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Revenue Cycle Presentation
Transcript of Revenue Cycle Presentation
Presentation All Hands Meeting, September 2012 Office Scheduling Hospital begins pre-registration and insurance verification. Pre-certification and pre-authorization occurs by surgeon's office and hospital. Admitted to outpatient surgery. Procedures Discharge HIM Billing Doctor orders tests. Demographic Information
Subscriber Information 1. Registration staff contacts patient for the following information: 2. Address and insurance are verified For insurance verification, the top payors are verified by RTE (Real Time Eligibility) -- this includes patient benefit information 1. Physician's office staff starts the pre-authorization process by contacting the patient's insurance company.
2. After review of patient's medical history and needs, a pre-certification is then authorized.
3. Hospital staff validates and documents authorization provided by the office. Signatures obtained
Copay collected 1. Patient reports to admitting. 2. Patient directed to the appropriate floor. Interface from other systems
Manual charge entry
Order generated charges
Result generated charges
Automated charges (room and board) Methods of charge entry Important data elements of charge Price (fee schedule)
Coding is done on the charge for professional billing
Hospital billing is coded through HIM Sent in ANSI standard language for electronic transactions.
Follows HIPAA regulations. 1. Electronic claim goes to insurance. 2. Insurance processes and reviews claim based on benefits and services provided. Ties in with all front end
Diagnosis Codes ICD9
Benefits that a patient has with their insurance company
Coinsurance (80/20, etc.) Managed care 3. Insurance company sends back payment information. 4. Payment is made to the provider. Electronic payment (ANSI standard)
Paper check/EOP (explanation of payment) This is your description of how your insurance company paid your claim including the following:
Who was paid
Denial reasons 5. Explanation of Benefits (the one that says, THIS IS NOT A BILL) to patient Paper or electronic remit posting 6. Provider posts payments. 7. Provider bills patient for copay/deductible/non-covered amounts. 8. If patient does not pay, outstanding balances go to charity or collections. (Good luck with the collector) Hospital Scheduling and Registration 1. Doctor transcribes orders for exams. 2. Three potential ways to achieve scheduling: Doctor's office calls central scheduling for the patient to set up the exam.
Patient is notified by doctor that they need to schedule an exam and call central scheduling themselves.
Patient walks into a facility and does a "walk-in" exam where the front desk schedules the exam for them. Clinical questions are answered.
Encounter types are entered.
HAR is created. 3. In all instances the following things are done: Order entry -- diagnosis entered on the Order from the provider
Problem list -- active problems entered by provider
Third party coding system
Manual code entry by HIM coder Methods of diagnosis/procedure code entry: Important data elements of coding: ICD-9-CM diagnosis and procedure codes
CPT-4 procedure codes Diagnosis/procedure coding is done after patient is discharged
The HIM coder reviews all clinical documentation, i.e., H&P, Discharge Summary, etc.
Reviews orders/results/problem list entered on visit
Determines appropriate ICD-9 diagnosis and procedures to apply to the encounter (as well as CPT codes that are necessary)
Reviews ADT or other information in the hospital chart that is relevant to the encounter
May query the provider to clarify pieces of documentation so a more specific code can be entered
Once coding is complete, billing can be initiated HIM Coding 6. After the exam, the patient is checked out. Co-pay collected 4. Registration staff contacts patient for the following information: 5. When the patient arrives the day of the exam, the front desk staff checks them into the system, and... Marks patient as arrived
Serves notice to the department exam is scheduled in that patient is ready to be seen Demographic Information
Address and insurance are verified (charging) (Health Information Management) Patient is discharged and the remainder of our revenue cycle continues.