Hospital Revenue Cycle Management ???????? - PowerPoint PPT Presentation

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Hospital Revenue Cycle Management ????????

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Title: Hospital Revenue Cycle Management ????????

1
Hospital Revenue Cycle Management????????

Health Systems Management
??????
Sylvia Pan
United Family Hospital and Clinics
Vice President

2
The Revenue Cycle is the how a medical facility
is reimbursed for its services ??????????????????
?,???????????- usually the first and last
encounter a patient has with the
institution.?????????????????????????? (?
??,????)
3
Revenue Cycle Overview
4
Admissions -Registration?? ??
Note that cashiering is not under admissions.
5
Registration????

Registration is the collection of the
appropriate demographic information to required
to submit a clean claim to a insurance provider.
Two types of registration
??????????????, ????????????. ????
1. Pre-registration Where the
facility had advance notice for the elective
procedure.
???? ?????????????????
2. Site Registration Registration
that occurs at the time of service.
???? ??????????

6
Demographics ???????

Name, address, phone number, email
??, ??, ????, ??????
Insurance carrier, identification number
??????, ???
Emergency contact
?????
Referring physician
????
Employer
??
Guarantor
???

7
Eligibility Determination?????????
Insurance Verification ???? - Is their
insurance coverage valid, ?????????? is
it credible ???? does it cover these
services ?????????????? PreCertification
Does the procedure have to be pre-certified by
the insurance company. ???? -
????????????????? Do they have a co-insurance or
deductible ?????????????????
8
Registration Collections????

Does patient have co-pays, deductible or
co-insurance ?
?????????????????
Must know payer contracts ??????????
Review insurance cards ?????
Build into pre-certification process
????????
Does patient have balances due on other service?
?????????????????
Delay or deny service if they cant pay?
?????????,?????????????

9
Charge Capture???????

Charging accurately for the services and
supplies used to treat the patient.
??????????????????
Super Bills ??
Bar Coding ??
Manual entry to I/S system ????I/S??

10
Late Charges ?????

Charges entered after bill has been created
?????, ????
Require rebilling ????????????
Some insurers will not accept
Late Charge Reports Tracking
??????????, ????????
System based electronic charging eliminates most
late charges
??????????????

11
Late Charges?????

Days of charge entry lag
date of service - date of charge entry days of
lag
???????? ????? ?????
should be 0 or 1 (with some exceptions)
?? 0 ? 1 ? ( ????????)

12
Charge Capture Metrics????????

Number of Missing Charges
number of missing charges/
total number of appointments
??????/???????
in outpatient setting should be close to 0
????????0

13
Hospital Charge Master???????

A hospital-specific computer file that includes
all hospital procedures, services, supplies and
drugs
that can be billed to payers.?????????????????????
?
Each record listed in the charge-master file has
five corresponding data items
????????????????????????HCPCS??????????

14
Hospital Charge Master Sample??????
15
Medical Coding ????

Converting or capturing the patient encounter in
an agreed upon numeric representation.
????????????????

16
Codes????

DRG
ICD-9, ICD-10
Procedural
Revenue
CPT
Evaluation and Management

17
Coding Metrics????

Dollars of Rejections for Coding
?????????????
dollars of coding rejections/
total dollars rejected claims
?????????/ ??????

18
Billing Job Description????????

Review accounts to verify insurance
??????
Review account coding for completeness
??????????
Obtain missing or incomplete data to complete the
bill
??????????
Submit claims(electronically or hard copy)
???????
Document billing activity
??????????????
Track trends miscoding of insurance or other
fields
??????????????

19
Secondary Billing??????

Primary Insurance Pays
???????
Second to primary is secondary insurance or
patient responsible for
?????????????
Deductible?????
co insurance ?????
Must bill with Explanation of Benefits of primary
insurance
????????????????????

20
Biller Quality-Productivity???????????

Accounts billed per day/ week
?????????
Electronic submission 100-125 day????100-125/?
Paper claims 25-50 day ??????25-50/?
. 98 of accounts that are billable are billed to
the correct payer
98????????????
No backlog of unbilled accounts
?????

21
Patient Bills ?????

Easy to read
??
balance due??????
date of service????
account number??
summary of service????
patient ??
reflect all prior payments adjustments???????????
Do not need itemization with detail unless
requested
??????,??????????

22
Payments ??

Bank transfer, ????
Checks by mail ????
Credit cards???
Checks to a lockbox????
Cash??

23
Cash Application

The posting of payments to patient accounts.??
Separate function from billers and collectors to
maintain segregation of duties. ????????????????
Control underpayments.?????????
Apply contractual allowances.?????????

24
Collections??

Facilitation the receipt of money the
institution would not receive without the
collectors effort.
????????????????????

25
Collector Job Description????????

Seek payment from insurance and patient (payers)
????????????
Resolve conflicts or issues of missing data with
payers
??????????????????????????????
work effectively with internal departments
??????????????
Track trends leading to payer denials disputes
???????????????
Document collection activity
?????????

26
Collections Metrics ????Key Reports????

Aged Trial Balance -monthly Charges, Payments
(receipts) and adjustments aged A/R per Month (
separates the A/R by "aging buckets," i.e., 0-30
days, 30-60 days, etc.)
????????????????,????????????????(?????0-30?,30-
60?????????????)
Gross and Net Collection Rates (by month)
???????????
Total A/R and Days in A/R Trends
????????
Total A/R and Days in A/R Trends by Major Payer
????????????

27
Gross Collection Rate????

How much money is collected on the charge for the
service.
?????????????
Total Payment / Gross Charges
Gross Collection
????/ ???????????
Hard to pick target depends on payers and
contracts.
?????????????

28
Net Collection Rate????

How much money is collected on what can be
collected (is not contractual write off).
??????????????????(???????????????????)
Total payments / (Gross charges-adjustments)
net collection
????/ (???-????)???????
Should be 100
??100

29
Collection Time Line ????(Sample)

Day 1 - Account Billed
???----???
Payment may take 17-90 days depending on payer
location and edits
??????17-90??????????????????
Day 17-90 follow up 1
?1??????17-90?
Day 24-94 follow up 2
?2??????24-94?
Day 31-103 follow up 3
?3??????31-103?
collections/ write off??????

30
Self-Pay Collections??????

Uninsured patients?????
Denied claims??????
Balances after insurance?????????

31
Denials Management????

Responsible for reviewing all denials????????
Filling appeals and recovering funds??????
Tracking trends??????
Conducting root cause analysis of trended data
?????????????
Working with departments and payers to prevent
future denials?????????????????

32
Write-off ????
All final denials written off should be
tracked. ?????????????? Standards Final
denials are defined as denials where all appeals
have been exhausted (denial management had
reviewed). It is strongly suggested at least two
appeals be done before write off
consideration. Remind contact the local tax
bureau for the business tax refund for the
write-off at the year end. ?? ??????????????????
??(????????)????????????????????????? ??
????????????????????????? (????)
33
? ? ? ? ? ? ? ????? UFH Network Investment
and management
?????? CHINDEX
????? 1997.8
???? 2008?
????? 2004.11
???? 2008.4.2
???? 2002.10
??SRC?? 2004.11
????? 2005.5
???? 2008?
34
?????????
???????
??????
???????
???????
??????
35
????????

????????????????????????
??????????????

80??????????
????????????????????(13???)
????7/24?????????????
??????JCI???????????

36
???????
?????? ?????? ?????? ?????? ?????? ??????
?????? ???????,?????????, ??????, ??????,
?????? ????,????,????, ??????????????????? ???????
?????,????????,????????,?????????????????,
???????
37
?????United Family Hospital????