Critiques of projects

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What is the department’s role within the organization, and what are its responsibilities?

The financial departments goals are to secure a method of payment in order to provide the required services for the patient. The finance department will distinguish if the patient has insurance through the insurance verification team. After it is established that the patient has coverage, the steps of obtaining a referral for in or out of network authorization will begin. Submitting clinicals on the patient’s behalf to obtain an authorization for the patient’s care is critical to the financial department. Once clinicals are submitted and reviewed as well as peer to peer interview for the referring Medical Professional to the insurance companies Medical Professional and an authorization is obtained the patient’s treatment is scheduled. The facility is contracted with a variety of plans such as: (M.U.S.E. 2018)

  • Indemnity Plans: Traditional insurance plans which insures against financial loss as a result of medical expenses
  • Preferred Provider Organization: “Any willing provider” which must be pre-certified. An enrollee can choose any provider that is willing to accept assignment of payment by the insurance company.
  • H ealth Maintenance Organizations: Providers that are under contract with the insurance plans . Enrollees must choose a preferred provider that is in contract and network with their insurance plan.
  • Point-of-Service: This is a combination plan where the enrollee has the freedom of choice of their provider or can choose one within the network.

In the case that the patient is not fortunate enough to carry an insurance policy, financial assistance screening will begin. The patient’s bank records, dependents, finances, and ability to pay will be compared to our financial matrix to determine what kind of help is granted. The state provides financial grants and charity to those in need and meets the requirements. Once it is discovered the patient qualifies for a program the treatment will begin.

Those patient s who neither qualify for financial assistance nor carry insurance coverage will need to pay out of pocket for the services rende red . A payment plan for services must be obtained.

What are the client needs or services that are addressed by this department?

The client’s needs and services are to be able to secure treatment within the guidelines of their financial program they qualified for or within the parameters of their insurance policy and authorization . The facility will need to obtain the method of payment for the patient for the services rendered in order to continue to be available for those who needs treatment. In order to capture the method of payment for the client’s treatments an authorization by insurance must be obtained, the patient must obtain charity or grants for treatment, or pay solely out of pocket.

What individuals and resources are needed to provide those services?

For this department the facility will need to employee an insurance verification specialist, a medical billing and coding specialist , as well as a financial counselor. An insurance verification specialist will be able to verify insurance coverage, inquire about authorization requirements, discover if the insurance plan is in or out of network, and the deductible and coinsurance amounts. The insurance verification specialist will work closely with the intake nurse and physician in order to gather the medical information needed to send for authorization if need be. The medical billing and coding specialist will be responsible for creating the claims and sending out the claim forms to obtain payment fr om the insurance companies . The medical billing and coding specialist will also be able to appeal any denials by the insurance company to secure payment. The financial counselor will be responsible for those patients who do not have insurance coverage. The financial counselor will interview each patient and request financial records such as pay stubs, bank statements, W2’s and information on the household to see if the patient qualifies for any grants or charity. If the patient does not meet financial counselor requirements for assistance a payment plan will be created for the patient’s treatment.

Between these three team members the objective of securing payment for each service rende red is greatly improved. The facility will need to secure funds either by insurance payments, grants from state and county, charity programs, donors and the community in order to continue being available for services to the public.


M.U.S.E. 2018 Managed Care Delivery and Insurance

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