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HFMA Revenue Cycle Credentialing Program

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The Healthcare Financial Management Association’s (HFMA) professional credentialing program recognizes healthcare workers who had reached an acceptable standard of knowledge and proficiency in the revenue cycle field. Employees who meet the requirements of the program earn the designation ‘Credentialed Revenue Cycle Representative’ (CRCR). The CRCR Program is recommended for revenue cycle staff including (but not limited to) Patient Access, Financial Representatives, Managed Care Operations, Health Information Management, Case Management and Compliance.

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HFMA Revenue Cycle Credentialing Program

  1. 1. HFMA’s Credentialed Revenue Cycle Representative (CRCR) Program Presented to Baylor Health Care System by Elsevier / MC Strategies Performance Improvement Solutions
  2. 2. CRCR Program Origin <ul><li>Providers’ unsolicited requests for HFMA achievement tool within revenue cycle arena </li></ul><ul><ul><li>Veterans Administration </li></ul></ul><ul><ul><li>3 large health systems </li></ul></ul><ul><ul><li>5 independent hospitals </li></ul></ul><ul><li>In response, HFMA: </li></ul><ul><ul><li>Reviewed market trends and existing offerings </li></ul></ul><ul><ul><li>Surveyed CFOs on value proposition </li></ul></ul><ul><ul><li>Formed peer Advisory Committee </li></ul></ul><ul><ul><ul><li>Financial executives from 12 provider organizations </li></ul></ul></ul>
  3. 3. HFMA’s Credentialed Revenue Cycle Representative (CRCR) Program <ul><li>Proctored, credentialing exam with online study guide </li></ul><ul><li>Validates a national level of achievement </li></ul><ul><li>Open to HFMA members and non-members </li></ul><ul><li>Provider and Corporate program models </li></ul>
  4. 4. Program Objectives <ul><li>Advances revenue cycle staff proficiency </li></ul><ul><li>Promotes a higher standard of performance among staff </li></ul><ul><li>Supports compliance initiatives </li></ul><ul><li>Develops talent </li></ul><ul><li>Promotes staff retention </li></ul><ul><li>Aids in expansion / growth management and Team Leaders </li></ul>
  5. 5. CRCR Study Guide <ul><li>Parameters and scope defined by Advisory Committee </li></ul><ul><li>Comprehensive online study guide covering: </li></ul><ul><ul><li>Compliance </li></ul></ul><ul><ul><li>Patient Access </li></ul></ul><ul><ul><li>Claims Processing </li></ul></ul><ul><ul><li>Account Resolution </li></ul></ul><ul><ul><li>Cash </li></ul></ul><ul><ul><li>Financial Management </li></ul></ul><ul><ul><li>Support Departments </li></ul></ul><ul><li>Approximately 12-15 hours of study </li></ul><ul><li>Engages learners using various interactivities to check learning and retention </li></ul><ul><li>Chapter review questions modeled after CRCR exam for fully preparatory experience </li></ul><ul><li>Updated annually </li></ul>
  6. 6. CRCR Exam <ul><li>Exam specifics </li></ul><ul><ul><li>Procter Guide provided </li></ul></ul><ul><ul><li>No fee to sit for proctored exam </li></ul></ul><ul><ul><li>Online, held in your computer lab </li></ul></ul><ul><ul><li>Exam auto-off in 3 hours </li></ul></ul><ul><ul><li>150 multiple-choice questions presented in random order (from pool of 250) </li></ul></ul><ul><ul><li>Questions weighted by chapter as defined by Advisory Committee </li></ul></ul><ul><ul><li>Calculator needed </li></ul></ul><ul><ul><li>Real-time scoring; 75% Passes </li></ul></ul><ul><li>Test date and location for group of participants coordinated by organization’s program administrator </li></ul><ul><li>Updated annually </li></ul>
