Revenue Cycle Management in Healthcare, Exams of Medicine

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HCAD 750 P2 revenue cycle - is the process that begins when a patient comes into the healthcare system and includes those activities that have to occur in order for a provider of the care to bill at the end of the patient's service encounter The healthcare revenue cycle encompasses - people, tools, methodologies, and techniques that medical institutions use to manage their patients' financial status Revenue management lifecycle - is a complex process that involves balancing people, processes, technology, and the environment in which the processes take place revenue management life-cycle can be broken down into 3 phases - the front-end, middle, and back end Front end of the revenue cycle includes - patient access functions such as scheduling of the patient for services, registration of the patient, prior or preauthorization for services, insurance verification, service estimates, and financial counseling middle process of the revenue cycle includes - case management, capture of charges for the services rendered, and coding for those services based on clinical documentation back end of the revenue cycle is typically viewed as - the business office or patient financial service process and includes claims processing and payment posting, follow up, customer service, collections of unpaid bills, and denial management insurance verification - is a vital component of the prearrival process for scheduled patients; it entails validating that the patient is a member of the insurance plan given and is covered for the scheduled service date 1 | P a g e preauthorization is also referred to as ___ and is the requirement that a - prior approval, authorization, precertification, or predetermination; healthcare provider obtain permission from the health insurer prior to predefined services being provided to the patients financial counselors - are staff dedicated to helping patients and physicians determine sources of reimbursement for healthcare services charity care - defined as healthcare services that have been or will be provided but are never expected to result in cash inflows point of service collection - is defined as the collection of the portion of the bill that is likely the responsibility of the patient prior to the provision of service medical necessity - a determination that a services is reasonable and necessary for the related diagnosis or treatment of illness or injury national coverage determinations - medicares national coverage policies are known as local coverage determinations - local fiscal intermediary policies are known as These policies define the specific international classification of diseases diagnosis codes that support medical necessity for many services provided: - national coverage determinations and local coverage determinations steerage - 2 | P a g e legal health record - is the documentation of the healthcare services provided to an individual in any aspect of healthcare delivery by a healthcare provider organization. patient registration - process provides the organization with the ability to accurately and uniquely identify its patients master patient index - is a key application within an organizations registration system. it uniquely identifies the individuals who have received services from the organization incomplete record processes - including deficiency analysis and chart completions practices, also change as a result of an EHR implementation release of information - a critical HIM function that may be handled internally or externally with a vendor, or use a blended approach that divides its volume between internal staff and a contracted company patient/member web portals - will be implemented to release health information to patients and facilitate communications between patients and providers through a web connection, utilizing a secure username and password chart reviews - often a daily occurrence in the health information service dept. coding workflows - to obtain the greatest benefits from the EHR system, these will need to be assessed and revised as an organization implements an EHR abstracting data from the patient record - 5 | P a g e is required to support some secondary uses of patient information within the organization billing software - is an application that is used to create a claim for services, to submit charges to third party payers or patients, to track receipt of payments, and to generate reports of billing- and claims-related activities. commonly electronically interfaced with the EHR system and the encoder software to facilitate the accuracy and productivity of the coding staff When implementing an EHR, the org should assign staff to monitor the number of claim denials for up to six months after the EHR implementation and evaluate the claim denial reasons to identify any potential data issues arising from the data transfers occurring between the EHR and the - claims scrubbing software transcription - remains an integral part of physician documentation; however, the method of documentation and transcription process will change significantly within an EHR environment data conversion - converting the data existing in paper based health records into an electronic health record system; can be expensive; it's important that the health information management dept be involved in the discussions and decision making because of the depts responsibilities associated with patient data management and role as official custodian of the org's legal health record workflow analysis - a technique used to study the flow of operations; first step in effective workflow redesign: analyzing all functional responsibilities of the dept and documenting the current workflow within the dept functionality training - is focused specifically on the capabilities and features of the software: how to navigate through the application, how to enter data into different modules within the application, and such workflow training - is focused on applying the systems capabilities and features withing the context of the specific workflow of a person doing a task or series of tasks 6 | P a g e electronic forms and templates - begins with communication between the front end user and the developer of the form, utilizing a standard dictionary for the organization contingency plan - an important piece of the overall EHR maintenance and will include a formal disaster recovery plan process and downtime planning disaster recovery plan - must protect patient safety, secures health information from loss or damage, ensures stability and continuity of care activities, and provides for orderly recovery of information security audit program - consists of a multidisciplinary team and effective program that establish a process and document a procedure, define and determine who and what will be audited, create and implement effective audit tools, define and determine who will conduct the audits and the frequency, define the process for confronting employees when audits determine a potential breach, and define and document the process for documenting audits and how long the data will be kept problem list - is defined as a compilation of clinically relevant physical and diagnostic concerns, procedures, and psycho social and cultural issues that may affect the health status and care of patients 7 | P a g e