Effective Writing Techniques Quiz

Healthcare Revenue Cycle Management

• This module focuses on the management of healthcare revenue cycles.

Objectives

• Review the importance of revenue in revenue cycle management.
• Review revenue enhancement strategies.
• Review the steps of a successful revenue cycle.
• Analyze current operations to identify areas costing money.
• Review financial policies and procedures.
• Review changes in Saudi healthcare reimbursement.
• Examine the RCM cycle under the new reimbursement system in KSA.
• Assess potential risks of poor RCM function.
• Discuss challenges of new RCM processes.
• Examine revenue cycle management as a profession.

Abbreviations

• RCM: Revenue Cycle Management
• A/R: Accounts Receivable
• RN: Registered Nurse
• MA: Medical Assistant
• HM: Health Maintenance
• PA: Physician Assistant
• SAR: Saudi Riyal
• ACHI: Australian Classification of Health Interventions
• ICD: International Classification of Diseases
• CHI: Council of Health Insurance
• MoH: Ministry of Health

Revenue Generation

• RCM is the process by healthcare systems track revenue from patient registration to collection.
• The Healthcare Financial Management Association (HFMA) defines the revenue cycle as all administrative and clinical functions contributing to revenue capture, management, and collection.
• Generating revenue is essential to sustain any business.
• Increasing revenue opportunities is a key to financial success.
• Strategies for limiting costs and increasing revenue are crucial.

Importance of Revenue

• Businesses, specifically medical practices, must generate revenue to remain open and operating.
• Medical practices, like all other businesses, are not paid in full for services immediately but must invoice and wait for reimbursement.
• Most payers require submission of invoices to a third party.

Revenue Cycle Management for Physicians/Providers

• Physicians are the primary source of revenue.
• Optimize physician productivity.
• Task delegation is important so physicians only do tasks requiring their expertise.
• Streamline workflows to ensure efficiency.
• Review procedures with the goal of increasing productivity.
• Follow up with pre-authorization when required.

Revenue Cycle Management for Healthcare Facilities

• All healthcare departments need to report the services performed to earn credit.
• Methods for selecting codes include using a technician or the treating physician.
• Hospital chargemasters (CDM/service master) outline all services and components.
• In KSA, only physicians can select the services to be rendered.
• Each department's tasks for coding, billing, and claims processing may vary based on the facility.
• Different billing types for various patient encounters in KSA include inpatient, day case, emergency, outpatient, home healthcare, and primary care.

Outpatient Facilities

• Outpatient medical services may include same-day surgeries, clinic visits, therapy, and diagnostic testing.
• Separate departments within the outpatient facility may all contribute to a single claim for a particular visit.
• Hospital-based ambulatory surgery centers (ASCs) and critical access hospitals (CAHs).
• Comprehensive outpatient rehabilitation facilities (CORFs).

Types of Patient Encounters in KSA

• Six types of patient encounters in KSA:
  • Hospital inpatient (overnight stays)
  • Day case (same-day discharge)
  • Emergency department
  • Outpatient
  • Home healthcare
  • Primary care

Types of Admissions in KSA

• Various types of patient admissions in KSA
• Each admission type has a designated code for data specifications.

Types of Care in KSA

• Various types of patient care in KSA
• Specific code numbers are used for each type.

Health Service Events

• Outpatient and emergency room care events.
• Contact between a healthcare user and a health agency requiring an attendance at a healthcare facility.
• Doesn't involve a hospital admission or discharge.
• Includes contact with physicians, specialists and other allied healthcare professionals in the facility.

Hospital Inpatient Events

• Involves a healthcare user being admitted and discharged.
• Contact between the user and the health agency.

Community Care Events

• Contact between a user and health agency at a location other than a healthcare facility (e.g., home visits, places of recreation).

Types of Outpatient Facilities

• Hospital-based ambulatory surgery centers
• Independent ambulatory surgery centers
• Hospital outpatient clinics
• Other outpatient facilities

Hospital and Independent ASC Features

• Financial independence is a key distinction between hospital-based and independent ASCs
• Separate tax ID number for claim submission.
• Physician services aren't typically coded/billed by facility unless the physician is employed by the ASC.

Outpatient Diagnostic Testing

• Some patients only require diagnostic services that can't be performed in a physician's office.
• Services include tests, results sent to physician, separate billing for interpretation.

Inpatient Departments

• Admitting offices are responsible for patient registration.
• Business offices handle claims processing and transactions.
• Healthcare information departments (HIM) organize and store medical records.

Inpatient Facilities

• Acute care hospitals
• Critical access hospitals
• Teaching hospitals
• Skilled nursing facilities
• Long-term care facilities

Patient Treatment and Documentation

• Clinical staff who perform activities on patients must document them.
• Documentation is essential for reimbursement.
• Medical necessity must be clearly documented for all treatments.

Coding and Grouping

• Converting diagnoses and procedures into standardized codes for submission to payers.
• Coding standards determined by KSA's Ministry of Health (MoH) and the Council of Health Insurance (CHI).
• Internal use for cost monitoring and detailed activity tracking.

Billing and Claims Management

• Invoices must accurately reflect coding and meet payer requirements.
• Complete and accurate data is crucial for timely, successful payments.
• Processes for resolution if payments are rejected must be established.

Revenue Cycle Management Processes (Critical Steps)

• Appointment scheduling
• Registration
• Charge capture
• Billing
• Denial management
• A/R follow-up

Appointment Scheduling

• Importance of scheduling effectiveness.
• Knowledge of the registration staff is crucial to first impressions of the practice.
• Staff should be able to handle multitasking, use appropriate technology.
• Timely information and scheduling.
• Reducing no-shows via reminders

Registration

• This is a critical financial function.
• Effective registration involves excellent knowledge of patient demographics, insurance, and payer details.
• Managing multitasking is essential.
• Tracking and recording payment details in a timely manner.

Front Desk Collections

• Average copay ranges.
• Procedures and policies for collecting payments.
• Tracking of collected payments.
• Timeliness for upfront collections

Audit Data Accuracy

• Tools for periodic audits on collected information
• Ensure accuracy of data fields (demographics, insurance details, services rendered).

Denial Management

• Handling payer rejections
• Providing additional information to the payer
• Appealing denials
• Analyzing reasons for denial.

Claim Rejections

• Technical and medical reasons for claim rejection
• Reviewing and correcting denial codes to improve reimbursement rates.

Days in A/R

• Days in A/R data helps to identify areas in clinics billing, coding, and collections processes.
• A lower A/R number indicates that the clinic manages its accounts receivable effectively.

Net Collection Ratio

• It measures how well a clinic collects permissible charges.

Adjustments to Collections Ratio

• Necessary adjustments affect the net collection ratio and days in A/R.
• The ratio analysis helps identify when payments may not be handled efficiently.

Healthcare Reimbursement Changes in KSA

• The Saudi health sector is undergoing a significant transformation.
• The Ministry of Health is transitioning from a unified payer/provider role to a governing corporatized payers and providers model.
• Critical changes include the establishment of the Program for Health Assurance and Purchasing (PHAP) and the firming-up of regulations for private insurers.

RCM Cycle Under New Reimbursement System in KSA

• RCM contains four operational parts:
  • Patient acceptance and registration
  • Treatment and documentation
  • Coding and grouping
  • Billing and claims management.
• Patient acceptance includes verifying medical and financial eligibility.