Section 1 - Revenue Cycle Overview Flashcards
1.2 HFMA’s Health Care Dollars & Sense - 3 Revenue Cycle Initiatives
Best Practices
- Patient Financial Communication
- Price Transparency
- Medical Account Resolution
- Financial counseling
Patient Centric Revenue Cycle
From request for service through closing the account with a zero balance and purging it from the system.
Post-service
Account activities that occur after the patient is discharged until the account reaches zero balance.
Charges are entered
Final coding (procedure and diagnosis codes)
Verify insurance and benefits
Billing edits
Claims submission (electronically)
Payment processing (electronic receipt and automatic posting to patient account)
Balance billing and resolution, as appropriate
Segments of Revenue Cycle
Pre-service (for scheduled patients)
Time of service (for scheduled and unscheduled). Complete final review prior to arrival
Post-service
Patient Financial Communications Best Practices
Bring Consistency, Clarity, Transparency.
Best practices - All interactions, ED, Advance of service, Time of Service (outside ED)
Measurement Criteria Framework - to guide evaluation of voluntary compliance.
Patient Communication in ED
Initiate financial discussions after the patient is screened and stabilized in accordance with EMTALA (Emergency Medical Treatment and Active Labor Act).
Support financial discussion during medical encounter as long as it does not impact patient care or disrupt patient flow (registration vs. discharge).
ED patients should be informed that their ability to pay will not interfere with treatment.
Uninsured should be informed that goal of collecting financial info is to identify paying solutions or financial assistance options that may aid them with their financial obligations.
Policies should be made available to the public.
Providers should have widely publicized toll-free # to discuss financial matters.
In pre-visit, keep track of contacts and avoid repeated requests for the same info.
Provide opportunity for patient advocate.
Routine (discussion with patient or guarantor)
Complex (under- uninsured - involve financial counselor)
Patient Share (Cost-sharing)
Told about various providers (and perhaps various bills)
Inform that actual costs may vary from estimates
May be timing issues related to payments that may affect their deductible.
If appropriate, patients should be asked if interested in receiving info about payment options or financial assistance options.
Need clear policies about prior balances.
Patient Interactions
Compassion
Patient Advocacy
Education
Take burden off patient by initiating conversions about financial matters -
BP - Verify patient info and patient’s preferred method of communication.
BP - Reinforce discussions with written information about financial assistance programs and summary of potential financial implications of services rendered. Include # to call with questions.
BP - Made policies available to the community
PRIVACY #1
Compliance Framework - 5 areas
Training Program - BP annual Process Compliance Executive Level Metrics Reporting Technology Feedback Process and Response
(1) Compliance Training Program (Rev Cycle) topics
Patient financial communications specific to staff role
Financial assistance policies
Patient financing options (payment plans)
Alternative solutions for uninsured (patient assistance program)
Standard language to be used in patient discussions
Laws and regs (EMTALA), Fair Debt Collections Practice Act, Telephone Consumer Protection Act.
(2) Process Compliance
BP - annual observation, monitoring, tracking of results
Evaluation can be performed by any outside dept
Evaluation should cover all relevant scenarios.
(5) Compliance Executive Level Metrics Reporting
BP - Evaluations from the 4 areas should be compiled into overall Compliance Report and presented to exec leadership on annul basis.
(3) Technology Compliance Evaluation
BP - Evaluation that tech supports verification of insurance eligibility, verification of prior balance, estimated cost of services - and the patient responsibility portion.
Perform evaluation by qualified internal or external person.
(4) Compliance Feedback process and response
Purpose to solicit feedback from key stakeholders and response to input, and ensure that patient complaints are resolved.
HFMA’s Adopter Program
BP - Providers who implement and support Adopter of Patient Financial Communication Best Practices.
Price Transparency
ACA, Health Insurance Exchange (Marketplace) high deductibles and coinsurance.
As bear more cost, expect clarity and communication re: these costs.
Need transparent pricing to make smart, educated decisions.
Need driven by both high liability and HSAs and other reimbursement arrangements.
Problem with hospital Charge Master - lists total charge, not net charges after payer’s contractual adjustment.
3 Things Patients Need to Make Estimates Meaningful
- Type of service based on CPT or MS-DRG
- Patient’s health plan
- Patient’s benefit plan
Price Transparency is applying the above.
In handling a call from patient -
Obtain order (or CPT). Verify insurance and benefits.
BP - Produce a patient friendly estimate form (software?)
Explain how insurance and patient portions were calculated.
HFMA Task Force developed 2 resource documents to assist with this process:
Price Transparency Report
Consumer Guide to Healthcare Prices (Understanding Healthcare Prices).
Patients decide based on Price, Quality & Safety.
Patients Identify, Compare and Choose among providers.
