Revenue Cycle Training

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Brief Overview of the Revenue Cycle Process for Hospitals/Physician Offices

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Revenue Cycle Training

  1. 1. a Beverly Brouse Creation Revenue Cycle Hospital and Physician Based
  2. 2. Key Billing Acronyms a Beverly Brouse Creation UB92 - Uniformed Billing Form (hospital) • HCFA 1500 - Physician Billing Form • CDM - Charge Description Master • CSA - Contractual Service Adjustment • DRG - Diagnostic Related Group (IP reimbursement method) • ATB - Aged Trail Balance (accounts receivable) • EOB - Explanation of Benefits (receive from payor) • ICD-9 - International Classification of Diseases (diagnosis) • HCPCS - Healthcare Common Procedure Coding System (drugs, devices, supplies) • CPT -Current Procedural Terminology (Procedures) • HIM - Health information Management (Medical Records Department) • HIS - Health information system • EMTALA - Emergency Medical Treatment and Liability Act • See exhibit A
  3. 3. Revenue Cycle a Beverly Brouse Creation • Scheduling of Appointment (Hospital IP surgery & most OP visits are scheduled. All Physician visits should be scheduled) • Pre-Registration Process (Best of practice suggests that at least 90% of scheduled visits should be pre-registered) • Registration Process • Charge Capture/Coding Process (Unique between hospital and physician practices) • Billing/CSA Posting Process • Follow-Up Process See flowcharts A and B
  4. 4. Scheduling & Pre-Registration a Beverly Brouse Creation • Schedules should be updated regularly for cancellations, no-shows or rescheduled appointments. (Daily schedules should be used to reconcile to daily charges). • Pre-registration occurs prior to the patient’s visit. • At time of pre-registration, the following should occur: 1. Verification of insurance coverage, 2. Verification of patient demographic information, 3. Identification of self-pay balances (including co-pays and deductibles), and 4. Obtain needed pre-authorizations • Information gathered during pre-registration should be documented in the system.
  5. 5. Registration a Beverly Brouse Creation • At time of registration, the following should occur: 1. Obtain copies of all insurance cards (primary, secondary & tertiary coverage). 2. Practice the Birthday Rule when the patient is a child. 3. Request a form of photo ID to verify the patient’s identity (this will ensure confidentiality of the patient’s medical records). 4. Verify patient demographic information and document this information in the system (verify against the patient’s ID). 5. Collect all monies due from patient (self-pay balances, co-pays and deductibles). The use of a day sheet is helpful when reconciling to daily deposits. • Registration information documented in system is usually automatically pulled onto the UB04 and/or HCFA1500. See exhibit D & E
  6. 6. a Beverly Brouse Creation Registration Continued • Registration in the ER is regulated and restricted by EMTALA. See flowchart C
  7. 7. a Beverly Brouse Creation Charge Capture/Coding • Physician, nurse or physician assistant document all services rendered to the patient. • Charges captured in system by clinical departments or on charge slips/superbills/charge tickets and forwarded for entry into HIS • Some CPT codes are hard coded in the CDM along with the charge • Medical records/HIM is responsible for the coding of HCPC and ICD9 codes (soft coded). • Once captured, codes are usually transferred from coding system to HIS by means of interfacing. See flowchart A
  8. 8. Claim Edits/CSA a Beverly Brouse Creation • Once claim is created, UBs/HCFA1500 are usually sent through some kind of scrubbing system for editing. • Errors identified during the editing process are corrected by billing personnel. • Prior to claim submission, CSA automatically calculated by the system and posted to the patient’ s account or manually posted after receipt of payor remit. (may vary by payor) • CSA is based on individual payor and their method of payment. (based on individual payor contracts)
  9. 9. a Beverly Brouse Creation Methods of Payment Calculations Payment based on… • DRG - fees paid based upon diagnosis (pre-defined). • Per Diem - fees paid based upon the length of the patient’ s stay. • Percent of Charges - fees paid based on a pre-determined percentage (outliers are usually also negotiated in the contract) • Capitation - fees based upon the estimated number of service occurrences (fixed payment received in advance regardless of number of services performed). • Fixed Rate - fees based upon specific procedures performed (pre-defined). • Fee for Service – fees for charges billed (no discount).
  10. 10. a Beverly Brouse Creation Claim Submission • Once sent through the scrubbing or editing process, claims are ready for submission to insurance carrier (backlogs may occur in clearing edits) (additional hold time may also occur before submission). • Most payors require electronic claim submission • Some secondary payors require hard copies of the UB04/HCFA1500 along with the primary payor’ s remit.
  11. 11. a Beverly Brouse Creation Collection Process • ATBs should run periodically and be used when following up on outstanding claims (ATBs list claims by aging category). • Claims are worked in order of age and dollar amount (oldest, higher dollar claims are worked first). • Productivity tracking should exist to monitor the efficiency of follow-up. • Follow-up personnel will also use EOBs as a tool to work outstanding claims. Per HIPAA regulations, third party payors must pay or deny a claim within 30 days of receipt.
  12. 12. a Beverly Brouse Creation Common Denials The following are samples of possible denials by insurance carriers: • Patient Not Covered - this is a registration weakness. • Untimely Filing - claim was received past the filing limit (this is typically a billing weakness). • Invalid ID Number - this is a registration weakness. • No Authorization on File - this is a pre-registration weakness. • Other Insurance Primary - this is a registration weakness. • Pre-Existing Condition – could be a registration weakness. Note: These are just a few of the many denials issued by payors.

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