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Revenue Cycle Management

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Chelsea Zhang

on 6 October 2014

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Transcript of Revenue Cycle Management

Revenue Cycle Management
Patient Access
Eligibility Assistance Services
Health Information Management
Hospital Billing Services
Billing Customer Service
Clinical Info & Hospital Coding
Billy Bob's Trip
Abdominal pain
Further examination is needed
Writes an Physician Order for CT Scan
Collect demographic, guarantor, encounter and insurance information.
A Hospital Account (HAR) is created, which stores all charges, payments and adjustments.
During the registration, it is determined that Billy Bob has Aetna as insurance which requires an authorization (approval from the insurance payer for treatment).
The authorization number is supplied in the system by Billy Bob's PCP office.
Patient Access determines that Billy Bob has a co-pay due for this visit.
This amount should be paid at the time of service or during pre-registration over the phone.
The charges associated with Billy Bob's CT Scan are entered electronically and posted to his hospital account.
This Process is called Charge Capture.
A Coder will review Billy Bob's Hospital Account and assign the appropriate clinical codes for billing.
The Billing Department will review Billy Bob's hospital account and then submit the Claim to the appropriate payer or insurance company.
After the claim is submitted to Aetna, the insurance company will send payment that will be posted to Billy Bob's account.
Adjustments are also posted to the account at this time. (Adjustments are described as a portion of the bill that the hospital has agreed not to charge the patient.)
Reimbursement Monitered
Billing will contact Aetna if the reimbursement is not what was expected.
Reimbursement is the act of compensating our facilities for an expense.
Insurance Follow Up
Billing is responsible for following up with the payer if the bill isn't paid during a specific amount of time. The Revenue Cycle of bill submission, posting of payments and adjustments and reimbursement monitoring continues until the bill reaches a ZERO balance.
Generation of Billing Statements
A bill is sent to the Guarantor if there is a balance in the patient's Hospital Account.
A guarantor is the person or entity that has a financial obligation/responsibility to pay the patient's remaining bill.
Patient statements are sent to the guarantor until the account balance reaches $0.
If a patient's bill is still not satisfied, the account will be turned over to a pre-collection agency for further action.
The agency will contact the patient/guarantor through telephone calls and letters for a specific amount of time.
Collection/Legal Agency - Bad Debt
If the patient's payment is still not paid after the pre-collection attempts, the account will be submitted to a collections agency and considered BAD DEBT.
Credit bureaus will be notified of patient's delinquent account.
This is the last step in the Revenue Cycle.
Payment and Adjustment
Claim Processing
Upfront Collection
Patient Interview
Committed to provide patients with safe, efficient and financially informed access to their healthcare services.
Meet and greet the patient
Gather demographic information
Determine guarantor and gather guarantor information
Complete insurance verification, authorization and referrals
Collect upfront payments
Interact with physicians, nurses, insurance companies and other supporting departments both internally and externally
Provide proper documents and obtain signatures
Collecting and maintaining patient's electronic charts
Assigning ICD (International Classification of Diseases) and CPT (Current Procedure Terminology) codes
Supervising HIPAA privacy practices
Interfacing with physicians, nurses and other supporting departments
Creating and submitting patient's bill
Posting payments and adjustments
Monitoring reimbursement
Follow up with insurance companies
Screening and referring accounts to (pre-)collection agencies and third party agencies.
Provide accurate, thorough, prompt and courteous attention to patients with billing questions and concerns.
Provide first and second-level research of account issues and maintain a broad system knowledge to assist callers with the greatest efficiency possible.
Professional Billing
Serving patients, families and clients by providing courteous, timely, cost-effective billing processes for physician offices.
They are highly-skilled professionals with experience in federal, state and local medical assistance programs.
Visit patients' home, if necessary, to complete the application and obtain necessary verifications.
Serve as the patient's advocate throughout the application process, ensuring that the patient receives all assistance to which they are entitled.
Long-term care services are available to those who qualify.
Work closely with other supporting departments and financial assistance programs.
Frequently Used Terms:
Registration is the c
ollection of demographic information that is required to satisfy regulatory, financial and clinical requirements. This information is used to create patient's bill.
Pre-registration is the c
ollection of registration information including insurance eligibility, benefits and authorizations before the patient arrives for medical services.
Patient Class:
Inpatient: Patient who receives healthcare services while admitted to the hospital overnight or longer.
Outpatient: Patient receives healthcare treatment without being admitted to the hospital. This can also include imaging, tests and some surgeries.
Emergency: Patient receives immediate medical attention through the Emergency Department.
Observation: Patient is being observed under 24 hours.
Frequently used Terms:
: Analyzing clinical statements and assigning codes using a standardizing system.
Revenue code
: Billing code that is used to categorize hospital services. These codes were developed by the National Uniform Billing Committee (NUBC).
Charge Master
: Contains a listing of a provider's price for healthcare services, goods and procedures.
ICD (International Classification of Diseases) codes
: Set of codes to correspond to patient's illness.
CPT (Current Procedure Terminology) codes
: Used to report medical, surgical and diagnostic services and procedures.
Billing Terms:
Request of payment for healthcare services and benefits that the patient receives.
Claim Submission:
Billable fees that are submitted to the insurance company via a universal claim.
Allowed Charge:
Contracted rate for individual charges determined by the insurance company for the patient's medical treatment.
Disallowance/Denial: A
payer declines to pay for all or part of a claim.
Common Acronyms:
RCM - Revenue Cycle Management
PAS - Patient Access Services
PAR - Patient Access Representatives
PAFR - Patient Access Financial Representatives
ADT - Admission, Discharge, Transfer
ED - Emergency Department
L&D - Labor and Delivery
WQ - Work Queue
MPI - Master Patient Index: Name, DOB, SSN #
MRN - Medical Record Numbers
HAR - Hospital Account Record
CSN - Customer Service Number
The Purpose of Patient Interview
Facilitate the gathering of pertinent information used in the registration process.
The information is gathered for regulatory, billing purposes and patient safety.
Regulatory Information
Some information gathered is required by the government.
Ethnicity/Race is used by the government for statistical reporting.
MSPQ: Medicare Secondary Payer Questionnaire - All Medicare patients
be asked the MSPQ at every patient encounter.
Billing Information
Some information is gathered for billing purposes.
The guarantor must be identified and setup appropriately.
Coverage information/plan type/ subscriber must be identified.
Verify employment.
Conduct financial discussion with the patient.
Patient Safety Information
Thorough search must be completed for every patient: Name, DOB and SSN.
Identify duplicate records and request MPI merge.
Verify armband information is for the correct patient.
Identify any patient special needs.
May I have your address please?

Can you please verify your home phone number?

Phone number
Employment status
Email address
Preferred language
Marital Status
Emergency Contact


Guarantor-Person or entity that is financially responsible for the bill.

A patient may have insurance, any unpaid balance due would be the responsibility of the guarantor.

Most patients over age 18 will be their own guarantor.
The presenting parent should be guarantor for minors.
Exceptions include:
Workers Comp
Patients under legal guardianship
Department of Social Services
Emancipated Minors

Guarantor Information

Always obtain current coverage information:
Commercial/Non Commercial coverage
Auto liability
Workers Compensation
Coverage member information:
Policy ID number
Group name
Group number

Insurance coverage

Review patient account and assign codes for compliance and accuracy to ensure reimbursement to Carilion facilities for services provided.
Full transcript