Paper
Thursday, 20 July 2006
This presentation is part of : Nursing Leadership and Management Initiatives
A Case Study Analysis of the Impact of Revenue Uncertainty on Hospital and Nursing Operations
Linda A. Walsh, RN, BSN, CEN, MICU/CCU, Jersey Shore University Medical Center, Neptune, NJ, USA, Margaret A. DeBari, RN, C, MA, Brennan 5, Jersey Shore University Medical Center, Neptune, NJ, USA, and Thomas Cox, PhD, RN, Department of Supportive Sciences and Health Systems, Seton Hall University, College of Nursing, Gainesville, FL, USA.
Learning Objective #1: Describe the revenue cycle in a modern, suburban, healthcare organization.
Learning Objective #2: Explain how revenue uncertainty risks arise, are managed, and influence healthcare operations and the delivery of nursing services.
Purpose: Describe and explain how the size, financing, and organizational structure of insurance risk assuming healthcare providers mediate clinical, financial, and insurance risk management operations in a suburban healthcare organization.

Background: Insurance risk transfers in: capitation, managed care, and DRGs, ‘Professional Caregiver Insurance Risk’, affect healthcare providers’ organizational structure, financial, and clinical operations, producing uncertain revenues from retrospective audits, unanticipated charity care, and disputed, delayed, and unresolved bills. Insurance risk assumption and the consequential resource uncertainties, constrain costs, marginalize operations, and reduce service capacity.

Approach: Graduate nursing students performed a case study, clarifying complex relationships between admissions, nursing services, billing, finance and investments, and collections. Their research examined and describes the organization’s managed care contracting and multi-source and uncertain revenue flows during the revenue cycle from pre-admission through final billing resolution.

Major Points & Rationale: Occult and overt insurance risk assumption and management affects all healthcare organization operations, including: Admissions, Finance, Nursing, Discharge, and Collections. Collaborative debriefing, interviews with administrators and clinicians, and document analysis revealed important aspects about the organization and delivery of healthcare services under the influence of clinical, financial, and managerial uncertainty.

Conclusions: This case study provides important insights into the clinical, financial, and managerial consequences of financial uncertainty on healthcare systems. Nurses must understand the financial, managerial, and clinical implications of insurance risk assumption to mediate adverse impacts on patient care. Nurses, who understand the roles, responsibilities, and working methods of individual departments and personnel involved in managing healthcare organization responses to uncertainty, will improve their ability to effectively participate in managing patient care in such contexts.

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