Revenue cycle management ppt ashish

An easy way to learn RCM end to end process

1. Revenue Cycle Management Created By - Ashish Sinha

2. What is RCM ? Revenue cycle management  (RCM) is the financial process that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.

3. RCM RCM includes four things: Provider Payer Patient Billing Company

4. Centre of Medicare & Medicaid Services (CMS) The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services. Medicare & Medicaid are two separate government firms managed by CMS: Medicare (US Citizen >64 years) Medicaid (US Citizen below BPL)

5. Health Insurance Insurance taken out to cover the cost of medical care. In USA there is General Health Insurance which includes main 4 things: Regular Checkup Vision Dental Hospital (Durable Medical Equipments)

6. Medicare Medicare are of 4 types: Part A Part B Part C Part D Part A:-Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

7. Medicare Part B:-Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Part C:- It is not a separate benefit. Part C is the part of Medicare policy that allows private health insurance companies to provide Medicare benefits. These Medicare private health plans, such as HMOs and PPOs, are known as  Medicare Advantage Plans . If you want, you can choose to get your Medicare coverage through a Medicare Advantage Plan instead of through Original Medicare.

8. Medicare Medicare Advantage Plans must offer at least the same benefits as Original Medicare (those covered under Parts A and B) but can do so with different rules, costs, and coverage restrictions. You also typically get Part D as part of your Medicare Advantage benefits package. Many different kinds of Medicare Advantage Plans are available. You may pay a monthly premium for this coverage, in addition to your Part B premium. Part D:- Medicare Part D (outpatient Prescription Drug Insurance)is the part of Medicare that provides outpatient prescription drug coverage. Part D is provided only through private insurance companies that have contracts with the government—it is never provided directly by the government (like Original Medicare is).

9. Medicare If you want Part D, you must choose Part D coverage that works with your Medicare health benefits. If you have Original Medicare, choose a stand-alone Part D plan (PDP) MCR Part A:- Inpatient Services MCR Part B:- Outpatient Services

10. Part D Prescription Drug Coverage  - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

11. Process Of Checkup Appointment Visit to Receptionist Give Insurance copy Visit to Doc Doctor will diagnose and provide solution

12. Process Of Checkup When you give insurance card to receptionist, He/ She will do patient demographics (Enter patient details in his/ her system e.g. Name, Address, Policy type etc.) Problem is also known as diagnosis and solution is the procedure steps taken by the doctor. After the Solution, your claim will be created which includes (DOS-Date of service, Procedure, Diagnosis & Charges)

13. Revenue Cycle Management Demographics Medical Coding Charge Entry Payment posting Accounts Receivable Patient Calling

14. Demographics The definition of patient  demographics  starts to get polluted with items such as patient and emergency contact information and patient medical records. Name Address Contact details Insurance type Policy Number Medical Records

15. Medical Coding Medical coding  is the transformation of healthcare diagnosis, procedures,  medical  services, and equipment into universal  medical alphanumeric codes.  Latest version of medical coding is ICD-10, earlier we are using ICD-9 ICD-9 was used till Oct’14,2015. ICD-10 was started after Oct’15,2015. It was developed and maintained by WHO. In USA CMS make guidelines of implementation.

16. Why do we need Coding ? Medical  billing and  coding  workers are the health care professionals in charge of processing patient data such as treatment records and related insurance information. Medical  insurance billers and  coders  are tasked with  coding  a patient's diagnosis along with a request for payments from the patient's insurance company.

17. Why We Code Let’s start with a simple question about medical coding: Why do we code medical reports? Wouldn’t it be enough to list the symptoms, diagnoses, and procedures, send them to an insurance company, and wait to hear which services will be reimbursed? To answer that, we have to look at the massive amount of data that every patient visit entails. If you go into the doctor with a sore throat, and present the doctor with symptoms like a fever, sore throat, and enlarged lymph nodes, these will be recorded, along with the procedures the doctor performs and the medicine the doctor prescribes. In a straightforward case like this, the doctor will only officially report his diagnosis, but that still means the portion of that report that will be coded contains a diagnosis, a procedure, and a prescription.

18. Why We Code Take a step back, and this is suddenly a lot of very specific information. And that’s just for a relatively simple doctor’s visit. What happens when a patient comes into the doctor with a complicated injury or sickness, like an ocular impairment related to their Type-2 diabetes? As injuries, conditions, and illnesses get more complex, the amount of data that needs to be conveyed to insurance companies increases significantly. According to the Centers for Disease Control (CDC), there were  over 1.2 billion patient visits in the past year . That’s a stat that includes visits to physician offices, hospital outpatient facilities and emergency rooms. If there were just five pieces of coded information per visit, which is an almost unrealistically low estimate, that’d be 6 billion individual pieces of information that needs to be transferred every year. In a system loaded with data, medical coding allows for the efficient transfer of huge amounts of information.

