Reimbursement describes the general process by which healthcare providers are paid for the services rendered. The term comes from the practice of providing the care before payment and then subsequently seeking reimbursement for the costs incurred from an insurance company or the patients themselves. It is the reimbursement process that identifies the services provided, reports those services, and completes the billing and collection functions necessary to receive the revenues earned. Without fair payment for services, the emergency department (ED) and the emergency physicians will not have the resources required to provide adequate patient care. The reimbursement process must be well organized and executed to sustain organizational vitality and thereby ensure access to quality emergency care for the surrounding community. Additionally, payments must be sufficient to attract and retain high-quality physicians willing to work nights, weekends, and holidays. The reimbursement and payment must be adequate to attract physician who can sustain a reasonable lifestyle commensurate with their extensive training and include repayment of the accumulated debts of training. Reimbursement will ultimately be adjusted for local and regional market forces.
Unlike the care provided in a medical office, the ED patient typically does not have a prior relationship with the providers or a scheduled appointment for a known condition. The unscheduled, episodic nature of a vast array of presenting problems requires a broader understanding of payment rules than for most other medical specialties. Layered on top of that broad spectrum of medical services are numerous government regulations; not the least of which is the Emergency Medical Treatment and Active Labor Act (EMTALA) that requires EDs to screen and treat, at least until the point of stabilization, all patients who present regardless of their ability or willingness to pay. Increased audit activity and the evolution of healthcare reform further complicate the process. For these reasons, the reimbursement process for emergency medicine is perhaps the most challenging in the industry.
This chapter will describe the fundamentals of reporting a medical service and obtaining reimbursement for that service. It will include the processes related to documentation, coding, billing, appeals, collections, and the overarching need for maximal compliance.
Each of these topic areas will be greatly expanded in subsequent chapters, but the basics of each step in the reimbursement process will be outlined here. The framework of the governmental regulatory process and private payer polices will be introduced as well as strategies to improve reimbursement now and into the future, including fee setting, contracting, and the relationship between the professional and facility fees and payments.
Let's consider the steps in the reimbursement process in greater detail (Box 77-1).
Box 77-1 Steps in the Reimbursement Process |Favorite Table|Download (.pdf)
Box 77-1 Steps in the Reimbursement Process
Provide the medical service
Document the service
Identify the service
Code the care (CPT, ICD-9, HCPCS, modifiers)
Bill (initial claim, appeals, A/R, collections)...