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Foundational Knowledge REVENUE CYCLE KEY POINTS 1.4 Revenue Cycle Electronic Claims Submission...

Foundational Knowledge REVENUE CYCLE KEY POINTS 1.4 Revenue Cycle Electronic Claims Submission Many third-party payers require electronic claims submission, with allowances for paper claim submission from providers that qualify as small practices. The billing application submits claims to the third-party payer for reimbursement. Third-party payments and adjustments are posted. Patient payments for deductible, copayment, and coinsurance are posted, and statements and itemized receipts are generated. Billing Management Billing management monitors payments billed and received each calendar month. The report allows for the opportunity for the practice to analyze trends of reimbursement. A rejected claims report can be run to show potential trends in denials. It identifies rejections and the reasons (for example was incorrect patient information included, incomplete or missing information, wrong insurance, or services not covered). This information has to be timely, as there are filing deadlines. The practice can then correct for errors and resubmit for payment, when applicable. Copayment Many third-party payers require a fixed copayment at the time of service, which is a patient financial responsibility. The third-party payer determines the copayment amount. Copayments are typically assigned to provider visits but will be defined by the plan. It is part of the CMAA’s job responsibility to collect the copayment at the time of visit, therefore, positively contributing to the revenue cycle. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review  Foundational Knowledge Billing Potential Errors Billing errors, such as diagnosis and procedure codes incorrectly translated from the encounter form, are common, and the medical administrative assistant provides valuable support by reviewing claims prior to submission. If the errors occur with demographic information or any of the billing data incorrectly input, it will cause the claim to reject, therefore, holding up the billing process. Patient Eligibility Verification Medical practices spend great amounts of time verifying insurance eligibility for the patient. Eligibility is verified when the appointment is made and when services are provided. This process is automated, either at the payer site, using a payer device, or using an app that is integrated into the practice management system. Payment Tracking Most EHR or practice management systems offer the monitoring of claims payment status. This process tracks claim submissions to third-party payers, claim status, and lastly, when payment is being sent to the provider. Payments are often made by direct deposit, which is the most efficient payment method for receiving claims reimbursement. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review  PREPARE DOCUMENTATION FOR BILLING practice management system (PMS). An efficient way The revenue cycle begins when the patient contacts the health care organization for an appointment to electronically manage administrative functions, such as scheduling appointments, integrating and does not end until the services and procedures provided to the patient are paid in full by the patient documentation from electronic health insurance carrier, the patient, or a combination of both. records, coding, billing, and revenue cycle tasks Today, most health care organizations use a practice management system (PMS) to perform revenue such as running aging reports and managing the accounts receivable. cycle tasks and streamline front office and back office workflows with automation. The practice management system is an efficient way to boost productivity and can help with sustainability and stronger financial performance. Scheduling appointments, 6.1 Revenue Cycle charge capture, coding, billing, generating financial/aging reports, generating patient statements, and managing the accounts receivable are all examples of how the PMS is efficiently used. Phases of the Revenue Cycle The CMAA’s role in each of the revenue cycle steps is described below. It is important to note the revenue cycle is based on basic concepts and will be adjusted to the specifics of the health care organization. Registration and Scheduling 6.2 Prior Authorization Process This step occurs when the 1. Organization submits request to payer. patient calls for an appointment. The CMAA will gather patient 2. Payer’s UR department reviews. information such as demographic 3. UR approves, modifies, or denies request. and insurance information, 4. Response is returned to organization. determine the type of appointment 5. Organization documents request status in the EHR. needed, and enter the appointment on the provider’s schedule. During 6. Schedules/reschedules service or procedure. appointment scheduling, the patient may be asked to arrive 15 min early to complete new patient registration forms or update existing information. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review  Patient Check-In The patient completes the registration (demographic and insurance), HIPAA, and other compliance and policy forms, along with medical history information. The CMAA will scan or copy the patient’s insurance card and cross-check the information completed on the registration form to the data entered in the practice management system (PMS) during the registration and scheduling step, then changes the patient’s status to checked in. Utilization Management Review preauthorization. Sometimes required by a payer Also known as utilization review (UR), this is the process of ensuring the patient has the appropriate to determine medical necessity for the proposed referral, precertification, predetermination, or preauthorization as needed. This process supports the services. revenue cycle by ensuring the payer, provider, and patient have met any required conditions and understand how the service will be reimbursed and what the patient responsibility amount will be. Not all services or procedures will require a UR. The CMAA must be familiar with rules and 6.3 UR Terms guidelines for third-party payers, as they will vary. precertification. Finding out if the service is When in doubt, always verify by contacting the payer to determine if UR is necessary for the covered by the patient’s plan. procedure or service. Documentation of UR is important for scheduling and claims purposes. For predetermination. Determining the payer’s example, once a preauthorization is obtained, document the authorization