19. Why We Code Coding also allows for uniform documentation between medical facilities. The code for streptococcal sore throat is the same in Arkansas as it is in Hawaii. Having uniform data allows for efficient research and analysis, which government and health agencies use to track health trends much more efficiently. If the CDC, for example, wants to analyze the prevalence of viral pneumonia, they can search for the number of recent pneumonia diagnoses by looking for the ICD-9-CM code 480. Finally, coding allows administrations to look at the prevalence and effectiveness of treatment in their facility. This is especially important to large medical facilities like hospitals. Like government agencies tracking, say, the incidence of a certain disease, medical facilities can track the efficiency of their practice by analyzing Now that we understand the importance of this practice, let’s take a look at the three types of code that you’ll have to become familiar with as a medical coder.

20. Types of Coding CPT Codes ( Current Procedural Terminology ) HCPCS ( Healthcare Common procedural Coding System ) DX Codes ( Diagnosis Codes ) Modifiers

21. CPT Codes Current Procedural Terminology ( CPT ) is a medical  code  set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. It is of 5 digits and could be numeric or alphanumeric. Alphabet will be the last letter. Used for MCR Part B Outpatient Services.

22. HCPCS The Healthcare Common Procedure Coding System ( HCPCS , often pronounced by its acronym as "hick picks") is a set of health care procedure  codes  based on the American Medical Association's Current Procedural Terminology ( CPT ). It is of 5 digits and could be numeric or alphanumeric. Alphabet will be the first letter. Used for Part A Inpatient Services

23. DX Codes Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into  codes  from a particular classification. In medical classification,  diagnosis codes  are used as part of the clinical coding process alongside intervention  codes . These are of 3-5 digits with decimal points and are of only numeric value

24. Modifiers Code  modifier  billing guidelines. Code  modifiers  help further describe a procedure code without changing the definition of the code. Modifier codes are of 2 digits either alpha or numeric. Its actually inform that where the problem is.

25. Certification of Coding CPC (Certified Professional Coders) CPC is for outpatient Services – Part B Certification provided by AAPC in USA CPC(H) (Certified Professional Coders Hospitals) It is for Inpatient services – Part A Certification provided by AAPC CCS (Certified Coding Specialist) Certification provide by AHIMA

26. Charge Entry – Medical Billing Medical billers and coders are tasked with coding a patient's diagnosis along with a request for payments from the patient's insurance company. It includes Diagnosis , Treatment & Charges.

27. Medical Billing Claims are in two forms:- HCFA / CMS1500 (Healthcare Finance Administration) It is used for Part B (Outpatient Services) It includes 33 fields (Approx) UB04 / CMS1450 It is used for MCR Part A (Inpatient / Hospital Services)

28. Medical Billing In earlier days when claims were send to Insurance companies called as Filing now known as Electronic Transmission / E-Filing.

29. Accounts Receivable The aggregate of money owed to the  health care  practice by all patients and/or insurers.

30. Accounts Receivable The aging of your AR is crucial to watch because the older bills get, the harder and more costly they become to collect When your AR slips and you have a very large backlog or balance, it can seem like you’ll never be able to tackle it. If patient insurance eligibility is not being verified or we’re not connecting with the patient prior to them presenting to the office, it creates a massive amount of work on the back end to try and resolve open AR or open claims.

31. Fee Schedule A  fee schedule  is a complete listing of  fees  used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of  fee  maximums is used to reimburse a physician and/or other providers on a  fee -for-service.

32. Accounts Receivable What is Billed Amount? A billed amount is the amount which was charged by the doctor for treatment. What is allowed amount? Allowed amount is the amount fixed by CMS to pay the doctor for his/her services.

33. Insurance A patient must have a Insurance or he/she can have multiple insurance also. Multiple Insurance be Like:- 1 st Insurance – Primary Insurance 2 nd Insurance – Secondary Insurance 3 rd Insurance – Tertiary Insurance

34. Account Receivable Co Insurance – If patient have more than 1 insurance Co Pay – Patient also need to pay in this type of Pay Co Insurance – In Co insurance the amount which was need to pay by the secondary insurance company (apart from the amount paid by the primary insurance) is called Co Insurance. Co Pay – In Co Pay the amount which need to pay by the patient (apart from the amount paid by the primary insurance) is called Co Pay.

35. Accounts Receivable Payers could be of two types:- Federal / Government Commercial Payers Federal payers are MCR (>64 years) &b MCD (Below BPL) {Companies Like CHAMPUS, TRICARE, CHAMPUR are for Defence } Commercial Payers are like AETNA, CIGNA, BCBS, UHG, ANTHEM etc.

36. Accounts Receivable TFL – Timely Filing Limit There is a time limit to file any claim. Different companies have different time frame. MCR – 1 year MCD – 60 days Commercial – 6 Months & can be vary from company to company

37. Accounts Receivable AR Days AR Days are like:- From Claim Filing day-----------> Payment Received day Average MCR took 18-24 days If we didn’t receive the payment within these days then the insurance compoany must send an EOB or ERA to Doc & Patient.

