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Revenue Cycle Management
The document provides a comprehensive overview of revenue cycle management, emphasizing the importance of viewing healthcare as a business to ensure profitability. It discusses the elements of the billing and collection cycle, including setting fee schedules, managing patient financial responsibilities, and the critical phases of claim submission and payment reconciliation. Strategies for improving financial policies, managing denials, and effective reporting are also highlighted to enhance the efficiency of the revenue cycle.
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Revenue Cycle Management
- 1. Revenue Cycle Management Wednesday, June 11, 2014 Disclaimer: Nothing that we are sharing is intended as legally binding or prescrip7ve advice. This presenta7on is a synthesis of publically available informa7on and best prac7ces.
- 2. In an industry, that’s ever changing, one thing remains consistent-‐ Delivery of healthcare must first be viewed as a Business. If you are not profitable, you can’t keep the doors open to provide services to your pa@ents in need. Revenue Cycle Management
- 3. Fee Schedule Financial Policies The Pa@ent Visit The Billing and Collec@on Cycle Reimbursement Analysis The Revenue Cycle
- 4. • cycle n. An interval of @me during which a characteris@c, oJen regularly repeated event or sequence of events occurs • The perfect cycle of revenue should really be this simple: – Provide Service – Submit Claim – Get Paid Focusing on the “Cycle”
- 5. How did you arrive at your fee schedule? – What does it cost you to provide service? • Have you done a cost study? – Can you manage this internally? – Should you reach out to a consultant? • Fees should be built based on what keeps your business running and profitable, rather than what sounds “reasonable an customary”. – Are you basing it on a percentage of Medicare? – Are you basing it on RVU’s? – Did you base it on your highest payer? – When you nego@ate contracts, you need to know your cost, to know if the contract makes good business sense. Fee Schedule
- 6. • UpdaCng your fee schedule – Maintain your fee schedule • Update the fee schedule every 3-‐12 months. – Does your soJware have a place to load RVU’s • Does your vendor/consultant offer a u@lity to upload published RVU’s into your prac@ce management soJware – Does your soJware have a place to load costs • How are you recovering costs of medical supplies? • Are you geYng paid more than your cost on vaccines? Fee Schedule
- 7. – What is your expecta@on of the pa@ent to fulfill their financial responsibility? • Do you require them to pay their por@on at the @me of service? – A survey by the MGMA found that 30 percent of pa@ents walk out the door without paying any amount at the @me of service. • Request full payment at the @me of service for non-‐covered and elec@ve services. • If the pa@ent is unable to pay in full, what Is the minimum amount accepted? • Do you offer payment plans? • Do you offer discounts for payment at the @me of service? – Is your expecta@on defined in wri@ng? • Is it posted on your website • Do you communicate it on your pa@ent portal • Is it included it in new pa@ent packet • Is there signage at the check-‐in and check-‐out areas. Financial Policies
- 8. Revenue Benefit Verifica@on Pa@ent Check in Intake Assessment Physician Encounter Charge Genera@on Checkout The Pa@ent Visit
- 9. – At what point does the Billing Cycle Begin? • When the pa@ent schedules the appointment? • When the benefits are verified? • AJer the service is provided? The moment the service has been provided, the billing cycle begins. Everything you did prior to the service being provided, determines how quickly you complete the cycle. The Pa@ent Visit
- 10. Service Provided • Charge Entry • Charge Audit Claim Filed • Claim Edits • Claim Reconcilia@on • Denial Management • Appeals Payment Received • Payment Reconcilia@on • Pos@ng Audit • Contract Analysis The Cycle
- 11. Service Provided Charge Entry Charge Review Charge Audit • Automated whenever possible • Eliminate charge lag • Timely filing limits prevented • Payer requirements • Modifiers where appropriate • Edits addressed • Payers are a^ached • For every service provided, a charge is submi^ed • Unbilled charges addressed • Charges have a unit price where appropriate
- 12. Claim Filed Claim Edits Claim Reconcilia@on Denial Management Appeals • CCI • Payer Specific Edits • Claims submi^ed should be reconciled with the claims received by the clearinghouse/payer • Payer acknowledgements • Online Claim status • Automated • Should be addressed within 24 hours • Denial Analysis to prevent the same denial • Automated • Appeal Le^ers
- 13. Payment Received Payment Reconcilia@on Pos@ng Audits Contract Analysis • ERA where possible • Confirma@on that the ERA hit the bank • Payments Posted are balanced to the funds received • Payments and adjustments are audited to ensure accuracy • Were you paid according to contract? • Were you paid 100% of your charge • Were you paid above your cost?
