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.

Test your knowledge on effective writing techniques and the importance of proper formatting in communication. This quiz explores common challenges writers face and strategies to engage the audience. Enhance your writing skills by understanding the crucial factors that contribute to quality writing.