Introduction: The healthcare industry in the US is completely different from the healthcare setup in India because people in the US believe in the “Prevention” model rather than the “Cure” model.
Business Process Outsourcing (BPO): In this case, business is outsourced from developed nations like the US to underdeveloped nations like India. Offshore and inshore outsourcing are two different forms.
Role of India in Business Process Outsourcing: India is a key player in BPO because of the following reasons:
Healthcare Revenue Cycle Management: HRCM is a thorough procedure that oversees claims processing, payment, and revenue generation by obtaining patient personal and treatment information while maintaining patient confidentiality.
The HRCM can be broadly divided into five steps:
Challenges for Healthcare Revenue Cycle Management: It can be challenging for organizations to keep their revenue cycle management practices consistent in light of the constantly evolving healthcare laws.
Role of Technology and AI in HRCM: Healthcare revenue cycle management strategies have been streamlined and improved because of systems like Health IT and EHR.
Influence of Denials on Health Care Revenue Cycle Management:
|Year||2016||2019 (2nd Half)||2020 ( 1 Q)||2020 ( 2 Q)||2020 ( 3 Q)|
B. Factors Contributing to Denials:
|Authorization||Service Not covered||Medical Documentation||Medical Necessity||Untimely Filing||Medical Coding||Provider Eligibility||Avoidable Care||Unknown|
C. Denials Based on Phases of RCM:
D. Denials can be prevented:
E. HRCM Market Growth Forecast:
|2021||$ 61440||8.4 %|
a. If the patient is on analgesic and if he/ she was diagnosed with a malignant neoplasm or cancer chemotherapy, then “G89.3” should be mentioned as a diagnosis.
b. If the patient was diagnosed with trauma, fracture, or accident, and is on analgesics for a longer duration, then “G89.21” should be mentioned.
c. Similarly, if the pain is chronic and because of a procedure or surgery, then “G89.28” should be mentioned.
d. If the pain is chronic, but the cause is not particular then G89.4 should be used.
e. The chances of denial will be very high if the code is inaccurate. “ R52 or Pain, unspecified” is a classic example of the same.
3. For anemia, the diagnosis code should be based on underlying medical conditions.
a. If the patient was diagnosed with renal failure, then “D63.1” should be mentioned as a diagnosis.
b. If the patient was diagnosed with neoplastic disease then “D63.0” should be mentioned.
c. If the patient is on cancer chemotherapy, then “D64.81” should be mentioned.
d. If the diagnosis is any other chronic condition like congestive heart failure, then “D63.8” can be mentioned.
e. Whereas for iron deficiency anemia, the diagnosis code should be decided based on the underlying cause for anemia. For e.g., “D50.0” should be used for “Iron deficiency anemia due to blood loss”.
f. If “D64.9” is mentioned as a diagnosis for anemia, the chances of denials will be very high since the code is not specific.
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