Revenue cycle management

Revenue cycle management

• 3.
  Physician’s Office OrEmergency Room Physician writes an order  To admit patient  To observe patient  For tests, procedures, lab, radiology, etc  For surgery  SDS  Inpatient surgery
• 4.
  Scheduling  Referrals  Authorizations Pre-cert or pre-auth must be obtained from insurance prior to treatment  Pre-cert or pre-auth number must be included on claim  Notifications  Some insurances do not require authorization.  Some insurance request to be notified.
• 5.
  Pre-Registration  Verify InsuranceCoverage  Verify Authorization  Verify Patient Demographics  Determine Patient Responsibility  Co-pays, deductibles  Co-insurance  Obtain Patient Responsibility up front  Collect deposits
• 6.
  Financial Counseling  Meetwith patients to review their financial obligations  Scheduling / Pre-registration process  Registration  Prior to discharge – inpatients  During discharge process – in and out patients  Once they are out the door the chances of collecting diminish dramatically
• 7.
  Registration’s Turn  Verifyany missing data  Verify Identity  Scan Insurance Cards and documentation  Obtain co-pays & patient responsibility $$$  Patient Signs required documents  Permission to treat, guaranty of payment, assignment of benefits  Other consent forms
• 8.
  And More …… Advance Directives  Notice of Financial Responsibility  MSP Questionnaire  Rights as a Medicare patient  ABNs  HIPAA – Privacy Notice  Red Flag Regulations  Etc.
• 9.
  Bed Management  BedAccommodation  Private  Semiprivate  Verified at Midnight  Charged at Midnight  Patients holding in ED for a bed
• 10.
  Case Management  Seeevery observation or inpatient  Case management monitors inpatient and observation patients’ care to ensure admission meets admission criteria  Interqual  Milliman Care Standards - used by insurances  Works with physicians to discharge the patient in the appropriate amount of time or ensure patient still meets inpatient criteria.  Monitors and works on delays to recovery.  Review patients status:  Medicare and Medicaid – every 3 days  All others - daily
• 11.
  Discharge Planning  Performedby case management.  Begins when patient is admitted.  Goal is to only keep patient in house as long as is medically necessary to provide excellent quality of care while maximizing reimbursement.  Discharge to appropriate community resource  May arrange transfer to SNF, Home Health, contact family, etc.  Work with physician and family  Consider what insurance will pay for
• 12.
  Charges are Entered Charges are maintained in the charge master (CDM)  A unique charge code identifies each service and test performed or supply provided  Many charges have CPT-4 or HCPCS codes attached, required for billing  Charges connect to Revenue Codes, required for billing  Charges are billed on UB04 and HCFA 1500 claim forms
• 13.
  Services are Documented Documentation must exist in the Medical Record to support all procedures performed and supplies used.  Physician and Clinical staff signatures are critical  Verbal orders must be signed  Documentation must be complete and legible
• 14.
  Electronic Medical Record Automate as much of the medical record as possible.  Eliminates filing issues  Allows for instantaneous access to medical record  Reduces storage space  Much of our medical record is electronic
• 15.
  Patient is Discharged Financial Counseling  Outstanding balances, co-pays, co-insurance, deductibles, bad debt, non-covered services  Discharge Planning  Discharge disposition – can affect reimbursement  Another facility  SNF  Home  Home health
• 16.
  Medical Records –“HIM”  Manages the medical record  Scans and files loose documentation  Verifies electronic records  Ensure physician, nurses and clinical staff have signed where necessary  Monitors, reports and obtains chart deficiencies  Coding and abstracting  DNFB management
• 17.
  Medical Records Coding Medical records chart reviewed by certified coder  Physician, nursing and ancillary documentation is critical  ICD- 9 codes: diagnoses, procedures  CPT-4 codes: procedures performed  Greatly impacts reimbursement  Heavily regulated
• 18.
  Insurance Processes Claim Pays claim  Denies claim  Immediately  After processing  Line item denials  Pends claim  Doesn’t notify hospital  Timely filing
• 19.
  Contact Us Futuristic Gigatech 46/4,Novel Tech Park, Garvebhavi Palya , Kudlu Gate, Hosur Main Road, Bangalore, Karnataka – 56 00 68. E-mail : [email protected] India Office: 0091 80 4093 4093 India Mobile: 0091 903 500 4530
• 20.
  QUESTIONS ???