Learn Revenue cycle healthcare management

Patient Intake

Patient access and patient registration are common names for the department that is typically responsible for obtaining the initial demographic and financial information from the patient. Individuals in this department perform what are sometimes called front-end functions, which include but are not limited to the following:

· Recording the reason for visit (admitting diagnosis)

· Verifying and recording patient identifying data, such as name, address, and date of birth. The Social Security number may be collected, but be aware that patients concerned with their privacy and data security may not agree to provide it

· Verifying and recording patient financial data such as insurance and guarantor

· Obtaining precertification/authorization, including submission of the notice of admissions (NOA) for inpatient stays (if required) from the insurer for services to be rendered

· Identifying patients who will need financial assistance to cover the cost of care

· Assigning patient tracking numbers, including the medical record number

· Assigning clinical-service tracking codes, if applicable.

Clinical Services

Once the patient is registered, he or she moves on to the appropriate service area, such as the laboratory, radiology, or same day surgery (SDS). As services are rendered, charges for those services are accumulated. There are two front-end activities involved in the provision of clinical services:

· documenting the service provided - , documentation is a critical component of reimbursement. If the service is not documented, or the documentation does not support the charges, the provider is not entitled to payment for that service.

· recording the associated charges - medical record is a long-established means of communication about provider services—if an event is not documented, it is deemed not to have occurred

Case Management / Utilization Management

The case management department plays a significant role within the revenue cycle process for all inpatient cases. Case management needs to make sure that all managed care patients, whether commercial, managed Medicaid, or managed Medicare, meet the payer’s specific utilization management medical-necessity standards.

Charge Capture

Along with documentation of services, the clinical services department must also record the charges for those services. Charges are not just for reimbursement; they may also be used for tracking volume as well as inventory. The mechanic must record the time spent working on the vehicle as well as the number of quarts of oil used and the disposition of the oil that was removed. With that data, the dealership can track how many oil changes each mechanic can do in a day, ensure timely replenishment of oil supplies, and monitor its costs for disposal of hazardous waste.

Billing

Once the services have been rendered and the encounter has ended (or the patient has been discharged), the payer can be billed. The preparation of the bill (also known as the claim) is a patient accounting function. Typically, healthcare organizations do not bill immediately on discharge. There is a waiting period, up to five days for inpatients and up to seven days for outpatients, that allows for reconciling activities versus charges, making corrections as needed, and applying any additional diagnostic and procedural coding. This waiting period is called the bill hold.

Tracking of outstanding patient accounts is an important performance measure. There are several components of tracking:

· Patients who are still being treated—These patients accumulate charges that cannot be billed because their encounter has not ended. Example

Outpatients with multiple visits, Inpatients who have not been discharged.

· Patients whose encounters have ended but for whom a final bill has not been prepared—The specific report that lists these encounters is often called the discharged, no final bill (DNFB) or unbilled report.

· Final bills that cannot be sent to the payer due to errors—These bills are on hold until the errors are corrected.

· Bills that have been denied (returned unpaid) from a third-party payer, also called denials—A third-party payer is an insurance company or entity, other than the patient, with whom the patient has a contractual relationship regarding payment for healthcare services.

Collections

Once the bill has been sent, the healthcare facility or provider expects payment within a specified time period. Some payers, such as Medicare, receive payments on a routine schedule, and claims review over and above automated edits may lag, with reconciliation of amounts due on a periodic basis.

Medicare and Medicaid- pay claims within 14 days of receipt of a clean claim Commercial pay within 30-45 days of receipt of a electronic/paper clean claim.

Some patients do not have the resources of a third-party payer or may be seeking services for which their third-party payer will not reimburse. Identifying these patients up front helps the provider manage arrangements for payment or guide the patient into counselling for an appropriate government assistance program, such as Medicaid.

HIM department has a wide variety of roles that HIM professionals may play in revenue cycle management. In fact, HIM professionals at all levels may play some role in managing or supporting an efficient and effective revenue cycle.

A quick look at the Health Information Career Map (AHIMA 2015) and the HIM academic competencies (see online appendix 1.3) illustrates that HIM professionals are well suited for a revenue cycle career path.

At the Entry level, there are billing- and insurance-related jobs. The entry-level competencies for HIM programs at the associate-degree level cover the work-based skills needed for these positions. For example, graduates of an accredited associate-degree HIM program can apply and evaluate the application of diagnosis and procedure codes appropriate to settings across the continuum of care, analyse current regulations and established guidelines in clinical classification systems, and evaluate revenue cycle management processes, coding, clinical documentation improvement, and revenue cycle auditing.

At the Advanced level, baccalaureate-level training in managing data, implementing processes for revenue cycle management, and reporting and applying principles of healthcare finance for revenue management supports HIM practitioners as managers of coding and the revenue cycle and in related consulting roles. Ultimately, HIM practitioners with additional training in leadership and strategic models can move into administrative roles

The goals for improving revenue cycle performance include but are not limited to improving data quality, producing clean claims, and reducing denial rates. Improved revenue cycle performance is not necessarily about treating more patients or expanding services, although those are certainly reasonable strategies for increasing revenue

Patient access and patient registration or Front office registration are common names for the department in the healthcare facility that is typically responsible for obtaining the initial demographic and financial information from the patient i.e.

• Along with documentation of services, the clinical services department must also record the charges for those services. Charges are not just for reimbursement; they may also be used for tracking volume as well as inventory.

• A process of recordkeeping applies in a clinical setting e.g. If a laboratory test is ordered for a hospital inpatient, a charge must be recorded in the patient’s account. Timely collection of laboratory charges enables the facility to track these services not just for reimbursement purposes but also to ensure sufficient laboratory staffing and supplies.