  7. 7. Tactical and Strategic Objectives <ul><li>Compliance: </li></ul><ul><ul><li>Medicare Secondary Payer </li></ul></ul><ul><ul><li>Diagnostic Related Group </li></ul></ul><ul><ul><li>Correct Coding Initiatives </li></ul></ul><ul><ul><li>CPT/Revenue Code Issues </li></ul></ul><ul><ul><li>Modifiers </li></ul></ul><ul><ul><li>HIPAA code sets </li></ul></ul><ul><li>Compliance: </li></ul><ul><ul><li>Explain purpose of compliance program and major components </li></ul></ul><ul><ul><li>Discuss OIG work lists and impact on PFS operations </li></ul></ul><ul><ul><li>Understand the impact of Medicare specific compliance issues </li></ul></ul>
  8. 8. Tactical and Strategic Objectives <ul><li>Patient Access: </li></ul><ul><ul><li>Validating patient information </li></ul></ul><ul><ul><li>Processing scheduled and unscheduled patients </li></ul></ul><ul><ul><li>Valid physician order </li></ul></ul><ul><ul><li>MSP requirements </li></ul></ul><ul><ul><li>Identify the steps for insurance verification </li></ul></ul><ul><ul><li>What is EMTALA </li></ul></ul><ul><li>Patient Access: </li></ul><ul><ul><li>Understand Medical Necessity Screening and the use of Medicare Advanced Beneficiary Notice </li></ul></ul><ul><ul><li>Describe typical managed care requirements and why it is important to resolve requirements within the payer’s timeframe </li></ul></ul><ul><ul><li>How does EMTALA impact Access processing </li></ul></ul>
  9. 9. Tactical and Strategic Objectives <ul><li>Claims Processing: </li></ul><ul><ul><li>Understand UB-04 </li></ul></ul><ul><ul><li>Understand CMS 1500 </li></ul></ul><ul><ul><li>Using claim edits and how each is resolved </li></ul></ul><ul><ul><li>Identify basic billing rules for major payers </li></ul></ul><ul><ul><li>Different types of payer claim rejections and reasons for denials </li></ul></ul><ul><li>Claims Processing: </li></ul><ul><ul><li>Explain components and advantages of submitting claims electronically </li></ul></ul><ul><ul><li>Understand importance of keeping chargemaster updated </li></ul></ul><ul><ul><li>Describe basic billing rules for different provider types, e.g., Rural, Hospice, SNIFs, Ambulance, Hospital physicians </li></ul></ul><ul><ul><li>Explain typical reasons for payer denials and how to avoid them </li></ul></ul>
  10. 10. Tactical and Strategic Objectives <ul><li>Account Resolution: </li></ul><ul><ul><li>Basic customer service principles with patients and payers </li></ul></ul><ul><ul><li>Describe third party account resolution activities </li></ul></ul><ul><ul><li>Lien issues </li></ul></ul><ul><ul><li>Define collections and reporting regulations (FDCA) </li></ul></ul><ul><ul><li>Medicare bad debt rules </li></ul></ul><ul><ul><li>Collection agency placement </li></ul></ul><ul><li>Account Resolution: </li></ul><ul><ul><li>Understand the required processing difference between bad debt and charity care </li></ul></ul><ul><ul><li>Describe types of bankruptcy and how they impact the patient’s financial responsibility to the hospital </li></ul></ul><ul><ul><li>Discuss administrative and technical denials and how to resolve them </li></ul></ul><ul><ul><li>Understand clinical denials and appeals process </li></ul></ul>
  11. 11. Tactical and Strategic Objectives <ul><li>Cash: </li></ul><ul><ul><li>General concepts of electronic funds transfers (EFT) </li></ul></ul><ul><ul><li>In-network and out-of-network payments </li></ul></ul><ul><ul><li>Define Silent PPO </li></ul></ul><ul><ul><li>Internal controls for cash posting </li></ul></ul><ul><ul><li>Describe daily reconciliation process for cash posting </li></ul></ul><ul><ul><li>Identify different types of General Ledger cash (non A/R) </li></ul></ul><ul><ul><li>Processing steps for bank deposits </li></ul></ul><ul><li>Cash: </li></ul><ul><ul><li>Explain balancing and control requirements of the cash posting process </li></ul></ul><ul><ul><li>Understand the impact of payer contractual adjustments </li></ul></ul><ul><ul><li>Define a credit balance and identify the reasons there are credit balances in A/R </li></ul></ul><ul><ul><li>Discuss processing activities required to resolve credit balances </li></ul></ul>
