Introduction to Revenue Cycle Management
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Transcript of Introduction to Revenue Cycle Management
The Healthcare Financial Management Association (HFMA) defines revenue cycle as:
"All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue."
In other words, it is a term that includes the entire life of a patient account from creation to payment. Revenue cycle processes flow into and affect one another. When processes are executed correctly, the cycle performs predictably. However, problems early in the cycle can have significant ripple effects. The further an error travels through the revenue cycle, the more costly revenue recovery becomes
REVENUE CYCLE MANAGEMENT 101DEFINITION OF REVENUE CYCLE:
Scheduling & Pre-registration
FinancialClearance
PricingCharge
Capture & Entry
CodingCDMStandardization
CDM (Charge Description Master): Is a file with comprehensive listing of items that can be billed to a patient or insurer by a healthcare provider.
ContractsClaim
ProcessingAccount
CollectionsDenial
ResolutionPaymentPosting
FinancialCounseling
Arrival &Registration
DenialPrevention
Technology
Customer Service
Performance Management and Monitoring
Change Management, Coaching and Training
Charge Integrity “Middle”Revenue Cycle
Patient Financial Services “Back End” Revenue Cycle
Patient Access “Front End” Revenue Cycle
Revenue Cycle Management
Revenue Cycle Management
Daily/month-end balanceMonth-end reporting
Open issues tracking
Key metric tracking
Non-collectible
adjustments
Ad-hoc reporting
analysis
Root cause analysis
Pre-Claim
Pre-Visit VisitClaim
SubmissionInbound
Processing
Month-End Closing
Performance Management
Account Receivables Management
Quality Management
ComplianceInformation Technology
Contract Negotiation
s
Eligibility Verification
EDI/ERA Enrollment
Fee Schedule
Scheduling/Registratio
n
BankingSet-up
Patient Check-in
Mail Processing
Claim Status
Patient Statements
Provider Credentiali
ng
Appointment
Reminders
Co-pay and deductible collection
Patient Payment
Arrangements
Encounter Documentati
on
Coding and Charge Capture
Scanning/Indexing
Bank Deposit
EFT,ERA Processing
Payment Posting
Revenue Allocation
Pre- Adjudicatio
n
Claim Submission
EDI Manageme
nt
Request for Information
Denial Analysis
Appeals and
Resolution
Inbound and
Outbound Calls
Collection Letters
Patient Refunds
Conveyance, Small
Balance Write-Off
Transition to
Collections
No-show rate
Charge Entry
Claim Scrubbing
Analytics
Cash collected
Revenue Cycle Management Support
Regulation monitoring
Coding and chart audits
Non-collectible adjustments
Coding support for billing
process
Practice management
system
EMR integration
Other application
integration
Interfaces/data exchange
Hosting and support
Process measures and
audits
Employee performance
audits
External audits
Front End Back EndTransaction Processing
Life of a claim
Total days in AR
Payers denial rates
Rejection analysis
Increased reimbursementthrough improved, consistent,and defendable chargedescription master (CDM)efficiencies and identificationof missed billing opportunities.
Reduced outstandingaccounts receivables anddenials through processimprovement andworkflow tools.
Improved accountabilityand immediate issueidentification throughdesign and implementationof managementperformance reporting.
RCM Benefits Include:
Benefit
Accelerated cash flow andimproved annual net revenueby streamlining every stepin the revenue cycle byfocusing on people, process,and technology.
Benefit Benefit Benefit
Charge Capture:Documented services are manually or electronically translated into billable fees.Claim Submission:Billable fees are submitted to the insurance company via a universal claim form for payment.Coding:The process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers.Patient Collections:Collecting patient balances, making payment arrangements.Pre-registration:Collection of all registration information, including eligibility, benefits and authorizations, prior to the patient's arrival for inpatient or outpatient procedures.Registration:Collection of a comprehensive set of data elements required in establishing a Medical Record Number and satisfying regulatory, financial and clinical requirements.Remittance Processing:Posting or applying payments/adjustments to the appropriate accounts, including rejects.Third Party Follow-up:Pursue collections from insurers after the initial claim has been filed.Utilization Review:Evaluation of the necessity, appropriateness, and efficiency of the use of medical services and facilities, which includes regular reviews of admissions, length of stay, services performed, and referrals.
REVENUE CYCLE TERMS REVIEW
YOUR ATTENTION
THANKS FOR
Introduction to revenue cycle presentation prepared by Mynor Veliz, CFOCopyright: Intermountain 2015