Medical Account Resolution
HFMA partnered with Association of Credit and Collections Professionals International (ACA) to form Medical Debt Task Force.
BP - Developed based on HFMA Patient-Friendly Billing and spans patient-centric revenue cycle.
Medical Account Resolution - Best Practices
See Resource -
Medical Account Resolution BP Workflow Chart.
- Educate - BP patient communication
- Bills - Clear, Concise, Correct and Patient-friendly
- Policies - Follow internally and by business affiliates
- Consistency - be consistent from billing disputes to payment application.
- Coordinate - coordinate with business affiliates to AVOID DUPLICATIVE PATIENT CONTACTS
- Juddment - good judgment about best way to communicate about patient bills.
- Timing - START ACCOUNT RESOLUTION WHEN FIRST STATEMENT IS SENT TO PATIENT
- Report and Track - Report back to credit bureaus when account is resolved (if account is reported). Track all patient complaints.
1.3 Patient Experience and Satisfaction
Today’s patients as consumers - want to know overall price and what they must pay out of pocket, prior to receiving service.
HCAHPS - 27 Q, Would you recommend this hospital to your friends and family?
Implement
Educate - what is copay, deductible, etc.
Communicate - clearly, such as price estimates, financial assistance options, early pay discounts.
Quality (1.3 Patient Experience)
40% of billing info obtained by Pt Access
When missing or inaccurate, delayed payment or nonpayment impacts patient experience.
BP - Insurance verification, pre-cert/pre-auth completed prior to scheduled visit.
Incorrect estimate or incorrect combination of health plan contract rules and patient benefit may result in debits or credits on the patient’s account.
BP - Verify with picture ID and insurance card. Review and reverify during registration.
BP - Collect copay, pt balance and coinsurance (requires charge estimate).
1.3 Billing Communication
BPs - Patient-friendly bills Expanded hours Staff identify themselves First call resolution Follow up within 48 hours Include customer service in performance appraisals.
1.3 Billing Impacts
Missing Information - missing auth, catch in pre-bill edits.
Delayed payments - incorrect health plan
Rework - no payment, delayed or partial payment.
1.3 Physician Impacts
Attending physician listed correctly
Consulting
Primary Care Provider
Results routing
Patient ID wrong
Duplicate records - historical records not accessed and considered during treatment.
Billing Information - many hospital-based physicians use hospital’s registration record to complete their billing.
Service delays at check-in if registration not completed in advance.
Case Management - need correct insurance info for post-service resources - SNF, DME.
SEE EXAMPLE OF ED REG NOT UPDATED AND CASE MGT MISSED 24-HR PAYER NOTIFICATION REQUIREMENT
1.4 Collaboration and Continuum of Care
IT Monitoring - e.g. charges coming from disparate systems. monitor daily for integrity.
Collaboration: Payer contracts - timely filing
Continuum of Care: Physician - Orders must include date, valid diagnosis, patient’s name, physician’s name and signature, description of tests ordered.
Schedule or instruct to call to schedule
Typically physician’s office obtains prior auths
SNF: Skilled Nursing Home or Rehab facility
Can be distinct part of a hospital if beds are on floor, ward (Medicare)
CAHs that provide Medicaid can use swing beds for SNF-level care.
For Medicare, SNF must have written transfer agreement with one or more participating hospitals and for the interchange of medical information.
Participating SNFs must comply with Advance Directives (OBRA - Omnibus Act of 1990).
- Inform all adults, in writing, of state laws regarding advance directives and its own policies.
- Document in chart whether or not patient has executed Advance Directive.
- Educate staff and community on issues concerning Advance Directives.
1.4 SNF Covered Level of Care
Care in SNF is covered if:
- Patient requires Skilled Nursing or Skilled Rehab services.
- Requires skilled services on a daily basis
- As practical matter, can only be provided on inpatient basis in SNF.
- Services must be reasonable and necessary for the treatment of a patient’s illness or injury.
1.4 Home Health Agency
Criteria 1. Qualifying Services - Must furnish at least one of these thru HHA. But may furnish 2nd qualifying service and additional services under arrangement with another HHA or organization. - Skilled nursing - Home health aid services - PT - Speech-language path - OT - Medical social services
Criteria 2 - Need policies established and by physician and RN and supervision by same.
Criteria 3 - Maintain clinical records
Criteria 4 - Licensed in State
Criteria 5 - Meeting Other Conditions
Health & safety conditions of HHS
PHYSICIAN CERT - patient confined to home. Not necessarily bedridden, but leaving home requires considerable and taxing effort. Expected that absences from home due to medical treatment.
PATIENT’S PLACE OF RESIDENCE -
Own dwelling, apartment or relative’s home or home for aged.
Not a SNF or hospital for purposes of Home Health coverage.
