Billing & Coding - Section 4: Revenue Cycle Basics Flashcards
All of the administrative and clinical processes which represent the “life” of a patient account from its creation until payment resolution for an encounter or a series of encounters
Revenue cycle
The revenue cycle is all of ____ and ____ processes which represent the “life” of a patient account from its creation until payment resolution for an encounter or a series of encounters
Administrative and clinic
The revenue cycle is all of the administrative and clinical processes which represent the “life” of a patient account from its ____ until payment ____ for an encounter or a series of encounters
Creation
Resolution
The inter-related functions of the revenue cycle, when executed efficiently, result in ____ ____ in the shortest amount of time (A/R Days)
Maximum reimbursement
A weakness in any of the individual processes of the revenue cycle can directly affect the overall ____
Performance
We tend to think of revenue cycle management as an after-the-fact/back-end function, when, in face, most of our opportunities for optimizing revenue cycle performance and maximizing reimbursement are found ____ in the revenue cycle
Early
Where in the revenue are most opportunities found for optimizing revenue cycle performance and maximizing reimbursement?
Early in the revenue cycle
True or False:
The revenue cycle start before the patient even walks in the door.
True
Insurance payments, patient payments, third-party accounts, statements, and bad debts are found in which part of the revenue cycle?
Payment
Engagement, scheduling, registration, demographics, and data collection are found in which part of the revenue cycle?
Patient access
Medical necessity, authorizations, charge capture, documentation, and coding are found in which part of the revenue cycle?
Services provided
Contracting, provider enrollment, billing, adjudication, denial and rejections are found in which part of the revenue cycle?
Claims process
Where does the revenue cycle start?
Patient access
Advertising, marketing, PR, anything that gives the patient access to our clinic describes what part of the revenue cycle?
Patient access
Errors created at registration:
Inaccurate or out-of-date ____ information
Demographic
Errors created at registration:
Patient registered under ____ ____ than on insurance card
Different name
Errors created at registration:
Relationship of ____ to ____ error
Patient to policyholder
Errors created at registration:
Failure to update ____ or ____ information
Insurance or personal
True or False:
In the registration process, it is okay to just ask if all of their information is the same
False; don’t just ask this
Errors created at registration:
____ information incorrect or incomplete
Policyholder
Errors created at registration:
Date of birth (DOB) ____
Missing
Errors created at registration:
Medical identity ____ issues (drivers license, photo on file)
Fraud
Errors created at registration
____ ____ ____ Questionnaire
*Our responsibility to ask these questions as a Medicare provider
Medicare Secondary Payer
Errors created at registration:
Workers comp/liability or TPL visit. Why is this an error?
Need to ensure patient is not at visit for something that was the fault of someone else because that could mean that another insurance is primary and Medicare is secondary
Why is it important to let the front desk staff know how key their job is in the revenue cycle?
Because most front desk staff do not understand that when they register a patient, they are creating the majority of the data fields for the claim that will be submitted to the payer
Upfront/POS collections:
Make sure your staff is knowledgeable about how different health plans are ____
Structured
Upfront/POS collections:
Understand ____-____ plans and off-setting HSA and MSAs
High-deductible
Upfront/POS collections:
Have a financial counselor or supervisor available to discuss ____ ____. Why should you have this?
Payment options; protect your patient access staff from confrontation
Upfront/POS collections:
Verify ____ and ____ in advance. Use system tools to reduce on-phone time or bottlenecks.
Deductibles and co-insurance
Upfront/POS collections:
Train staff to be casual but direct about the patient’s anticipated ____ ____ of the service
Cost share
Upfront/POS collections:
Good customer service does not mean what?
We are too nice to take care of business
What is a good way to relate to your patients that they may have a cost share in their services?
You know when you go to Walmart that you will be expected to pay for the milk and bread in your hand before you walk out of the store
Errors occurring when services are provided or before:
Medical ____ not met
Necessity
Errors occurring when services are provided or before:
Service not provided at the required ____
Frequency
Errors occurring when services are provided or before:
____ coverage determinations
National
Errors occurring when services are provided or before:
Pre-____ for services/procedures
Authorization
Errors occurring when services are provided or before:
____ required?
Referral
Errors occurring when services are provided or before:
____ ____ Notice not issued
Advance Beneficiary
Errors occurring when services are provided or before:
Non-____ services are performend
Covered
Errors occurring when services are provided or before:
____ complaints
Doorknob
Errors occurring when services are provided or before:
Not all charges ____
Captured
Errors occurring when services are provided or before:
Not all services ____
Documented
Maximize provision of services:
____ administrative and clinical workflows
Efficient
Maximize provision of services:
Orders and ordering ____
Protocols
Maximize provision of services:
Minimize ____ processes
Manual
Maximize provision of services:
Have ____ and ____ in place to ensure charge capture and documentation
Checks and balances
Maximize provision of services:
____ your PM and EHR/EMR systems
Maximize
Maximize provision of services:
Don’t be afraid to re-engineer ____
Processes
Maximize provision of services:
Targeted ____ and ____ training on use of EHR
Provider and staff
Maximize provision of services:
Internal billing and coding ____
Reviews
If you discover an issue in charge capture, don’t be afraid to do what?
