Paradigm IAS Academy

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The Revenue CycleWhat is it?
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Where does the Revenue Cycle Start?
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Physicians Office Or Emergency Room

• Physician writes an order
• To admit patient
• To observe patient
• For tests, procedures, lab, radiology, etc
• For surgery
• SDS
• Inpatient surgery

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Scheduling

• Referrals
• Authorizations
• Pre-cert or pre-auth must be obtained from
  insurance prior to treatment
• Pre-cert or pre-auth number must be included on
  claim
• Notifications
• Some insurances do not require authorization.
• Some insurance request to be notified.

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Pre-Registration

• Verify Insurance Coverage
• Verify Authorization
• Verify Patient Demographics
• Determine Patient Responsibility
• Co-pays, deductibles
• Co-insurance
• Obtain Patient Responsibility up front
• Collect deposits

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Financial Counseling

• Meet with patients to review their financial
  obligations
• Scheduling / Pre-registration process
• Registration
• Prior to discharge inpatients
• During discharge process in and out patients
• Once they are out the door the
• chances of collecting diminish
• dramatically

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Registrations Turn

• Verify any missing data
• Verify Identity
• Scan Insurance Cards and documentation
• Obtain co-pays patient responsibility
• Patient Signs required documents
• Permission to treat, guaranty of payment,
  assignment of benefits
• Other consent forms

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And More

• Advance Directives
• Notice of Financial Responsibility
• MSP Questionnaire
• Rights as a Medicare patient
• ABNs
• HIPAA Privacy Notice
• Red Flag Regulations
• Etc.

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Bed Management

• Bed Accommodation
• Private
• Semiprivate
• Verified at Midnight
• Charged at Midnight
• Patients holding in ED for a bed

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Case Management

• See every observation or inpatient
• Case management monitors inpatient and
  observation patients care to ensure admission
  meets admission criteria
• Interqual
• Milliman Care Standards - used by insurances
• Works with physicians to discharge the patient in
  the appropriate amount of time or ensure patient
  still meets inpatient criteria.
• Monitors and works on delays to recovery.
• Review patients status
• Medicare and Medicaid every 3 days
• All others - daily

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Discharge Planning

• Performed by case management.
• Begins when patient is admitted.
• Goal is to only keep patient in house as long as
  is medically necessary to provide excellent
  quality of care while maximizing reimbursement.
• Discharge to appropriate community resource
• May arrange transfer to SNF, Home Health, contact
  family, etc.
• Work with physician and family
• Consider what insurance will pay for

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Charges are Entered

• Charges are maintained in the charge master (CDM)
• A unique charge code identifies each service and
  test performed or supply provided
• Many charges have CPT-4 or HCPCS codes attached,
  required for billing
• Charges connect to Revenue Codes, required for
  billing
• Charges are billed on UB04 and HCFA 1500 claim
  forms

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Services are Documented

• Documentation must exist in the Medical Record to
  support all procedures performed and supplies
  used.
• Physician and Clinical staff signatures are
  critical
• Verbal orders must be signed
• Documentation must be complete and legible

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Electronic Medical Record

• Automate as much of the medical record as
  possible.
• Eliminates filing issues
• Allows for instantaneous access to medical record
• Reduces storage space
• Much of our medical record is electronic

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Patient is Discharged

• Financial Counseling
• Outstanding balances, co-pays, co-insurance,
  deductibles, bad debt, non-covered services
• Discharge Planning
• Discharge disposition can affect reimbursement
• Another facility
• SNF
• Home
• Home health

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Medical Records HIM

• Manages the medical record
• Scans and files loose documentation
• Verifies electronic records
• Ensure physician, nurses and clinical staff have
  signed where necessary
• Monitors, reports and obtains chart deficiencies
• Coding and abstracting
• DNFB management

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Medical Records Coding

• Medical records chart reviewed by certified coder
• Physician, nursing and ancillary documentation is
  critical
• ICD- 9 codes diagnoses, procedures
• CPT-4 codes procedures performed
• Greatly impacts reimbursement
• Heavily regulated

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Insurance Processes Claim

• Pays claim
• Denies claim
• Immediately
• After processing
• Line item denials
• Pends claim
• Doesnt notify hospital
• Timely filing

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Contact Us

• Futuristic Gigatech
• 46/4, Novel Tech Park,Garvebhavi Palya , Kudlu
  Gate,Hosur Main Road, Bangalore, Karnataka 56
  00 68.
• E-mail info_at_futuristicgigatech.comIndia
  Office 0091 80 4093 4093India Mobile [phone]
  500 4530

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QUESTIONS ???