The document outlines the structure and challenges of Revenue Cycle Management (RCM), including elements such as charge capture, claims submission, denial management, and financial counseling. It emphasizes the importance of documenting physician practices, maintaining an accurate Charge Description Master (CDM), and managing accounts receivable effectively to improve financial stability. It also addresses the role of analytics in assessing performance and highlights the need for quality improvement and staff training to address common challenges in health information management.

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2. Agenda
The Structure of the RCM
Internal Challenges
External Challenges

3. The RCM Structure
Documentation of Visit
Medical Coding
CDM Management
Charge Capture
Claims Submission
Payment Processing and Posting
Denial Management
A/R Follow-up and Appeals
Patient Scheduling
Pre-Registration / Registration
Financial Counseling
Patient Co-pay collection

4. Patient Access
Patient Access Components
Scheduling
Pre-registration
Registration
Financial Counseling
Point of Service Collections

5. Physician Documentation
Cutting and pasting practices
Lack of Keyboard skills
Delayed documentation
Symptoms Versus Diagnoses
Missing Diagnosis
Dependance on EHR
Common Physician Documentation Issues
Evaluate Current status of patient
Develop Plan of Care
Evaluate care given
Provide for Continuity of Care

6. HIM
CDI :
Information
Compliance
Coding :
Information
Abstraction
HIM Operations:
Information
Governance
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Health information management encompasses Information governance, Information compliance, Information Abstraction

7. CDM
Why should we Maintain the Charge Description Master
Regulatory changes
Changes in regulatory reimbursement guidelines
Changes in payer specific policies
Modifications to allowable data requirements by chargemaster vendor
Identifying services or procedures conducted but not currently represented;
Linked and exploding charges
Changes in department codes to represent where charge item is charged

8. Why do we need it?
Payments are often related to charges
Charges drive prices and rates for reimbursement
Charges reflect resource utilization
Charges help with measuring labor cost and productivity
Errors in charge capture create significant rework and billing
delays
Procedures
Services
Pharmacy
Supplies
Inpatient Room and
Board
Charge Capture

9. Billing
Billing
Claims Editing
Claims Submission
Payment Posting

10. Accounts Receivable
Why is A/R Follow-Up Important
Payments Overdue
Missing Claims
Denied Claims
Pending Claims
Financial Instability
Outstanding Accounts timelines

11. Denial Management
 Demographic denials?
 Benefit denials?
 Pre-Authorization?
 Coding denials?
 Back-end billing denials?

12. Denial Management
How to work your denials:
Determine the root cause behind the denial
Classify the denials by source and Make your Decision
Engage key stakeholders to correct the information
Resubmit or appeal the claim
Track the details and stay organized

13. What are revenue cycle analytics?
Is your end user getting the right information?
Can you evaluate performance of providers, teams and locations?
Do your revenue cycle analytics tools give you actionable insights?
Can you customize reporting with your current platform?
“If you can’t measure it, you can’t manage it.”
Quality Metrics

14. How to Improve
Educate Employees on the Significance of Their Contribution
Prepare the work environment to be Quality Driven
Performance Expectations
Incentivize Accuracy
In-built Error-detection Mechanisms

15. Billing and collections errors
Health information technology challenges
Lack of staff training
Failure to monitor the entire claims process
Failure to have a financial policy
Here are the Top five challenges faced by the executives within the RCM operations
Challenges