Re-engineer the process
How can you get around inefficiencies and redundacies?
By having a well-designed EHR and ensuring your staff is trained on it
Charge capture errors:
____ inefficiences
Workflow
Charge capture errors:
Poorly ____ templates or forms
Designed
Charge capture errors:
____ notes
Illegible
Charge capture notes:
System ____ and security matrix problems
Limitations
Charge capture errors:
Visits not ____/no ____ reconciliation process
Reconciled, daily
Charge capture errors:
Missed ____ (labs, drugs, or added services?
Charges
Charge capture errors:
____ tickets/unsigned records
Open
Charge capture errors:
Charges for services not ____
Performed
Charge capture errors:
Number of units reported not based on ____ description
HCPCS
Number of units reported not based on HCPCS is common with ____ code drugs
J
Charge capture errors:
NDC information ____
Missing
Charge capture errors:
____-based services
Time
Charge capture errors:
____ schedule and pricing methodology problems
Fee
Common fee schedule errors:
Invalid, obsolete, or missing ____
Codes
Common fee schedule errors:
Codes not updated ____
Regularly
Common fee schedule errors:
New service not ____
Added
Common fee schedule errors:
____ code descriptions/naming coventions
Inconsistent
Common fee schedule errors:
Inconsistent fee setting methodologies -
Price not set the ____ ____
Prices not ____
Price ____ Medicare PFS
Same way
Updated
Below
Common fee schedule errors:
Insufficient ____ of clinical or office staff
Training
Common fee schedule errors:
No periodic review or ____
Analysis
Common fee schedule errors:
____ not set up to drop correctly
Charges
Codes change at least once each ____ but could be as often as quarterly
Year
Codes changes at least once each year but could be as often as ____
Quarterly
Documentation errors:
____ performed by not documented/captured
Services
Documentation errors:
____ ____ not addressed, or diagnosis inconsistent with chief complaint
Chief complaint
Documentation errors:
Documentation does not support ____ ____
Medical necessity
Documentation errors:
Discrepancies in the ____
Record
Documentation errors:
____ results not on chart or reviewed
Lab
Documentation errors:
Not all pertinent ____ documented
Diagnoses
Documentation errors:
Poorly designed or written ____/templates
Notes
Documentation errors:
Inadequate ____ mastery
EHR
Documentation errors:
Incomplete or delinquent ____
Records
Errors in claim processing:
____ not set up correctly in your systems
Payers
Errors in claim processing:
Providers not set up correctly in your ____
System
Errors in claim processing:
Incomplete credentialing or provider ____
Enrollment
Errors in claim processing:
NUBC ____ not followed
Guidelines
Errors in claim processing:
Missing condition codes or ____
Modifiers
Errors in claim processing:
Bypassing or overriding CCI ____
Edits
Errors in claim processing:
____, software problems, EDI issues
Clearinghouse
Errors in claim processing:
Submitting ____ claims
Duplicate
Errors in claim processing:
Missing or incomplete patient ____
Information
Errors in claim processing:
Claim submitted to wrong ____
Payer
Errors in claims processing:
Use of non-specified ____
Codes
Errors in claims processing:
Conflicts with ____’s business rules or billing guidelines
Payer’s
Where is the first place to look if you’re having trouble getting claims out the door?
How the system is set up
How can the front desk contribute to claims being submitted to the wrong payer?
Front desk can enter incorrect payer when setting up demographics for patient
Error in the denial or appeal process:
Is it a bill error, rejection, or ____?
Denial
Errors in the denial or appeal process:
Understanding ____ vs. cancelling a claim
Correcting
Errors in the denial or appeal process:
The biggest problems with handling denials properly are ____ and following the payer’s specific instructions and guidelines for correcting claims and for the appeal process
Timing
Errors in the denial or appeal process:
Poor ____, internally and externally, is also obstacles to clean claims
Communication
Errors in the denial or appeal process:
Maintain solid ____ with provider representatives
Relationships
Typically, there is a ____ relationship between total charges, payments, and adjustments
Proportionate
If adjustments are up when payments are down, what is this?
A red flag
Any change in the overall percentage of adjustments relative to other posting activity should be ____
Investigated
If charges go up, what should happen to payments?
