The Revenue Cycle

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 Blue indicates HSF Clinical Green indicates HSF Admin
Center Owned Department Owned Owned Responsibility
Responsibility Responsibility
 Documentation & Coding

Scheduling
Revenue Cycle
Payment Processing

A/R Follow-up

Registration
Charge Processing
Resubmission & Appeals

Claim & Statement

Production

Legal Collections Secondary Claims

UVa and HSF Revenue Cycle
 It all begins with the patient
entering the UVa Health System
needing services
 Appointment Patient
Patient Exam
Scheduling Registration

Documentation
The & Coding
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment
Statement
& Appeals Processing
Production
Appointment Scheduling Process
– Begin Revenue Cycle
• Verification of insurance
• Authorizations and certifications
• Pre-registration gathering demographics
• Identify the referring physician
 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
 Appointment Patient
Patient Exam
Scheduling Registration

Documentation
The & Coding
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment
Statement
& Appeals Processing
Production
 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
 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
 Appointment Patient
Patient Exam
Scheduling Registration

Documentation
The & Coding
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment
Statement
& Appeals Processing
Production
 Patient Exam
• Patient identifies concern/problem
• Procedures performed and/or treatment
provided
• Discharge diagnosis
• Physician documentation initially recorded
 Patient Exam: Goals
• Reasonable/timely access
• Complete clinical service
• Informative to patient
• Appropriate documentation for patient care and for
correct billing to third party
 Appointment Patient
Patient Exam
Scheduling Registration

Documentation
The & Coding
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment
Statement
& Appeals Processing
Production
Documentation & Coding Process

• Physician documents services

• Services coded by Physicians and/or coders:
CPT codes (procedures), ICD-9 (diagnosis),
HCPC (supplies, drugs, etc.)
Documentation & Coding: Goals
• Documentation complete and signed by provider
• Codes accurately reflect patient service(s)
• Coding reviewed to insure it reflects
documentation
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment
Statement
& Appeals Processing
Production
 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
 Charge Processing: Goals
• Accuracy of service and charge
• Appropriate edits to scrub data
• Charges entered timely for prompt
payment
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment
Statement
& Appeals Processing
Production
 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
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)
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Claim &
Guarantor Billing Payment
Resubmission Statement
& Appeals Processing Production
 Payment Processing
• Electronically or manually post remittances from
payers and patients
– Payments
– Denials or rejections
– Adjustments
• Refunds
• Reconciliation of charges, payments and adjustments
 Payment Processing: Goals
• All payments and denials processed within 24 hours of receipt
• Process all refunds within one week of credit balance
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment Statement
& Appeals Processing Production
 Resubmission & Appeals
• Invalid registration
• Medical Documentation required
• Correct coding /charge corrections
• Missing referral/pre-authorizations
• Payments included in primary service
 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
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
Cycle
A/R Follow-up Charge
Processing
2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment Statement
& Appeals Processing Production
 2

Secondary Claims/
Guarantor Billing
• Claims edited to insure completeness
and correctness
• Secondary claims and patient
statement production
• Resubmission & appeals, if necessary
 2

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
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
Cycle Charge
A/R Follow-up
Processing

2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment Statement
& Appeals Processing Production
 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
 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
 Appointment Patient
Patient Exam
Scheduling Registration
Documentation
& Coding
The
Legal Collections
Revenue
A/R Follow-up
Cycle
Charge
Processing

2
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment Statement
& Appeals Processing Production
 Legal Collections
FOCUS IS ON THE LEGAL SYSTEM
• Warrant in debt
• Garnishments
• Liens
• Payment arrangements (Legal budget plans)
 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
 Appointment Patient
Patient Exam
Scheduling Registration
* * Documentation
& Coding
Legal Collections
* The *

Revenue
*
A/R Follow-up
Cycle
* Charge
Processing
* *
2 * *
Secondary Claims/
Guarantor Billing Claim &
Resubmission Payment Statement
* Measured
against & Appeals Processing Production
Benchmark
s
A successful Revenue Cycle depends on…

• Accurate data
• Working together
• Effective communication
 Revenue Cycle Goals
• Improve the process
• Increase collections
• Let doctors practice medicine
• Enhance patient satisfaction
Everyone has a role to play!
All of us benefit by working
together…