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WEEK 4 (MOD 1) > REVENUE CYCLE CONCEPTS > Flashcards

REVENUE CYCLE CONCEPTS Flashcards

1
Q

includes both administrative & clinical supervision of day-to-day operations to capture & collect payment for services rendered

A

Revenue Cycle

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2
Q

revenue cycle begins with pt registration & ends when…

A

final payment is made to the org

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3
Q

What are the revenue components? (try to remember as much as you can)

A

Registration & Scheduling
PT Check-in
Utilization Management (U/M)
HC Documentation & Encounter
Charge Capture & Coding
PT Check-out
Billing
Payer Adjudication
Receiving & Posting Reimbursement
Appeals & Claims Corrections
PT Responsibility Collection, Payments, & Posting

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4
Q

they may place demands on orgs to provide more data or to follow their specific rules…

A

Payers

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5
Q

no matter how small or big, they need to have workflow checks in place that reduce the risk of delayed payments or missed revenue …

A

Providers & Organizations

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6
Q

What is the best practice when the claims are denied?

A

perform analysis to determine where the errors are occurring (ex. separating errors by depts.)

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7
Q

Front office errors…

A
  • Eligibility error
  • Data entry error
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8
Q

Billing/coding errors…

A
  • Code linkage error (when dx & procedure codes doesn’t match)
  • Preauthorization not claimed (request from payer)
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9
Q

Back-office errors…

A
  • Documentation errors
  • Missing/incomplete encounter form documentation
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10
Q

What does revenue cycle management do and what is it’s importance to healthcare orgs?

A
  • vital for ensuring financial stability of a healthcare org
  • collect full payment of services rendered in a timely & efficient manner
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11
Q

Who are the primary stakeholders in healthcare?

A
  • Payers
  • Patients
  • Providers
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12
Q

What is the goal of the revenue cycle management?

A

collect full payment for services rendered in a timely and efficient manner

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13
Q

it is a basic step of revenue cycle that begins with communication between the pt & staff to begin services…

A

Registration & Scheduling

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14
Q

this process
- informs the pt & the org abt the pt’s coverage details
- where copayments are collected
- registration forms are signed
- ensures coverage is valid
- beneficiary is verified for the eligibility under its policyholder (name, DOB, ID#)
- verification of benefits & verification of OOPM

A

Patient Check-in

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15
Q

this step of the revenue cycle
- occurs at different times & more than once
- determines the referrals & preauthorizations are required
- precertification & screening for medical necessity is part of this process

A

Utilization Management Review (U/M)

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16
Q

this step is where the pt encounter is performed & supporting documentation is entered into the medical record…

A

Healthcare Encounter & Documentation

17
Q

it is the process of selecting & entering codes based on the documentation in the pt’s records & entered into the EHR …

A

Charge Capture

18
Q

it involves confirming appropriate CPT, HCPCS, & ICD-10-CM code assignment & linkage…

19
Q

this is important bc ICD-10-CM codes supports medical necessity of the HCPCS & CPT codes selected …

20
Q

this process …
- determines additional OOPM
- follow-up appts & other instructions
- referrals
- review signatures
- U/M review is performed again

A

Patient Check-out

21
Q

it is when …
- the charges are validated & transmitted
- submission of the claims (electronic & paper form) happens

22
Q

What is the electronic & paper format of claims sent to the payer?

A
  • 837P format — electronic
  • CMS-1500 — paper
23
Q

it is the step where the payer will review the claim and reimburse services at allowed amount or apply the charges to copay amounts …

A

Payer Adjudication

24
Q

What two forms (electronically or paper) that the payer send to the provider which details how the claim was processed & paid?

A
  • Remittance Advice (RA) — electronic
  • Explanation of Benefits (EOB)
25
Q

How long does it take from claim submission before the provider receives payment from payer?

A

10-30 days

26
Q

this is the step where …
- the amounts specified in the RA/EOB must be collected
- remaining amounts such as copays need to be collected too

A

Patient Responsibility Collection, Payments, and Posting

27
Q

it regulates the third party debt collector’s actions & practices …

A

Fair Debt Collection Practices Act (FDCPA)

28
Q

registration forms PT must sign during check-in

A

Assignment of Benefits (AOB)
medical record release forms
Financial Policy
HIPAA privacy notifs

29
Q

it is a method where PT request for the payer to pay the HCO who provided services rendered directly

A

Assignment of Benefits (AOB)

WEEK 4 (MOD 1) (5 decks)

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