Payments should also go up
Red flag would be when charge and adjustments are ____ but payments are ____
Up, down
If adjustments are ____ but payments are ____, there’s a big red flag!
Up, down
Common collection and payment errors:
Errors in ____ payments and adjustments
Posting
Common collection and payment errors:
Adjustment and payment ____ misleading
Categories
Common collection and payment errors:
Posting guidelines, ____ and ____, benchmarks not in place
Checks and balances
Common collection and payment errors:
Errors created by ____ posting of remittance advices
Electronic
Common collection and payment errors:
Failure to reconcile A/R activity in system to ____ ____ ____, actual deposits, and EFTs. Use your system reports and tools.
Daily cash reports
Common collection and payment errors:
Not collection or assigning ____, ____, or ____ amounts at the time of service
Copays, deductibles, and coinsurance
Common collection and payment errors:
Not having established, written ____ policies
Financial
Common collection and payment errors:
Not enforcing or following up with ____ plans
Payment
Common collection and payment errors:
Not sending statements in a ____ manner
Timely
Common collection and payment errors:
____ and communication with patients about their financial responsibility to their care
Transparency
True or False:
It’s important to collect copays, deductible, and coinsurance amounts upfront because the chance of collecting on the backend is diminshed
True
What should be established and communicated when contracting with 3rd parties for billing, AR, and collection services?
Clear, objective expectations
You must have written financial policies for collection processes, bad debt write-off, and cost report treatment of bad debt. All ____ ____ must be managed using the same guidelines.
Financial classes
Why should credit balances be investigated in a timely manner?
To determine if the amount was created by a posting error or if overpayment was received
Strive to have a ____ A/R
Clean
True or False:
The older a balance is, the harder it is to collect
True
Why should you solicit feedback from your team regarding performance improvement in the revenue cycle?
They interact with patients every day or bill/code claims so they are a great resource
If you are capturing charges at the same time you’re providing services, you have a ____ workflow
Efficient
Total amount of all outstanding patient balances; may include total charges for accounts not yet paid or adjusted; may include both insurance balances or patient responsibility balances
Accounts receivable
The gold standard for the revenue cycle is that the payment window should be no more ____ days on primary claim
45 days
True or False:
The payment window could be as short as 2 weeks
True
A calculation of how long it takes on overage to collect one day’s revenue. The calculation can be based on either gross or net amount of revenue.
AR Days
Before EDI and ET, we could expect AR Days to be between ____-____ day, but now we can expect a much shorter time period for clean claims
45 to 60 days
How do you calculate AR Days?
Total AR for a given period / the average daily patient service revenue for the same period
Account aging represents the outstanding AR amounts assigned to aging bucket based on how many days have elapsed since when?
The original DOS
The aging can represent ____ or ____ balances
Patient or insurance
AR amounts which have been determined to be uncollectible
Bad debt
The difference between the gross charge and the amount we have agreed to receive for the service based on contract or agreements with a payer
Contractual adjustment
Amounts adjusted off of the gross charge for reasons other than contractual adjustments.
Other adjustments
How should posting categories be set up?
In a way that helps us identify problems, trends, or external/internal issues
Amounts posted which represent cash payments from either the patient or a 3rd party (amount we get in the door)
Payments
What is the below an example of?
Agreed to $100/visit with a commercial payer. The charge for the visit is $150, but we receive $100.
A contractual adjustment
Amounts posted which reduce the balance but do not represent a transaction from a direct payment source
Credit
The results or posting more adjustments, payments, and credits which exceed the dollar amount of gross charges
Credit balance
The credit balance may represent a true ____ or can result from posting errors
Overpayment
The credit balance may represent a true overpayment or can result from ____ errors
Posting
It is important to understand the ____ ____ limit for each of the insurance carriers you work with
Timely filing
What is the timely filing limit for Medicare?
365 days
True or False:
The timely filing limit for all carriers if 365 days
False; Medicare is 365 days. Know the timely filing limit for each of your carriers!
Some carriers will have ____-day timely filing limits
90-day
It is recommended that you keep track of timely filing limits for each carrier you work with using what method?
Spreadsheet
True or False:
Even though claims are submitted electronically, there are still a lot of issues with timely filing for most clinics
False; rarely have problems, except with new RHCs are everything is being set up
For almost all Medicaid plans, there will be a ____ between state and managed plans with a prescribed way to escalate a problem
Liaison
RHCs can expect payment for services within ____ days of a clean claim being filed for most primary payers
30 days
Your MAC will automatically hold all of your RHC claims for a ____-day minimum
14 day
Why is online access to insurance companies high recommended?
To easily review payments and/or claim issues that have arisen
Why is enrolling in EFT a great way to better manage your revenue cycle?
It allows for quicker payment of claims
