Patient-Centric Revenue Cycle
The major processing steps required for a request for service through closing the account at zero balance.
Pre-Service
Scheduled & pre-registered pt.,cost est., data colleted
Time-Of-Service
Scheduled & Unscheduled-caser mgmt. & discharge, consents, pt is id’d, copay & amt collected, pre reg record activated.Unsched pt have comprehensive regis & financial processing
Post-Service
After pt is discharged-bill to healthplan, pt account monitored until payment reaches zero
Healthcare Dollars and Sense
Name given to the 3 HFMA revenue cycle initiatives:
Patient Financial Communications
Price Transparency
Medical Account Resolution
Patient financial communications best practices purpose & principles
· All patient financial interactions
· Emergency department
· Advance of service
· Time of service (outside the emergency department)
· Measurement criteria framework
Best Practices for price transparency
As part pf the consumer driven programs, patients need pricing information to make informed healthcare choices in hospitals to inquire about costs and fees prior to agreeing to service.
A. Required information for pricing include: type of hospital service (based on CPT/HCPCS or MS-DRG code), patients’ health plan and/or benefit plan
Medical account resolution
Educate, bills, policies, consistency, coordinate, judgement, timing, report and track
Financial Counseling
If appropriate, patient is referred to for financial assistance. Typically patient share, prior balances, balance resolution
Typical elements of financial discussions
Including provision of care, registration, insurance verification, and financial counseling (patient share, prior balances, balance resolution)
Provision of care
The patient to make mutually acceptable payment arrangements to resolve outstanding balance. Ability to pay will not interfere with treatment.
Balance resolution
Discussions may occur concerning prior balances that are being handled by collection by provider, a collection of agency, or other organization
Price transparency
On Health Insurance Marketplace / Health Insurance Exchange have consumer cost sharing requirement. Patients expect clarity & communication of costs, helps consumers make smarter decisions about care received.
The need for Pricing Transparency
Patients need pricing information, key info needed are type of hospital service on CPT or MS-DRG code, patients health and benefit plans
Medical Account Resolution
HFMA partnered with ACA (Association of Credit & Collections) along with others to work on medical debt task force.
What are the Medical Account Resolution Best Practices
Educate, bills, policies, consistency, coordinate, judgement, timing, and report & track. (See diagram)
What option is NOT a main HFMA Healthcare Dollars and Sense revenue cycle initiative?
Medical account resolution
Process compliance
Price transparency
Patient financial communications
Process compliance
Patient Satisfaction Metric with in the Industry (HCAHPS)
Hospital Consumer Assessment of Healthcare Providers and Systems
From patients perspective, CMS implemented value based purchasing program that focus’ on core measures, one of which is HCAHPS. Objective is to provide a standardized method for evaluating patients’ perspective on hospital care.
CMS implementation of value-based purchasing
HCAHPS
Objective of the HCAHPS initiative
Provide a standardized method for evaluating patients’ perspective on hospital care.
HCAHPS Survey
27 questions related to clinical care and patient engagement – one question for all of satisfaction “Would you recommend this hospital to your friends or family?”
Importance of the survey to the hospital
Question on survey that asks “Would you recommend this hospital to your friends and family?”
Rev Cycle Team Members role in Patient Satisfaction
Leadership and staff must always remember 3 talking points:
Implement, Educate, Communicate
How do you improve the overall patient experience
Requires revenue cycle leadership and staff to simultaneously be inquisitive, responsive, innovative and flexible.
What is the Revenue Cycle Team members role in patient satisfaction?
Implement – processes that are patient-centric & efficient, especially in registration, admitting and financial counseling. (Positive first impression)
Educate – patients about insurance coverage & meaning and amount of copayments, deductibles, and coinsurance. (Can alleviate discomfort or concerns on payment expectations).
Communicate – financial information clearly, consistently and timely (prices estimates, financial assistance options, early pay discounts) in supporting “Transparency”.
Who plays a critical role in retaining patients as customers?
Revenue Cycle team members –
FACT: staff should provide clear communication and good customer service, which will give the provider a competitive edge.
Key element to clear revenue cycle communication
Helping patients & families understand their financial responsibilities for care, and what services or programs are available to help them if needed.
Is there a book or guide to help in treating the patient?
The “Paramount Customer Service Guideline” is to treat the patient as you would wish to be treated.
Cost of poor quality patient experiences
There are hard (loss of future revenue) and soft (customer passing on information about their experience through potential patients or social media channels) costs.
Explain what the hard costs are for dissatisfied customers
Loss of future revenue. ** The provider should always make certain that the patient’s response to the HCAHPS survey question, “Would you recommend this hospital to your friends and family?” – is always “Yes”.
Explain what the soft costs are for dissatisfied customers
Is less easily defined and quantified, is the customer’s passing on information about their negative experience to potential patients or through social media channels. This type of “advertising” may influence others not to use a particular provider.
Quality – how much of the billing information is obtained during the registration process (access service)
40% – When the data is missing or inaccurate, delayed payment or nonpayment for services occurs thus impacting the patient’s experience.