  12. 12. Tactical and Strategic Objectives <ul><li>Financial Management: </li></ul><ul><ul><li>Difference between “Gross” A/R and “Net A/R </li></ul></ul><ul><ul><li>Describe Pay for Performance initiatives </li></ul></ul><ul><ul><li>Describe what is part of “Discharged Not Final Billed” </li></ul></ul><ul><ul><li>How to calculate cash collected as % of net revenue </li></ul></ul><ul><li>Financial Management: </li></ul><ul><ul><li>Explain balancing and control requirements of the cash posting process </li></ul></ul><ul><ul><li>Understand payer contractual adjustments </li></ul></ul><ul><ul><li>Define a credit balance and identify the reasons there are credit balances in A/R </li></ul></ul><ul><ul><li>Discuss processing activities required to resolve credit balances </li></ul></ul>
  13. 13. Tactical and Strategic Objectives <ul><li>Other Departments: </li></ul><ul><ul><li>Role of HIM </li></ul></ul><ul><ul><li>Role ancillary departments play in revenue cycle </li></ul></ul><ul><ul><li>Skilled nursing </li></ul></ul><ul><ul><li>Home health </li></ul></ul><ul><ul><li>DME </li></ul></ul><ul><ul><li>Hospice </li></ul></ul><ul><ul><li>Assisted living </li></ul></ul><ul><ul><li>Physician office scheduling and orders </li></ul></ul><ul><li>Other Departments: </li></ul><ul><ul><li>Understanding the role of UR/case management </li></ul></ul><ul><ul><li>Describe importance of info systems and technology to revenue cycle processing </li></ul></ul><ul><ul><li>Understand the continuum of care and what programs are involved </li></ul></ul>
  14. 14. Recommended CRCR Participants <ul><li>Patient Access </li></ul><ul><li>Financial Representatives </li></ul><ul><li>Patient Accounts </li></ul><ul><li>Compliance </li></ul><ul><li>Managed Care Operations </li></ul><ul><li>Decision Support </li></ul><ul><li>Health Information Management </li></ul><ul><li>Case Management </li></ul><ul><li>Finance </li></ul>
  15. 15. CRCR Experience <ul><li>Testers should have a working knowledge of revenue cycle </li></ul><ul><li>Approximately 50% pass first exam; 70% pass with retest </li></ul><ul><li>Most achievers have 3 years experience </li></ul><ul><ul><li>Experience does not equal knowledge: staff with over 20 years experience have not passed </li></ul></ul><ul><li>Program used as means to recognize individual initiative versus tenure </li></ul><ul><li>Directors notice difference with inter-department communications </li></ul><ul><li>Directors notice difference in Billing/Collections conversations with payers </li></ul><ul><li>CRCR designee sense of accomplishment: </li></ul><ul><ul><li>“ I will be able to show and prove not only my years of hands-on work experience within healthcare finance but also my will and desire to further my knowledge base and grow with the ever changing healthcare financial world as a whole.” Jennifer Brantley, NCICS, CPC-H. CRCR; Patient Accounts Specialist III </li></ul></ul>
  16. 16. Questions <ul><li>Bill Saunders Regional Account Manager MC Strategies :: Elsevier </li></ul><ul><li>214-537-6290 </li></ul><ul><li>[email_address] </li></ul><ul><li>Meg Flanagan HFMA Organizational Solutions Consultant 708-492-3310 [email_address] </li></ul>

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