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crcr-section 1 Patient centric revenue cycle Intro


Question Answer
What is the Patient Centric Revenue Cycle Pre -service, time of service , and Post service
What happens during Pre-Service scheduling and pre access cost are calculated (Pre Registration)
What happens during Time of Service Case Management, service is provided, and discharge planning and consents are signed
What happens during Post service Bill is electronically sent to health plan and patient account is monitored for payment until a zero balance
What three categories are on the Balance Sheet Assets, Liability and Equity
What is a balance sheet a statement of the summary of the organizations wealth as of the date of the statement. It represents the summary of the organizations assets liability and accumulated excesses from operations minus any accumulated losses.
Net Assets the value of excesses and losses
What three categories are on the Income Statement Revenue expenses and profit
What is the income statement ties to the balance sheet and is the summary of the organizations revenues expenses and any excess or loss from operations
What is on the Cash Flow Statement Operation Investment Financing
What is the cash flow statement The summary of how cash was used and where it was obtained
What is gross revenues The total charge entered for all the services patients received
What is Net Revenue an estimate of the dollar amount contractual, discounts, and allowances that will be applied against those revenues. It is the difference between the amount billed and the amount the payers have committed to pay based on an agreement with the provider
Which statement does the net revenue appear On the Income Statement
What is the gross charges after recognizing any contractual agreement Net Revenue
What are the three reserve amounts on a financial statement 1. contractual allowances 2. Bad Debts 3. Charity Care
What are contractual allowances The difference between a provider's billed charges and the actual payment from the insurer reflecting a discount below the billed charges accepted by the provider
What three things impact Patient Service Revenue and Net accounts receivable 1. self pay discounts 2. adjustments to charity 3. bad debt provisions
What are Bad Debts a deduction from the total accounts receivable
Where are bad debts found On the Income statement as a deduction from patient service revenue , net contractual adjustments and other discounts and charity
What is Patient Service Revenue Revenue the healthcare center generates from treating patients
What are examples of patient service revenue payments from medicaid medicare and commercial insurance
Net Accounts Receivable A/R is a term used to denote money owed to your practice for services you have rendered and billed
How are Bad Debts calculated deducted from the total A/R found on the income statement as a deduction from patient service revenue, net contractual adjustments and other discounts and charity
Bad Debts The amount not recoverable from patients after collection efforts
Charity Care impacts recoverable amounts of A/R. Reduces gross revenue. The total amounts are footnoted on a financial statement
What is the Net Receivables Reserve estimated and deducted from Gross Receivable
What are the five components of the Net Receivables Reserve 1. contractual allowances 2. self pay adjustments 3. Bad debt 4. charity 5.other allowances
Provider Revenue the difference between gross revenue and net revenue
Reserve Amount on a financial statement contractual allowance, bad debts and charity care
What are the three initiatives of the HFMA Dollars and Sense 1. Financial Communication 2. Price Transparency 3. Medical Account Resolution
When is the best time to have patient financial discussions At the time of service or in advance
Price Transparency information on the price of healthcare services
What are the three things needed for an accurate price estimate 1. CPT code /MS DRG 2. Patient's health plan 3. patient's benefit plan
Medical Account Resolution occurs after service is rendered. It is the activity that applies to patient's with outstanding account balances
Whest are the eight best practices for Medical Account Resolution 1. Educate 2. Clear and concise bills 3. policies are followed 4. consistency 5. coordination to avoid duplicate contact 6. judgement to communicate with patients about bills 7. Timing 8. report and track
Affordable Care Act ( ACA) signed into law in 2010 designed to reform the healthcare system that rewards greater value, improves quality of care and increases efficiency in the delivery of services
What are the four provisions of the ACA 1. improve quality of care 2. reform health care delivery system 3. encourage price transparency and the modernization of financial systems 4. Reduce issues of waste fraud and abuse
ACO Accountable Care Organization
What is an ACO delivery system of hospitals, physicians, and other healthcare providers who work collaboratively to manage and coordinate the care of a patient population
What are the three purposes of the ACO 1. appropriateness of care 2. prevention of duplicated services 3. Prevention of medical errors for a population of patients
MSSP Medicare Shared Savings Programs
CMS Center for Medicare & Medicaid Innovation
What does CMS do a federal government agency charged with the on going development of new models for delivery and payment of services for medicare and medicaid
Name four ACOs 1. MSSP 2. Pioneer 3. Investment Model 4. ESRD Care Model
ESRD End Stage Renal Disease
KPI Key Performance Indicators
What are KPIs a standard for A/R and provides a method of measuring collection and control of A/R
Benchmarking used to compare KPIs in an organization to an agreed upon average, or expected standard within the same industry
What is the significance of Benchmarking it varies depending on the type of provider, geographic region, size of the provider base, types of services and hard to agree upon
Map Keys strategic indicators that set the standard for patient centric revenue cycle excellence in the healthcare industry
What are the five major groups of KPIs 1. Patient Access 2. Pre Billing 3. claims 4. Account Resolution 5. Financial Management
What are four techniques to measure A/R 1. Days of Revenue in Receivables 2. A/R Aging Analysis 3. Credit Balances (days outstanding) 4. other measures
Days of Revenue in Receivables is also called Net days in A/R or A/R Days
What is A/R days Measures how fast receivables are collected. It is an indicator of the overall A/R performance and an indicator of overall revenue cycle efficiency
How do to calculate A/R days This is the net A/R from the balance sheet divided by Patient Service Revenue on the income statement
What is the time period for A/R Days end of month, 3 months, or fiscal year
What is the significance of A/R Days It uses revenue actually posted to accounts during the specified period including holidays and weekends
Why use A/R days for specific payers it is used to evaluate the collection efficiency and payment process on third party health plans or self pay patient
What are the benchmarks for days A/R The industry standard is to base the calculation on net A/R and net patient service revenue. This provides a relevant statement of cash owed to the organization for patient services for 40-45 days
What are the trends of days A/R decreasing values are favorable. Values below the median are favorable.