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- 15. Management Iden@fy where the ownership within your prac@ce is for the following: • Fee Schedule – Establishing Fees • Evalua@ng the cost to provide service – Nego@a@ng Payer Contracts • What is the cost compared to the payers allowable • Don’t ignore indirect costs with specific payers – Higher denial rates ? – More appeals? – Are they paying with a credit card, and where fees to process them are incurred? – What’s the administra@ve burden? • What por@on of your business does the payer account for? • Go from “evergreen” to “nevergreen”
- 16. Management • Financial Policies – Financial Policy • Who develops/maintains the policy? • Who is responsible for the consistent execu@on? – Financial Clearance • Benefit Verifica@on process – Automate – 1-‐3 days prior – Evaluate the process (Denials related to eligibility) – Communica@ng the expecta@ons to the staff as well as the pa@ent. – Execu@on of Pa@ent obliga@on • Know/communicate the pa@ent por@on prior to the visit • Require staff to collect it • Evaluate how successful the process is (Pa@ent Aging Reports)
- 17. Management • Tools You’ll need for Pa@ent Financial Responsibility – Merchant Services • Credit Card Processor • Check Scanning – Integrated with the PM SoJware? – Eligibility Tool • Integrated with the PM SoJware • Perform queries in bulk – Pa@ent Por@on Es@mator – Pa@ent Portal
- 18. Management • Pa@ent Receivables – Review and analyzes pa@ent receivables weekly for the previous week to determine how effec@ve the collec@on process is at the @me of service. • Co-‐Pays and Deduc@bles should almost never make the list. • Review by CPT to iden@fy trends of items that staff may not have been aware was non covered. • The findings should be communicated and discussed weekly. – Analyze and report the pa@ent aging based on the date the pa@ent became responsible at the end of each month. • Pa@ent AR greater than 90 days should be less than 10%. – Pa@ent balances should be referred to collec@ons at 91 days. – Automate the process • Anyone who is involved in the collec@on process from the front end of the cycle to the back end of cycles should be aware of this key indicator. – Manage Bad Debt – Reconcile Bad debt in your Prac@ce Management SoJware with your collec@on agency. – Monitor collec@on agency performance
- 19. Management • Charges – Solicit feedback from the staff performing the charge process. • How oJen are they, making changes and what are they changing. – Does there need to be training of the end user? – Are there system set up issues that need to be addressed? • Manage and report charge lag and unbilled charges. • The findings should be communicated and discussed weekly. • Claims – What issues are iden@fied through the claims reconcilia@on? – Monitor Clearinghouse rejec@ons daily • Are they being worked daily? • What are they are correc@ng and how can they be prevented? • Denials • Report Denial % Monthly – Should be less than 2% of your submi^ed charges • Evaluate what is being denied weekly • Take ac@on to prevent the same denials in the future • Monitor ac@on taken on denials – Worked within 24 hours? – Did their work result in payment?
- 20. Management • Pos@ng – Are pa@ents being billed appropriately? – Are adjustments Appropriate? – Are payment reconciling with receipts • Contract Analysis – Are you being paid according to your contract? – Are you being paid at 100% of your charge • Evaluate the fees, and increase as appropriate so that you are not leaving money on the table. – Are you paid more than the cost?
- 21. End of Month Repor@ng ! Iden@fy key indicators for your group or prac@ce ! Days in AR ! Denial Percentage ! % of AR over 90 Days by payer and pa@ent ! Charge Lag Communicate results to anyone who has involvement with the cycle so that they can align their efforts and share in the success of your results.
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