38. Accounts Receivable What is EOB? An  explanation of benefits  (commonly referred to as an  EOB  form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. The  EOB  is commonly attached to a check or statement of electronic payment. What is ERA? Second,  Electronic Remittance Advice  ( ERA ) is an electronic report in a standard, computer-readable format sent by insurance companies to providers as an explanation of payment and adjudication of  medical  claims.

39. Accounts Receivable Reasons of Non Receiving of Payment. Denials On Hold Partially paid Explanation will be given by the Insurance company in each case of Non Payment.

40. Accounts Receivable What is receivable ? It is total value of claims filed in $ value. Time frame for Accounts Receivable:- 30 - 60-90-120 We need to close the AR maximum within 90 days of claims.

41. Payment Posting It is a type of accounting- enter details of payment from Insurance companies. 6 things to look at during  payment posting :  Payments  entered within 1 day or less of receipt. Explanation of Benefits (EOB).  calculate write offs, coinsurance, deductibles and patient  payments .

42. Payment Posting Details of all payment data comes in payment posting. A/C Closing Cut Off Date – It is important to have a cut off date so that we can check the monthly or annual amount income of the company. Payment posting also includes Monthly Closing amount Total billed amount Total allowed amount Total write off amount

43. Patient AR Normally every citizen of USA have Insurance policy but many circumstances occurs where patient need to pay the amount. Co-Pay No Insurance No Coverage Deductible Out of state coverage Benefits exhausted Workers compensation also not covered by normal Insurance companies

44. Patient AR Co Pay – Partial amount need to pay by the patient. No Insurance – If patient not carrying any Insurance policy No Coverage – If Insurance policy is not covering for that particular treatment. Deductible - The amount you pay for covered  health care  services before your insurance plan starts to pay. With a $2,000  deductible , for example, you pay the first $2,000 of covered services yourself. After you pay your  deductible , you usually pay only a copayment or coinsurance for covered services. (Deductible amount could be your tax also.

45. Patient AR Out of state coverage – In USA different have there different policies. It is possible that if you have an insurance policy issued under Texas state will not work in Pennsylvania. Benefits Exhausted – If the amount need to pay the doctor is crossing the Insurance amount limit in that case patient need to pay the amount. Workers Compensation – It is a policy provided by the corporate’s to their employee. They have there different criteria's.

46. PHI & HIPAA According to the US Department of Health and Human Services,  protected health information (PHI)  is individually identifiable information. HIPAA  ( Health Insurance Portability and Accountability  Act of 1996) is United States legislation that provides data privacy and security provisions for safeguarding medical information.

47. EMR – Electronic Medical Records U.SEMR is also called EHR (Electronic Health Records) or CPR (Computerized Patient Records) EMR systems capture patient data EMR software integrates with other data sources EMR assists in provider decision making EMR captures data at the point of care using a database, rules engine and knowledge bases as the primary sources of information, then integrates it with other records for that Member. 5. Integration with multiple databases is through HL7(Health Level 7) Eg : EMR would include integration with hospital, billing, practice management, laboratory, imaging and pharmacy systems. Functions of an EMR : 1. Patient Charting 2. Order Communication Systems 3. Clinical Decision-Making Support Systems 4. Document/Image Management 5. Patient Portal 6. Statistics and Reporting Only 25% of Providers have adopted EMR in the .

48. PHI & HIPAA A  covered entity  is any health plan, health care clearing house, or health care provider who transmits any health information in electronic form in connection with a qualified transaction and their business associates. HIPAA Affected Areas are expected to adhere to the HIPAA Privacy and Security Rules as well as any other area or unit that creates, uses, or stores PHI from another HIPAA Affected Area or outside covered entity. Data are "individually identifiable" if they include any of the 18 types of identifiers for an individual or for the individual's employer or family member, or if the provider or researcher is aware that the information could be used, either alone or in combination with other information, to identify an individual. These identifiers are:

49. PHI & HIPAA Name Address (all geographic subdivisions smaller than state, including street address, city, county, or ZIP code) All elements (except years) of dates related to an individual (including birth date, admission date, discharge date, date of death, and exact age if over 89) Telephone numbers FAX number Email address

50. PHI & HIPAA Social Security number Medical record number Health plan beneficiary number Account number Certificate/license number Vehicle identifiers and serial numbers, including license plate numbers

51. PHI & HIPAA Device identifiers or serial numbers Web URLs IP address Biometric identifiers, including finger or voice prints Full-face photographic images and any comparable images Any other unique identifying number, characteristic, or code All protected health information is subject to federal Health Insurance Portability and Accountability Act (HIPAA)regulation.

52. RCM THANK YOU Made By – Ashish Sinha