Module 6: Billing and the Revenue Cycle Objectives of Module 6 Understand the steps of the revenue cycle and how mistakes can affect a health care organization's finances. Learn ho... Module 6: Billing and the Revenue Cycle Objectives of Module 6 Understand the steps of the revenue cycle and how mistakes can affect a health care organization's finances. Learn how to create, submit, and track claims with third-party payers. Identify errors in claims, process appeals, and handle payments. Recognize different insurance payment models and programs. Assess how denied or incorrectly paid claims impact the revenue cycle. Overview of the Revenue Cycle Certified Medical Administrative Assistants (CMAAs) handle many essential tasks in health care organizations, including managing the revenue cycle. The revenue cycle begins when a patient schedules an appointment and ends when all payments are made, either by the patient, insurance, or both. Errors in any step of this process, like incorrect patient information or coding mistakes, can delay payments and reduce the organization’s cash flow. Key Phases of the Revenue Cycle Registration and Scheduling: Collect patient demographic details and insurance information. Schedule appointments and confirm any pre-visit requirements, like arriving early to complete forms. Check-In: Patients complete forms for demographics, insurance, HIPAA compliance, and medical history. The CMAA ensures all information is correct in the Practice Management System (PMS) and marks the patient as checked in. Utilization Management Review: Also known as utilization review, this ensures patients have referrals, preauthorizations, or approvals as required by their insurance. The CMAA documents details like authorization numbers and verifies their validity before procedures. Health Care Encounter and Documentation: Providers examine the patient, document their medical history, and create a treatment plan. CMAAs confirm insurance coverage and ensure preauthorizations are documented in the medical record. Charge Capture and Coding: Procedures and diagnoses are coded (CPT, HCPCS, and ICD-10-CM) to prepare claims for billing. Codes must match the medical necessity to avoid claim denials. Patient Check-Out: Collect copays, coinsurance, or deductibles. Provide an after-visit summary (AVS) that includes details of the visit, tests ordered, and patient instructions. Billing: Verify patient demographics, insurance, and codes to ensure accuracy before submitting claims. Errors, like mismatched codes, should be corrected before submission. Payer Adjudication: Insurance reviews claims to determine payments and patient responsibility (deductibles, copays, etc.). The organization receives a remittance advice (RA) outlining payment details. Appeals and Claims Corrections: If claims are denied, the CMAA files appeals or makes corrections per payer guidelines. Each payer has specific rules and deadlines for appeals. Payment Collection: Collect balances from patients, often starting with fixed copays. Reconciling payments daily ensures accurate financial records. Common Terms and Tools Preauthorization: Insurance approval confirming medical necessity. Remittance Advice (RA): Document explaining payments and adjustments. Clearinghouse: Organization that reviews claims for errors before submitting them to payers. Timely Filing: Deadline for submitting claims to insurance (varies by payer). Participating (PAR) Providers: Providers who agree to the insurance payer’s fee schedule. Non-Participating (Non-PAR) Providers: Providers who do not follow the payer’s fee schedule. Insurance Payment Models Fee-for-Service: Providers are paid for each service they perform. Pay-for-Performance (P4P): Providers earn bonuses for meeting specific quality goals. Capitation: Providers are paid a set monthly amount for each enrolled patient, regardless of how many times they visit. Carve-Outs: Certain services excluded from capitation and billed separately. Medicare vs. Medicaid Medicare: A federal program primarily for people over 65, those with disabilities, or those with end-stage renal disease. It includes: Part A: Hospital stays (no premium). Part B: Outpatient services (requires premium). Part C (Medicare Advantage): Combines A and B, plus extras like vision and dental. Part D: Prescription drugs (requires premium). Medicaid: State-run programs for low-income individuals, pregnant people, and others with specific medical needs. Qualifications vary by state. Other Key Points Annual Wellness Visits (AWVs): Must include elements like health risk assessments to meet CMS requirements. Audits: Claims are subject to random or triggered audits to ensure compliance with documentation and coding standards. Read more