Within the “Quality Billing Communication” area, what revenue cycle activities for improving include?
Modifying billing formation & statements for easier patient comprehension.
Extending normal business hours for patient inquiries and complaints.
Make sure that all staff answer phone courteously & give the customer his/her name for future references.
Resolving questions or complaints with out transferring the customer to another person whenever possible.
Follow up on all customer inquiries or complaints within 48 hours.
Including customer service responsibilities in every staff member’s performance plan and holding staff accountable during performance reviews.
What are the 5 strategies used by the revenue cycle leadership team am & staff for improving overall patient experiences.
- Insurance verification, pre-certification, and pre-authorization processes should be completed prior to the patient’s scheduled visit
2 Incorrect estimate or incorrect application of the combination of health plan contract rules and patient benefit rules may later result in debits or credits on the patient’s account after the insurance company has processed the claim
3 Key information should be verified by means of a picture id and an insurance card. Information obtained during a previous visit should be reviewed and re-verified during admission/registration.
4 Any co-payments, co-insurance amounts, deductibles, or other self-pay balances should be collected on site as part of the access process. Co-payments are usually straightforward; however, co-insurance balances often require charge estimation.
5 A successful encounter has occurred if the information necessary to bill and collect the patient’s account is completed in a friendly, courteous, and timely manner.
Rework
Rework consumes valuable staff time which could be used for other tasks.
The higher the % of claims requiring rework – the higher the costs and the longer it takes to obtain payment.
Where insurance requirement have not been met (missing authorization, care that is not medically necessary, etc.) there may be no payment or only a partial payment.
What are some Physician impacts?
Can be affected by access service quality in multiple ways – physician identification, MPI number search, patient identification, billing information, and service delays.
How can the Physician identification impact access service quality/Physician impacts?
If the physician’s id information is missing or incorrect – patient will not have correct physician listed, physician will not be informed of procedure results or changes in patient status.
This includes id information for attending physicians, consulting physicians, and primary care providers.
How can the Patient Identification impact access service quality/Physician impacts?
If the wrong patient is id, the physician may provide inappropriate care.
How can the Billing information impact access service quality / Physician impacts?
Many physicians, especially hospital-based physicians, use the hospital’s registration record to complete billing. If patient information is wrong or missing, it impacts the physician’s billing costs.
How can Service Delays impact access service quality / Physician impacts?
If access processing that could have been completed before arrival is completed at the time of service, patients can be delayed at registration and will not reach the service area within a timely manner.
What is included in the “Access Service” process points?
Key information verified by picture id and insurance cared. Information from previous visit needs to be verified.
Any copayments, coinsurance amounts, deductibles, or other self-pay balances should be collected on site. Coinsurance often requires estimation.
A successful encounter has occurred if the information necessary to bill and collect the patient’s account is completed in a friendly, courteous, and timely manner.
How can case management impact access service quality?
Case management depends on access services to id and confirm correct insurance information.
Case management initiates activities such as pre-certification, admission notifications, concurrent review, and discharge planning based on the patient’s coverage.
If incorrect information is received, required activities may not be completed by case management. Inactivity from case review could impact payment, and in addition, case management may not pursue post-service resources for medical equipment, skilled nursing facility, rehab, home health, or hospice services if they are unaware of the benefits.
Explain how collaborating with information technology works with in the revenue cycle.
Streamlining operations
Increasing productivity
Assessing profitability by health plan & patient type
Providing quality care
Explain how clinical services works within the revenue cycle.
Primary responsibility is preparing and serving the patient, but a number of their activities support revenue cycle as well.
1 · Prepare for patients arrival to ensure timely service
2 · Time of service review the patient face sheet, chart, armband, and DR order for accuracy
3 · Signatures on consent forms
4 · Enter charges accurately and timely
5 · Documenting care delivered and/or service provided on patients chart
6 · Coordinating additional healthcare needs during the patients’ continuum of care.
7 · Manage bed placement, endure daily census info is correct.
Explain how finance works and collaborates within the revenue cycle.
Other departments work closely with the revenue cycle.
1 · Decision Support and Cost Reporting department – usually responsible for compliance with state and federal reimbursement reporting requirements.
2 · This department provides modeling for contract negotiation scenarios, and estimates the impact of regulatory payment changes on the provider’s financial performance.
Explain how health plan contracting works within the revenue cycle.
1 · Each contract must be reviewed for mutual understanding for accounting system and how reimbursements must be calculated.
2 · Appeal of denials should be specifically detailed in the contract and timely filing limitations reviewed to ensure that the provider can comply.
Which options are NOT a continuum of care provider?
SNF
Health Plan Contracting
Physician
Hospice
Is – SNF, Physician, Hospice, Home Health Agency, Assisted Living, DME
Is Not – Health Plan Contracting
Identify programs and services that are part of the continuum of care.
