Ch. 1 Overview of Revenue Cycle Flashcards
revenue cycle is the
life cycle of a payment claim that begins when the patient checks in at the front desk and ends after all payments or denials and appeals have been made
revenue cycle management consist of
all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
health care reimbursement began in
1930s
texas at baylor universisty
in 1965 the social security act was amended to add?
medicare and medicaid
challenges that face US health care system
-rising health care cost
-need to improve quality and safety
-need to improve coordination and accountability of care and service between providers and payers (the system is complex so its vital that claims are accurate)
HIPPA
covers the way healthcare plans and providers exchange information as they conduct business
prohibits HCP from disclosing PHI without Pt consent
health care clearinghouses
converts nonstandard transactions into standard transactions and transmit data to health plans (only hippa covered entity that can check claims from doctors from errors)
covered entities (CE)
healthcare organizations required to comply with HIPPA
Protected Health Information (PHI) includes things like
name
dob
email and residential address
account number
etc
HIPPA allows release without pt authorization with
treatment
payment
health care operations
to ensure public health and safety
ePHI
all individually health information a CE creates, recieves, maintains, or transmits in electronic form
The Security Rule
requires CEs to maintain reasonable and appropriate administrative, technical, and physical safeguards
minimum necessary
disclosures to other HCP for treatment purposes must be only the minimum amount of PHI needed to accomplish intended purpose
Medicare integrity program
looks over providers’ claims and payments to find fraud or abuse
false claims act
prohibit federal contractors from knowingly filing a fraudulent claim
medicare/medicaid patient and program protection act 1987
added fines for any Medicare/Medicaid fraud
operation restore trust
1985- target HCP for committing fraud and abuse
fraud
knowingly submitting false claims or making misrepresentations to obtain payment for which no entitlement otherwise exists (cms.gov)
abuse
practices that directly or indirectly result in unnecessary costs to Medicare (cms.gov)
Front-end revenue cycle
payer negotiation
Appointment scheduling
insurance verification
middle end of the revenue cycle
patient is seen
charges captured on the encounter form
transferred to CMS-1500 Claim form
claims transmitted electronically to clearinghouse
Back-end revenue cycle
payment received, posted to accounts receivable
denied claims examined for coding error/missing data
claims adjudication, remittance advice, explanation of benefits
clean claim
claim completed correctly with no errors or omissions
Claims adjudication
Process in which, upon receipt of a claim, the payer compares the claim to payer edits and the patient’s health plan benefits to verify that all required information is available to process the claim, that the claim is not a duplicate submission, and that the procedures performed or services provided are covered benefit
Capitation
pre-established fixed payment per patient per unit of time in advance to the physician
fee schedule
predetermined list of fees that the payer allows for the payment of all health care services
Health information management role
ensure accurate documentation support codes assigned
medical record documentation
health record EMR/PHYSICAL: is the property of a hospital, clinic, health care organization
health information provided: is owned by the patient
Clinical classification systems
used for reimbursement, public health reporting, quality of care assessment, education, research, and monitoring performance
i.e ICD-10-CM/PCS
Clinical terminologies
provide common reference points for comparison and collection of data about the entire healthcare process, recorded by multiple different individuals, systems, healthcare care organization
i.e SNOMED CT
Artificial intelligence (AI)
used to fill in the gaps and cut costs In the revenue cycle
technology that use machine learning algorithm and software to mimic human cognition
Robotic Process Automation
automation of repetitive tasks in the workflow
Predictive analytics
used to forecast or predict revenue
to correct problems before they occur
revenue cycle management chart flow
physician ordering
patient registration
charge captured
diagnosis/procedure, coding/auditing
patient discharge processing
billing/claims processing
resubmitting claims
3rd party payer reimbursement posting
appeals process
patient billing
self-pay reimbursement posting
collections
collections reimbursement posting
copay
A provision in the insurance policy that requires the policyholder (patient) to pay a specified dollar amount to a heath care provider for each visit or medical service received.
coinsurance
The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
deductibles
An amount for which the patient is financially responsible before the insurance policy pays.
third party payer
An insurance company that patients have a contract with to provide coverage for health services.
remittance advice
statement summary prepared by the insurance carrier, usually in batch form containing multiple patients/beneficiaries, received by the provider to explain what the plan has paid on each beneficiary claim covered by their plan. This information includes the charge, the allowed amount, the amount paid by the insurance, the co-insurance responsibility, and the amount the patient is responsible for paying.
explanation of benefits
A statement summary received by the patient that explains what the insurance plan has paid to the provider. It also lists the plan deductible that the patient has met and what their out-of-pocket expenses are.
