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Tue, 22 Mar 2016 19:57:03 GMT

Hi Everyone! Happy Spring :)

I thought we'd talk about Revenue Cycle today!

The revenue cycle is the process of generating office revenue. It is, in basic terms, how you get paid for the patients you see. It involves everyone in your office from the phone operator to the clinical staff to the billing staff. The revenue cycle starts when the patient calls your office for an appointment and your staff captures the patient's name, phone number, and their insurance eligibility and coverage information. The cycle ends when the balance on their account is zero.

The cycle is best supported by effective EHR and Practice Management systems. Electronic billing is required among third party payers, managed care, and Medicaid. Best practices of a successful revenue cycle results in higher collections ratios.

The first step is the appointment scheduling process. This is essentially your pre-registration process. This is important as it can start your revenue cycle off on the right path for the fastest reimbursement. On the scheduling phone call, patient demographics should be recorded such as name, date of birth, guarantor information, referring doctor information, and insurance information. Any referrals or treatment authorizations should be discussed now to make sure they are obtained. This will make it possible to verify insurance benefits and authorizations for the patient prior to their visit. The financial obligation policy could be mentioned on the scheduling call as well.

See picture which shows the parts of the revenue cycle.

Questions?

Wed, 23 Mar 2016 00:08:22 GMT

Hi -
I hope everyone is having a great evening!

Here is some revenue cycle terminology to review

ABN – Advanced Beneficiary Notice – For consumers with Medicare Part B, an ABN form must be completed by the patient before services are rendered that may be determined not medically reasonable and necessary.

Adjudication – Determination of an insurance carrier or patient’s financial liability/responsibility, after a medical claim has been applied to a person’s insurance benefits.

Allowable Charge – Approved charge amount a third party payer will allow for providers services.

Appeals

AR – Accounts Receivable

Balance Billing – Amount billed to patient after insurance has adjudicated the claim and paid the provider.

Benefits – Specific to what an insurance plan will cover.

Charge Master – Contains prices for all services and goods. Used to generate a patient’s bill.

Claim – Bill submitted to insurance for services rendered to patient

Coinsurance – Percentage of cost of covered services that are paid by patient. Considered a cost-sharing requirement under the insurance policy.

Contractual Payor Allowance – pre-determined insurance and Medicare payment schedules

COB - Coordination of Benefits - Ensures that insurance claims are not paid multiple times when a patient has coverage under multiple insurance plans. One insurer is designated as the primary insurer. The primary insurance is billed first. If the claim is denied or did not pay in full, the claim would then be passed to the secondary insurance.

Copay – A designated fee a patient is responsible for when seeking medical care at an office, surgical center, ER and hospital. Amount is set by insurance plan

Deductible – Vary by plan. A deductible is a set dollar amount that a patient is required to pay a provider before insurance benefits kick in.

EOB – Explanation of Benefits - Insurance statement to the patient that explains the benefits and payments corresponding to a medical visit.

FSA – Flexible Spending Account - Allows an employee to put a designated portion of his/her pre-tax earnings aside to pay for qualified expenses related to their medical care.

J-Codes – Used to identify certain drugs. Part of the HCPCS Level II.

Maximum Out-of-Pocket Expenses – Limit on total number of co-payments or total cost of deductibles and co-insurance under insurance benefit plan.

Out-Of-Network Benefits – Benefits that cover physicians and hospitals that are not contracted with insurance plan. Some insurance carriers offer lower reimbursement with a higher out of pocket expense to a patient who may choose to go out of network. Some insurance carriers will not cover any portion of services provided out of network.

Out-of-Pocket Expenses – A set dollar amount a patient has to pay out of his or her own pocket for a particular service during a designated time period.

Participating Provider – A physician or Licensed practitioner who is under a contract with a health plan.

Patient Liability – Amount a patient is legally responsible to cover. These include co-payments, co-insurance and deductibles.

Practice Management System (PMS) – software that handles the day-to-day operations in a medical practice. Used to capture patient demographics for registration, scheduling of appointments, performs billing tasks and generates reports.

UCR – Usual, Customary and Reasonable – what most health care providers or facilities charge for a particular procedure or service within a geographic region.