Profit margins are shrinking for hospitals across the country. Bundled payment structures are on the rise, making it difficult to determine if reimbursement is accurate. Healthcare providers cannot afford to miss out on negotiated reimbursement. Additionally, charge structures and payment for surgical services are not as transparent as other services like radiology. The cost to perform surgical procedures is among the highest of all services provided in a hospital setting. Hospital finances can suffer, or flourish, based on operating room revenue. But how do you know if you are actually missing out on surgical reimbursement?
Most analytical reports on reimbursement can tell you how your price compares to a fee schedule, or per unit, payment. However, because most providers charge for surgical services on time-based or acuity-based structure, it’s difficult to see how the chargemaster price directly relates to the payment for a procedure.
Example: Surgical Procedure Charges vs Payment
In this example, it is clear to see that the total procedure charge falls below the negotiated commercial payment which means there is a potential for only receiving payment for billed charges. Yet, performing this type of review case by case would take an inordinate amount of time and would not provide direction on how to correct the overarching charge issues. An Operating Room Charge Analysis includes a systematic review of surgical encounters, which requires thorough payor contract analysis, reimbursement, and surgical encounter modeling as well as charge systems and process examination. Through the clarity of these analytics, you can easily see what types of procedure charges fall short of reimbursement in addition to how to adjust prices and structures to create a defensible surgical charge that generates full reimbursement on every case.
Taking the time to guarantee alignment of surgical charges and reimbursement can keep your hospital in the black and help avoid pricing transparency nightmares.
About MedCom Solutions
MedCom Solutions specializes in Operating Room Charge Analysis to hospitals establish defensible charging structure and improve the bottom line. MedCom Solutions creates patented technology and state-of-the-art software to help medical service providers meet rapidly escalating and changing medical billing demands. Our Chargemaster, Pricing, and Compliance solutions have yielded hundreds of millions in net revenue for healthcare providers across the country.
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