The relationship between providers and payors has evolved greatly over the past couple of decades, from one of distrust, to "partnerships," and now back to an era of distrust and antagonism. Payors have become very active in performing audits, and the inevitable set-offs, take-backs or general recoupment processes have followed. Although hospitals have at least some of the structure in place to address these issues on the facility side, there are large inadequacies on the professional side.
To understand the issues that may arise on the professional side, it is instructive to look at an area that is currently receiving a lot of attention: emergency department services. Consider this hypothetical: A patient, a 62-year-old male, is involved in a minor car accident, and comes into an emergency room complaining of chest pains, nausea and minor cuts. The attending doctor orders X-rays, does an EKG to monitor the patient's heart rate, has blood work done, and sutures up the cuts. Notes of the care provided to the patient are documented in the patient's chart, and long after the patient is discharged, the information is sent to the billing department. The ultimate bill is then submitted to the payor, and payment is subsequently sent to the provider. This happens several months after treatment.
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