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Revenue Cycle Management (RCM)

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the supervision of all administrative and clinical functions that contribute to the capture, management and collection of patient service revenue.

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Pre-Claims Submission Activities

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PreAdmit/Scheduling/Admissions/Registration/Patient Access Service/Front End Processes

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Case Management/Utilization Review

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a. Inpatient Medical Necessity (Admission Criteria) b. Determination of Appropriate Level of Care c. Procedural Pre-Certification d. Medical Necessity for Ambulatory Diagnostic Testing

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Charge Capture

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the process of collecting all services, procedures, and supplies provided during patient care

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Coding Patient Records

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Best Practice - 98% accuracy

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Hard Coding

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use of the CDM to code repetitive services

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Manual Coding

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HIM Department - all diagnoses and significant procedures

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Scrubber

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internal auditing - prior to claims submission and Payer Auditing of Submitted Claim

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Outpatient Code Editor (OCE)

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logic (algorithms) w/in computer software that evaluates data

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Rejected Claim/Line Item

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Can be Corrected and Resubmitted

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Denied Claim/Line Item

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Must be Appealed

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Suspended

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usually awaiting additional information

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Assignment of OPPS Ambulatory Payment Classification (APC)

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1. CPT/HCPCS status indicators 2. APC 3. Payment indicator a. Discounts b. Packaging

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Assignment of ASC (Ambulatory Surgical Center)

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Payment Group

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National Correct Coding Initiative (NCCI)

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a. Column 1/Column 2 Correct Coding Edits One of the codes is a component of a more comprehensive code - unbundling b. Mutually Exclusive Codes cannot reasonably be done in the same session - i.e., initial/subsequent, total/partial

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Medically Unlikely Edits (MUE)

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maximum units of service a provider would report under most circumstances for a single beneficiary on a single date of service

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Clean Claim

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request for payment that contains only accurate information (no errors in data)

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Claims Submission uses:

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1. Transaction Rule (HIPAA) 2. Standard Code Sets (HIPAA) 3. UB-04 (837I) - Facility bill form 4. CMS-1500 (837P) - Physician bill form

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Accounts Receivable (A/R) Department -

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A department in a healthcare facility that manages the amounts of money owed to the facility by customers who have received services with reimbursement to be made at a later date by a third party payer or the patient/responsible party.

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Accounts Receivable -

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Charges for patient services for which the healthcare facility is awaiting payment.

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Days in A/R -

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A statistic that measures approximately how many days it takes to collect any dollar placed into A/R. Best practice is less than 50 days.

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Dollar in A/R -

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Total dollar amount of A/R, with or without credit balances

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Credit Balances -

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Balances on an account that are to be refunded to an insurer or the patient/responsible party

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Aging of Accounts -

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The aging of A/R dollars after the claim has been dropped for billing. Aging buckets are usually in 30 day increments and may broaden as the accounts get older. Best practice is no more than 15-20% of final billed A/R greater than 90 days.

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Late Charges -

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Charges not posted to a patient's account within the facility's established bill hold period.

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Timely Filing Limit -

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The time period within which a valid claim may be submitted to the insurer to be considered for payment.

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Bill Hold -

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Established timeframe between date of service/discharge and the date the claim is dropped and sent to the payer. Best practice is 4 days. Timeframe usually between 3-5 days.

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Discharged Not Final Billed (DNFB) -

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Refers to accounts where the patient has been discharged but the charges have not been processed and the bill has not been submitted.

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Fiscal Intermediary, Carrier, and MAC (Medicare Administrative Contractor) -

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Medicare contracted with payers who were referred to as Fiscal Intermediary to pay Medicare Part A (inpatient) claims, Fiscal Carriers for Part B claims; now all is done by MAC

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Explanation of Benefits (EOB) -

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report sent from the healthcare insurer to the policyholder and provider that describes the healthcare service, its cost, applicable cost-sharing, and the amount the healthcare insurer will cover

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Remittance Advice Form (835) -

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report sent by 3rd party payer that outlines claim rejections, denials, and payments to the facility; sent via electronic data interchange

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Revenue & Charges

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synonymous, they reflect the amount the facility is seeking for services rendered and become the A/R for the account

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Contractual Allowances -

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The difference between the actual charge and the contracted amount is the contractual allowance or contractual write-off. Patients are not responsible for any of the contractual allowance.

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Carve Outs -

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Services that are not paid under the usual rate but, rather at a special rate. With OPPS APC's an example would be those items with a "pass-through" status

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Bad Debt -

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Refers to accounts that have an outstanding balance (money owed) by the patient and in accordance with the policies of the healthcare facility has been defined as uncollectible; services for which the HCO expected, but did not receive payment

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Write-Off -

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1. amount deducted from a provider's claim; difference b/t the actual charge and the allowable charge. Some agreements b/t providers and healthcare insurance companies prohibit providers from charging patients this excess difference 2. action taken to eliminate balance of a bill after the bill has been submitted and a partial payment has been made or payment has been denied and all avenues of collecting payment have been exhausted

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Adjustment -

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The process of writing off an unpaid balance on a patient's account to make the account zero balance.

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Cash & Reimbursement -

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are synonymous and refer to the amount of money the facility receives for the services rendered

HIMT2410 Chapter 9: Revenue Cycle Management – Flashcards

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