is seamless.

5.0 % Mechanics of Writing (Includes spelling, punctuation, grammar, language use.)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present.

Some mechanical errors or typos are present but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.

The prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.

The writer is clearly in command of standard, written, academic English.

3.0 %Format

3.0 % Paper Format (1- inch margins; 12-point-font; double-spaced; Times New Roman, Arial, or Courier)

GCU template is not used appropriately or documentation format is rarely followed correctly.

GCU template is used, but some elements are missing or mistaken; lack of control with formatting is apparent.

GCU template is used, and formatting is correct, although some minor errors may be present.

GCU template is fully used; There are virtually no errors in formatting style.

All format elements are correct.

100 % Total Weightage

Coder Interview with a Health Care Provider Sample Answer

Coder Interview

Introduction

In this paper, I will report the findings of an interview that I conducted in which the respondent was a specified health care provider situated in New York. The facility is a major provider of in and out-patient medical care. The rationale for selecting the care provider was that it has a coder/billing process, which it uses to satisfy reimbursement requirements for billing purposes. Hence, the facility fits the aim of this paper particularly well. From the information provided by the respondent, it is apparent that the multi-faceted billing approval process and the flat rates are what set the medical coding process from the procedures adopted in other markets. Besides, the paper takes the standpoint that the role of government and private insurers determining how reimbursement is done is rather conflicting.

How are health care charging and pricing processes different from other industries?

One of the principal purposes of the interview was to identify how different healthcare and pricing processes are from other industries. In line with Feldstein’s (2012) thoughts, it was revealed that, unlike in other sectors, charging and pricing processes in a medical institution are not executed by a single person. Instead, coding in such an organization requires the approval not only from the front office administrators but also the back office. Usually, the billing and coding process commences when a patient arrives at the care center. It can also start when a patient schedules an appointment with a physician (Feldstein, 2012). It only ends when the final reimbursement is collected from an insurance firm from which the client has an existing health insurance policy. In other industries, charging is initiated and completed at the point of sale. Besides, businesses in other industries do not deal with third parties such as insurance companies.

The interview responses also revealed that, in stark contrast to the other sectors, medical care facilities, especially for inpatient services, usually charge flat fees for all diagnosis-related cases. While this is the case, as it was revealed during the interview, to accommodate complex cases that require care facilities to use resources that exceed what has been reserved for diagnosis-related cases, most care facility systems provide what Feldstein (2012) acknowledges as “outlier” payments. In the other sectors, while a customer may seek related products and services, he or she is charged different prices, depending on some specified factors. This means that there is nothing like flat fees in such sectors.

How do private and government insurers and payers impact actual reimbursement?

The interview also sought to determine whether private and government insurers and payers impact the actual reimbursement. Several discoveries, which have been reflected in the existing research, were made. According to the respondent, the government is the largest single health care payer in the U.S. (Troy, 2015). As such, the government has considerable authority to determine how much it is to reimburse the care facilities for services rendered. As a matter of fact, through Medicare and Medicaid, what the federal government reimburses is subsidized. Private health insurance companies, as well, influence reimbursements, according to the interviews I conducted. In line with Troy’s (2015) thoughts, private insurance companies negotiate costs with the affiliated care centers on behalf of the clients. While this is the case, with private insurers, there is always a cap. Thus, private insurers will only reimburse care providers up to the specified amount. It is a patient to pay in the case that the limit is exceeded.

Coder Interview with a Health Care Provider Conclusion

In conclusion, the interview that I conducted with the coder was an enlightening one. As evidenced in the report above, the approach that is used by organizations in the health sector is entirely different, given that the process of billing is executed by some departments before it goes through. The issue of flat rates and “Outliers” also define the difference between coding in the medical domain and other spheres. The interview also revealed that both the government and private insurers along with payers impact reimbursements. However, while the government insurer seeks to subsidize the reimbursement, private insurers put a limit on what medical centers are to be compensated.

Coder Interview with a Health Care Provider References

Feldstein, P. J. (2012). Health care economics. Belmont, CA: Cengage Learning.

Troy, T. D. (2015). How the Government as a Payer Shapes the Health Care Marketplace. American Health Policy Institute. Retrieved from http://www.americanhealthpolicy.org/Content/documents/resources/Government_as_Payer_12012015.pdf

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