What is A/R Aging Analysis reports that divide A/R into 30/60/90/120 days over categories based on date of service/discharge or bill date
What is the shortcoming of AR Aging Analysis it can mask the impact of processing delays that occur between the completion of the service and the production of the claim
How to calculate Net Days in Patient A/R Net Patient A/R divided by Average Daily Net Patient Service Receivable
What are three reason why A/R is not being collected 1. Failure to complete comprehensive access processing either pre-service or at the time of service 2. not obtaining time of service payments 3. delays in billing
What are the six reasons that delays in billing exist 1. Late charging 2. delayed medical coding 3. delays in insurance verification 4. missing required information 5. delayed payment posting 6. lack of follow-up on A/R
Aging reports on third party payers must be done on a regular bases to track the number and dollar amount to help determine which payers are late or on time
What is the purpose of the ascending/ descending balance report It is a quick analysis to identify if a large number of small balances are not collected and what large balances are collected.
what is the Collection of Copays Analysis determines if a large number of accounts with a single outstanding balance that is equal to the payer's copay amounts are being collected during pre service and/or time of service
What are the two techniques to measure A/R 1. DNFB 2. Suspense period
DNFB Discharge Not Final Billed
What is Net Days in Patient A/R uses revenues actually posted during a time period. The revenue total is divided by the number of days in that period. The resulting number is the average daily revenue divided by A/R total balance for the last day of the reporting period
ADR Average daily revenue
What are the three things a 30 day ADR must have 1. total revenues posted to accounts each month 2. total revenues for three months divided by the number of days in each month 3. All revenues must be posted up even the last day of the specific date.
What happens to ADR at the end of a three month period it is divided into the A/R balance on the specific date
What is the benchmark for A/R Days It is the general indicator of the efficiency of the collection revenue posting and financial operations or accounts receivable.
What are two techniques to Measure A/R 1. Discharge Not Final Billed 2. The suspense period
DNFB Discharge Not Final Billed
What is DNFB part if A/R that identifies the charges for patients where the services are completed but the provider has not been able to bill the claim
What three things must happen before bill submission 1. All charging is complete 2. All medical record coding is complete 3. Insurance verification is complete
What is the suspense period established by providers. It is the period where billing systems allow for the completion of the activities before a claim qualifies for billing
What are the benchmarks for the suspense periods 3 days
FBNS Final Bill Not Submitted to Payer
What is FBNS A KPT that recognizes that claims may be held in a claim scrubber for additional editing prior to being released to the payer. It is an additional indicator of billing lag.
What is the benchmark for FBNS it's kept close to zero.
