The Healthcare Financial Management Association (HFMA) defines revenue cycle as:

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

In other words, it is a term that includes the entire life of a patient account from creation to payment. Revenue cycle processes flow into and affect one another. When processes are executed correctly, the cycle performs predictably. However, problems early in the cycle can have significant ripple effects. The further an error travels through the revenue cycle, the more costly revenue recovery becomes

REVENUE CYCLE MANAGEMENT 101DEFINITION OF REVENUE CYCLE:

Scheduling & Pre-registration

FinancialClearance

PricingCharge

Capture & Entry

CodingCDMStandardization

CDM (Charge Description Master): Is a file with comprehensive listing of items that can be billed to a patient or insurer by a healthcare provider.

ContractsClaim

ProcessingAccount

CollectionsDenial

ResolutionPaymentPosting

FinancialCounseling

Arrival &Registration

DenialPrevention

Technology

Customer Service

Performance Management and Monitoring

Change Management, Coaching and Training

Charge Integrity “Middle”Revenue Cycle

Patient Financial Services “Back End” Revenue Cycle

Patient Access “Front End” Revenue Cycle

Revenue Cycle Management

Revenue Cycle Management

Daily/month-end balanceMonth-end reporting

Open issues tracking

Key metric tracking

Non-collectible

adjustments

Ad-hoc reporting

analysis

Root cause analysis

Pre-Claim

Pre-Visit VisitClaim

SubmissionInbound

Processing

Month-End Closing

Performance Management

Account Receivables Management

Quality Management

ComplianceInformation Technology

Contract Negotiation

s

Eligibility Verification

EDI/ERA Enrollment

Fee Schedule

Scheduling/Registratio

n

BankingSet-up

Patient Check-in

Mail Processing

Claim Status

Patient Statements

Provider Credentiali

ng

Appointment

Reminders

Co-pay and deductible collection

Patient Payment

Arrangements

Encounter Documentati

on

Coding and Charge Capture

Scanning/Indexing

Bank Deposit

EFT,ERA Processing

Payment Posting

Revenue Allocation

Pre- Adjudicatio

n

Claim Submission

EDI Manageme

nt

Request for Information

Denial Analysis

Appeals and

Resolution

Inbound and

Outbound Calls

Collection Letters

Patient Refunds

Conveyance, Small

Balance Write-Off

Transition to

Collections

No-show rate

Charge Entry

Claim Scrubbing

Analytics

Cash collected

Revenue Cycle Management Support

Regulation monitoring

Coding and chart audits

Non-collectible adjustments

Coding support for billing

process

Practice management

system

EMR integration

Other application

integration

Interfaces/data exchange

Hosting and support

Process measures and

audits

Employee performance

audits

External audits

Front End Back EndTransaction Processing

Life of a claim

Total days in AR

Payers denial rates

Rejection analysis

Increased reimbursementthrough improved, consistent,and defendable chargedescription master (CDM)efficiencies and identificationof missed billing opportunities.

Reduced outstandingaccounts receivables anddenials through processimprovement andworkflow tools.

Improved accountabilityand immediate issueidentification throughdesign and implementationof managementperformance reporting.

RCM Benefits Include:

Benefit

Accelerated cash flow andimproved annual net revenueby streamlining every stepin the revenue cycle byfocusing on people, process,and technology.

Benefit Benefit Benefit

Charge Capture:Documented services are manually or electronically translated into billable fees.Claim Submission:Billable fees are submitted to the insurance company via a universal claim form for payment.Coding:The process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers.Patient Collections:Collecting patient balances, making payment arrangements.Pre-registration:Collection of all registration information, including eligibility, benefits and authorizations, prior to the patient's arrival for inpatient or outpatient procedures.Registration:Collection of a comprehensive set of data elements required in establishing a Medical Record Number and satisfying regulatory, financial and clinical requirements.Remittance Processing:Posting or applying payments/adjustments to the appropriate accounts, including rejects.Third Party Follow-up:Pursue collections from insurers after the initial claim has been filed.Utilization Review:Evaluation of the necessity, appropriateness, and efficiency of the use of medical services and facilities, which includes regular reviews of admissions, length of stay, services performed, and referrals.

REVENUE CYCLE TERMS REVIEW

YOUR ATTENTION

THANKS FOR

Introduction to revenue cycle presentation prepared by Mynor Veliz, CFOCopyright: Intermountain 2015