The Revenue Cycle

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The Revenue Cycle
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UVa and HSF Revenue Cycle Presentation

• PRESENTATION GOALS
• To illustrate and explain the Billing and
  Collection Revenue Cycle.
• To identify who is responsible for each
  Functional Activity.
• UNDERSTANDING THE PROCESS
• On the slides we will represent each of the major
  Functional Activities with an icon. We have
  color coded each Functional Activity to
  illustrate who has ownership of this activity
  (e.g. Medical Center, Clinical Department, HSF).
  These Functional Activities will be briefly
  described in the presentation.
• SPECIAL EXPLANATIONS
• Some Functional Activities can be the
  responsibility of two of the partners in the
  Health System.

Orange indicates Medical Center Owned
Responsibility
Blue indicates HSF Clinical Department Owned
Responsibility
Green indicates HSF Admin Owned Responsibility
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Revenue Cycle
Documentation Coding
Scheduling
Payment Processing
A/R Follow-up
Registration
Charge Processing
Resubmission Appeals
Claim Statement Production
Secondary Claims
Legal Collections
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UVa and HSF Revenue Cycle
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It all begins with the patient entering the UVa
Health System needing services
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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Appointment Scheduling Process

• Begin Revenue Cycle
• Verification of insurance
• Authorizations and certifications
• Pre-registration gathering demographics
• Identify the referring physician

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Appointment Scheduling Goals

• Goals are those of Clinical Dept and Patient
  Services
• Get appointment within time desired by patient
• Patient is informed of referral process
• Inform patient to bring insurance card and
• co-payment

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Patient Registration Process

• Begin Revenue Cycle
• Verification of insurance
• Authorization and certifications
• Registration gathering demographics
• Identify referring physician
• Initial review of financial requirements
• Co-pay collection for all appropriate patients

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Patient Registration Goals

• Insure Pre-authorization received
• Insure verification of insurance and PCP
  validated
• For all appropriate patients collect co-pay and
  verify demographic information

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Patient Exam

• Patient identifies concern/problem
• Procedures performed and/or treatment
• provided
• Discharge diagnosis
• Physician documentation initially recorded

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Patient Exam Goals

• Reasonable/timely access
• Complete clinical service
• Informative to patient
• Appropriate documentation for patient care and
  for correct billing to third party

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Documentation Coding Process

• Physician documents services
• Services coded by Physicians and/or coders CPT
  codes (procedures), ICD-9 (diagnosis), HCPC
  (supplies, drugs, etc.)

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Documentation Coding Goals

• Documentation complete and signed by provider
• Codes accurately reflect patient service(s)
• Coding reviewed to insure it reflects
  documentation

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Charge Processing

• Keyers and coders enter data into Transaction
  Editing System (TES)
• Fee entered automatically or manually
• Claims Manager software scrubs entries for
  correctness
• Problems sent to department workfile for
  processing
• Reconciliation performed to insure all entries
  received and entered into TES

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Charge Processing Goals

• Accuracy of service and charge
• Appropriate edits to scrub data
• Charges entered timely for prompt payment

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Claim Statement Production

• Claims edited to insure completeness and
  correctness
• Claims sent daily to carriers for processing
• Claims flow 70 electronic and 30 paper
• Billing statements sent to patients for
• self-pay balances

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Claim Statement Production Goals

• Get accurate claims out daily
• Increase of electronic claims
• Keep average cost per claim better than benchmark
• Get statements out to patients for self-pay
  balances every Monday within the current billing
  cycle (30 days)

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Payment Processing

• Electronically or manually post remittances from
  payers and patients
• Payments
• Denials or rejections
• Adjustments
• Refunds
• Reconciliation of charges, payments and
  adjustments

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Payment Processing Goals

• All payments and denials processed within 24
  hours of receipt
• Process all refunds within one week of credit
  balance

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Resubmission Appeals

• Invalid registration
• Medical Documentation required
• Correct coding /charge corrections
• Missing referral/pre-authorizations
• Payments included in primary service

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Resubmission Appeals Goals

• All invoices requiring an HSF appeal processed
  are completed within one week of receiving
  rejection
• Process all responses from clinical departments
  within one day of receiving information

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Secondary Claims/Guarantor Billing

• Claims edited to insure completeness
• and correctness
• Secondary claims and patient
• statement production
• Resubmission appeals, if necessary

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Secondary Claims/Guarantor Billing Goals

• All secondary claims submitted within 2 days of
  receiving primary payment, e.g. Medigap Plans
• Follow up on all outstanding self-pay balances
  within 10 days of statement submission
• Additional 120 day follow-up on all
  outstanding self-pay balances prior to bad debt
  transfer

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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A/R Follow-up

• Third party collection on appeals
• Self pay follow-up (Dunning cycles)
• Payment arrangements (Budget plans)
• Improve claim edits as an outcome
• Bad debt transfer

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A/R Follow-up Goals

• Process all denials requiring departmental
  involvement within one week receipt of reject
• Daily follow-up on all outstanding requests with
  clinical departments within one week of initial
  request
• Follow-up on all no response invoices within 45
  days of submission of claim

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TheRevenueCycle
PatientRegistration
Appointment Scheduling
Patient Exam
Documentation Coding
Legal Collections
Charge Processing
A/R Follow-up
Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
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Legal Collections

• FOCUS IS ON THE LEGAL SYSTEM
• Warrant in debt
• Garnishments
• Liens
• Payment arrangements (Legal budget plans)

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Legal Collections Goals

• All accounts with employer information processed
  for garnishments within 60 days transfer to bad
  debt
• Follow-up on all budget plan accounts monthly to
  insure appropriate payment
• Weekly Warrants in debt issued
• Weekly court appearances

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TheRevenueCycle
Patient Registration
Appointment Scheduling
Patient Exam


Documentation Coding

Legal Collections


Charge Processing
A/R Follow-up





Secondary Claims/ Guarantor Billing
Claim Statement Production
PaymentProcessing
Resubmission Appeals
Measured against Benchmarks
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A successful Revenue Cycle depends on

• Accurate data
• Working together
• Effective communication

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Revenue Cycle Goals

• Improve the process
• Increase collections
• Let doctors practice medicine
• Enhance patient satisfaction

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Everyone has a role to play! All of us benefit
by working together