Scrubber Technology is designated to be a safety net in the claims process and not another delay point in the billing process
What is cost to collect the revenue cycle cost (expense) divided by the total patient services cash collected (collections)
What are the three components of cost to collect 1. patient expense 2. Patient accounting expense 3. HIM expense
HIM Health Information Management
What is HIM a hospital department that manages all aspects of a patient medical record
What is the best practice for cost to collect between 1.6% to 2.4%
What is High DNFB 15 or more days and anything over 28% of A/R
What is Low DNFB 4 days or less or 7.5% of A/R
What is the net collection rate A KPI that is the cash collected as a percentage of net revenue. It tells how much cash has been collected as a percent of what's available to collect. It is the ratio of the cash net revenue
What is the Net Collection rate if:Gross Revenue =900,000 Contractual Allowance=100,000 charity= 35,000 Bad Debt =25,000 96.7%
POS Points of service
What is POS cash the percentage of patient cash collected at or up to seven days after an occasion of service as a percentage of the self pay cash collected for the period. It is a reflection of the success of the patient financial communication approach
What is the best practice for the net collection rate 95% or higher
What is POS cash if:POS for the month =$450,700 Self Pay=2,900500 15.5%
What are high performance benchmarks for POS cash 25-37%
What is the benchmark for denials as a percentage of net revenue less than 2% of the claims on the first submission
What seven steps need to be tracked in order to minimize denials 1. percent of first submission 2. the number and dollar value 3. find out the source, reason, and location 4. the percentage of claims reworked 5. lag time between receipt, rebill or appeal 6. percent of initial payment 7. percent of write off
What are credit balances-days outstanding the dollars in the credit balance at the account level divided by the three month daily average of total net patient service revenue. resolved in a timely manner
What are the benchmarks for credit balanced less than 1% of the days outstanding in the A/R
HCAHPS Hospital Consumer Assessment of Healthcare Providers and systems
What is HCAHPS Implemented by CMS to provide a standardized method for evaluating patient perspective on hospital care. 27 questions related to clinical care and patient engagement
What are the two most important questions on HCAHPS Would you recommend this hospital to your friends and family and how was the revenue cycle team members role in patient satisfaction. Hospital recommendation should always be "YES"
What are the four points to improving the patient experience of the revenue cycle leadership and staff need to be inquisitive, responsive, innovate and flexible
Implementation of revenue cycle improvements patient centric efficiency in admitting, registration, and financial counseling make a positive impression
Education of revenue cycle ensuring patients understand insurance information and the meaning of the amount of the copay, deductible and coinsurance to alleviate discomfort and /or concern on payment expectations
Communication of the revenue cycle price estimate, financial assistants options and early pay discounts must be clear, consistent, and timely. This supports transparency
What are four patient access service processes 1. verify insurance and identification on every visit during admission/registration 2. copay coinsurance deducible an other self pay balance is paid 3. information necessary for billing is complete in a courteous timely manner 4. Payment collection
What is a patient consumers of healthcare that want to be informed of out of pocket cost, price of service prior to care, payment expectations and terms of payments
What are the two cost of dissatisfied patients 1. hard cost: loss of future revenue 2. soft cost: sharing negative experience to potential patients or through social media causing others not to uses a provider
What are examples of quality not being met inaccurate data and delayed payment or nonpayment can impact the patient experience
What are six ways the billing communication can be improved 1. modifying billing statements 2. extending business hours for inquiries & complaints 3. making sure that all staff is courteous & gives their name for future reference 4. first call resolve 5. customer follow up 6. performance reviews
What is rework consumes time and it takes longer to obtain payment for missing authorization. May cause partial payment or no payment
What happens when physician information is incorrect the chart is incorrect and the physician's results are incorrect and cause changes in patient status
What happens with incorrect patient identification the doctor my provide inappropriate care
What happens if the MPI number is incorrect or duplicated historical records are not accessed and not considered during treatment
What happens if incorrect billing information occurs if information is incomplete it will effect the physicians billing cost
What causes service delays long registration time and the patient is late for the service area
How does collaboration with information technology effect the healthcare industry 1. Streamlines operations 2. increases productivity 3. assessing profitability by health plan and patient type 4. providing quality care
What is IT monitoring ensures that systems are operating and claim data is accurate and complete
What are advanced directive requirements SNF must comply with the provisions of the OBRA of 1990
SNF Skilled Nursing Facility
OBRA Omnibus Budget Reconciliation Act
What is post acute care skilled nursing care, home health, durable medical equipment, hospice, and assisted living
What is skilled nursing care a separate building or hospital division that accepts patients in need of rehabilitation or care qualifying for medicare eligible skilled coverage. Under medicare it must be certified to meet specific qualifications
What is a transfer agreement Usually for medicare patients. A written arrangement with one or more participation hospital or SNF to send patient between organizations and to exchange information
What is a home health agency A public or private organization that directly or indirectly with other providers assist patient care in the home
DME Durable Medical Equipment
What is DME prescribed by a medical provider for use in the home. Used for medical purposes
What are examples of DME wheel chair, walker, hospital bed diabetes testing equipment and cpap
What is Hospice provide services at home for the terminally ill
What is Assisted Living for adults that need additional help with everyday task but do not need 24 hour nursing care
What is a compliance program a systematic procedure instituted by an organization to ensure government provisions are met
The burden of truth falls on the healthcare facility . What are the four things that need to be in place for a solid compliance program 1. a plan 2. following the plan 3. make sure the plan is corporation wide 3. know what happens if the plan is not followed
Why is it important to have a corporate compliance plan it protects healthcare providers from false claims
FERA Fraud enforcement Recovery Act
What is FERA IT amended the false claims act and it allows individuals and government to report misuse of government fund with out retribution.