A. Physician
- Determine need for service & writes the order
- Order should include: date, valid diagnosis, patient’s name, physicians name & signature, and description of tests or test ordered.
- Physicians office is responsible for scheduling
appts or instructing patients to call/schedule appts. - Physicians & Physician offices play the key
supportive roles in the revenue cycle such as authorizations
B. Skilled Nursing Facility - Distinct part of hospital as a SNF
- Transfer agreements
- Advance directive requirements
- Covered level of care – to be covered, need all 4 factors met
a. Patient required skilled nursing services / rehab
b. Requires skilled services on a daily basis
c. Daily skilled services can be provided only on an inpatient basis for SNF
d. Service must be reasonable & necessary for the treatment of patient
C. Home Health Agency (Public or Private) – criteria is as follows:
a. Qualifying services
b. Policies
c. Clinical Records
d. Licenses
e.. Additional Conditions
f. Medicare coverage requirement – Physician certify patient is confined to home, Hospitals & SNF not considered a place of residence
D. Durable Medical Equipment
a. Prescribed by doctor for use in home
E. Hospice – terminally ill patients
a. Medicare allows coverage for two – 90 days periods & unlimited number of subsequent periods that are up to 60 days each.
b. Core services – nursing care, physician services, medical social services, and counseling.
F. Assisted living.
a. For adults who need help with everyday tasks.
b. Not covered by Medicare
Which option is NOT a department that supports and collaborates with the revenue cycle?
Clinical services
Assisted Living Services
Finance
Information Technology
Assisted Living
Continuum of Care
- A way of coordinating and linking healthcare resources to avoid duplication thus facilitating a seamless movement among care settings.
- Involves healthcare professionals in multiple settings at multiple levels working together with the overall goal of coordinating patients’ healthcare.
What is the objective of the HCAHPS initiative?
To provide a standard for collecting or reporting patients’ perspectives on care that would support valid comparisons amongst all providers.
Which option is NOT a main HFMA Healthcare Dollars & Sense revenue cycle initiative?
Price Transparency
Medical Account Resolution
Patient Financial Communications
Process Compliance
Process Compliance
What are the 6 rev cycle activities for improving communication?
- Modify billing formats for easier patient comprehension
- ,Extend normal business hours
- All staff answer the phone with courteously, give name for reference
- Resolve questions or complaints with our transferring the customer to another person whenever possible.
- Follow up on all customer inquiries or complaints with in 48 hours
- Include customer service responsibilities in all staff pe’s& hold staff accountable
What are a few of the IT Software applications that are or could be automated?
- Appt or resource scheduling
- Admit, discharge, & transfer – registration
3 Patient account systems
Continuum of Care philosophy
Looks at the healthcare system as a whole and seeks to implement linkages to connect patients who are leaving the acute care setting with post-acute facilities and services that will help the transition to home or to a residential care.
What are the post-acute services
Typically include skilled nursing, home health, durable medical equipment, hospice, and assisted living.
Identify programs and services that are part of the continuum of care for Physician
A. Determine the need for service and must write the order
B. Scheduling appointments or instruct the patient to call and schedule appointments.
C. Pre authorizations
D. Completeness and timing
Identify programs and services that are part of the continuum of care for Skilled Nursing Facility
A. Distinct part of hospital, follow CMS guidelines
B. Advance directive provisions
- Inform of state laws and own policies
- Document individuals medical record
- Educate staff and community on issues
C. Transfer agreements must have a written transfer agreement with one or more participating hospitals.
D. Covered level of care – all 4 below must be met - Patient requires skilled nursing/rehab services
- Patient required skilled services on a daily basis
- Services can only be provided on an inpatient basis
- Services must be reasonable/necessary treatment for illness or injury
Identify programs and services that are part of the continuum of care for Home Health Agency
A. Qualifying services
B. Policies
C. Clinical records
D. Licenses
E. Additional conditions
- Medicare coverage requirement
a. Physician certify patient is confined to home
b. Hospitals and SNF’s not considered a place of residence
Identify programs and services that are part of the continuum of care for Durable Medical Equipment (DME)
· Equipment prescribed by doctor for use in home
Identify programs and services that are part of the continuum of care for Hospice
A. Terminally ill, services include nursing care, physician services, medical social services, and counseling.
B. Medicare coverage for two 90 day periods, unlimited number of subsequent periods that are up to 60 days each
Identify programs and services that are part of the continuum of care for Assisted Living
A. Adults that need help with everyday tasks such as dressing, bathing, eating, and bathroom but do not need full time nursing care.
B. Combo of housing, personalized support services, healthcare.
C. Medicare does not cover the cost of assisted living.
Identify the purpose of essential elements in a corporate compliance program
A.· Have a plan
B. · Follow the plan
- · Plan is corp compliance prog
- · Know what happens if you don’t follow the plan
C. · Review the code of conduct to verify you follow the plan - · Chief Compliance Officer Role oversees code of conduct
- · Know the benefits of the codes of conduct
- · Code of conduct represents the organizations compliance program as well as the organizations culture.