FCA False Claim Act
What is the code of conduct used to verify that the compliance plan is effective. It is overseen by the chief compliance officer and represents the company compliance program and culture
What does the chief compliance officer do support top management in the organization and has oversight over top personnel. reports to the board of directors and CEO and maintains independence and is not pressured. Makes decisions about violations
What are the six areas of the code of conduct 1. Human resources 2. privacy/confidentiality 3. quality of care 4. billing/coding 5. conflict of interest 6. Laws/regulation
what are the benefits of the code of conduct helps employees understanding their role and responsibility while fostering an environment where concerns and questions are raised without fear of retaliation
CCO Chief Compliance Officers
OIG Office of the Inspector General
What does the OIG do develops the model of the compliance plan. Protects the integrity of the HHS Department programs and operates and the well being of beneficiaries by detecting and preventing fraud waste and abuse
HHS Health and Human Services
What are OIG responsibilities Identify opportunities to improve program economy efficiency and effectiveness. Hold those accountable who do not meet program requirements or who violate federal law
What is the OIG work plan published annually compliance issues and object that will be focused throughout the year
HIPPA Health Insurance Portability Accountability Act 1996
What is Hippa Federal legislation protecting the confidentiality and security of healthcare information
PHI Patient Health Information
BAA Business Association Agreement
What is the OIC Work Plan for 2016 1. Reconciliation 2. Inpatient and Outpatient stays using the 3. midnight rule 3. Medical Devices 4. Provider Based Status 5. Medicare payment during MS-DRG payment window
NPI National provider identifiers
DRG Diagnosis Related Group
What is the medicare DRG three day rule outpatient services provided by a hospital must be billed as patient stay. Includes pre admission diagnostic services and non diagnostic services
What are the consequences of the violations of DRG window the second claim will be denied and the entire bill may be canceled. A new claim will need to be submitted, fines, revocation of medicare status and criminal charges
Pre Admission Diagnostic Services service is provided to beneficiaries on the day of inpatient admission or during the three days before the date of admission are required to be included on the bill for inpatient stay unless there is no Part A coverage
Non Diagnostic Services also call DRG Window Service provided to beneficiaries on the date of inpatient admission or during the three day period before the date of admission will be billed as inpatient unless the services are unrelated to admission then they are covered by Part B
One day rule applies to Non IPPS hospitals including cancer, inpatient rehabilitation, long term care and children's hospitals
IPPS Inpatient Prospective Payment System
CCI Correct Coding Initiative
What is CCI used to promote the uses of correct coding methods on a national bases and prevent errors due to improper coding. developed by CMS
Medical Necessity Screen is paid for by medicare and performed by the provider for compliance with medicare
ABN Advance Beneficiary Notice of Non Coverage
What is an ABN used when medicare doesn't pay and the provider tells the beneficiary that they are fully responsible. use form CMS-R-131
The Two Midnight rule IPPS will consider hospital admission spanning two midnights as appropriate for payment under IPPS rule anything less is considered outpatient. Inpatient only is the exception to this rule
MSP Medicare Secondary Payer
What is MSP Protects Medicare Trust Fund by ensuring that medicare does not pay for services and items other health insurance is responsible for paying
A secondary Payer situation if there are less than 20 employees Medicare is the primary. If it is a work accident or car accident then the liability payer is responsible and Medicare may pay after 120 days
Disability for ages 65 and under with GHP and there are 100 or more employees Medicare is primary
GHP Group Health Plan
OPPS Outpatient Prospective Payment Center
How is ESRD affected by Medicare if covered by GHP and the 30 month coordination period has not been met then GHP pays . After the 30 month coordination period Medicare pays.
What are modifiers Allows a hospital to indicate a specific circumstance that has affected a procedure without changing the definition or code
What are level I modifiers they provide information about the performance of a procedure. It applies to the CPT code and consist of two number
What are level II modifiers provides additional information about anatomical location or about the procedure or service. This applies to HCPCS codes and is two letters or a letter and number
What are references to review for law and ethics 1. Mission and Value statement s 2. compliance policy 3. decision making models 4.legal counsel 5. Laws and regulation
What creates Healthcare Complexity Patient and healthcare expectation, public scrutiny, increased legislation and entitlement programs, and socioeconomic issues
Ethical Behavior is influenced by experiences and the value system
Ethical Violations Financial misconduct, overcharging, theft of property, falsifying records to boost reimbursement, miscoding claims

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