number, expiration date, reimbursement amount for the service. and any specified details in the patient’s health record. preauthorization. Finding out if the payer considers a service medically necessary based on Prior to the procedure or service being performed, verify that the authorization is still valid. It is the patient’s specific condition. possible for a procedure to be rescheduled due to various circumstances, and the authorization is no longer valid. In these cases, a request for an extension or new authorization must be obtained and documented in the PMS. A patient’s eligibility must also be verified when scheduling. Using preauthorization as an example, the authorization provides approval for the procedure or service, yet reimbursement is still contingent on the eligibility of the patient at the time of service and is based on the claim details to support medical necessity. Health Care Encounter and Documentation The health care encounter and documentation are part of the clinical aspect of the revenue cycle. The provider will review the patient’s medical history and reason for the encounter, perform a physical exam as indicated, order any diagnostic or lab tests, and perform an assessment and develop a treatment plan. The CMAA would verify coverage for certain procedures, obtain the preauthorization, and document it in the PMS or medical record. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review  Charge Capture and Coding Once the encounter and documentation are complete, charge capture or charge entry is performed. This is the process of capturing each procedure code and corresponding diagnosis code for the encounter in preparation for billing. Depending on organizational policy, the provider may select the codes (CPT®, HCPCS, and ICD-10-CM) for the encounter, and the CMAA may verify the codes for completeness and import or enter them into the billing application. It is important to ensure that the diagnosis code(s) supports the medical necessity of the procedural codes. Patient Check-Out When the encounter with the provider has ended, the patient will proceed to check-out. If a return appointment needs to be scheduled, ask the patient what day/time works best for their schedule. Collect the copay if it was not collected during the check-in process and any coinsurance or deductible amounts that may have incurred during the encounter and have been verified with the insurance company. Some organizations use real-time adjudication to support this task. The patient will be presented with an after-visit summary (AVS), which includes demographic information on file, the reason for the encounter, vital signs, tests/labs ordered, the conditions managed at the time of the encounter, and related patient instructions or educational materials. Most importantly, the patient should feel they received top-quality care from check-in to check- out. The CMAA should thank the patient for allowing the health care organization to be part of their health care needs and encourage them to call the office with any questions or concerns once they return home. Billing Prior to billing claims to the third-party payer, the CMAA should verify patient demographic and insurance information, as well as review the CPT, HCPCS, and ICD-10-CM codes to ensure that codes are appropriately linked to demonstrate medical necessity. For example, the CPT code for an ankle x-ray should not be linked to the ICD-10-CM code for bronchitis. Make the appropriate corrections per the organization’s policies and procedures. Query the provider as necessary. Taking a moment to review the claim information will reduce the potential for denied claims. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review  Payer Adjudication Adjudication is the process by which the insurance carrier reviews the benefits and coverage and then either processes or denies the claim. The adjudication process will also identify patient responsibility associated with deductibles, copays, or coinsurance. Notification will be sent to the remittance advice. A response from the payer of health care organization via remittance advice. claims payment and an explanation of patient responsibility amounts and any adjustments made to the billed amount by the payer. Receiving and Posting Reimbursement The remittance advice is the notice of payment to the health care organization, explains any adjustments made to the payment, and provides patient responsibility for any deductible, copay, or coinsurance amounts. The CMAA may be tasked with reviewing the remittance advice and comparing it to the patient account to ensure the proper payments and adjustments were posted correctly by the automated system or by posting manually. Reviewing and comparing the remittance advice to the patient account will ensure proper billing to the patient and correct reimbursement to the organization. Appeals/Claims Corrections During the payer adjudication process, if claims contain errors or are not supported by the insurance plan benefits or coverage requirements, or meet the payer requirements for medical necessity, they will be denied. For any denied claims, the CMAA will contact the payer following their policy and procedures for correcting or appealing a claim. Some payers require that appeals be filed electronically; others request a paper form with documentation to support medical necessity. Each payer has its own requirements and deadlines to file an appeal. When an incorrect payment is made to the health care organization, the CMAA will need to contact the payer for assistance. Patient Responsibility Collection, Payments, and Posting Collecting fixed copays and outstanding balances at the time of patient check-in/out is strongly recommended as it increases the efficiency of patient collections. Proper training on payment collection is important. There are times the CMAA may need to conduct a one-on-one conversation with the patient to discuss policies and procedures for outstanding balances. Reconciling patient payments and deposits daily for accuracy before posting will maintain the financial stability of the health care organization. Before closing out transactions for the day, compare the daily transactions to the electronic journal to ensure accuracy. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review  Referral and Insurance Authorizations The term referral may have various meanings. In referral. An order from a provider for a patient to see general, a referral is when care for a specified service or a specialist or to obtain specific medical services. condition is transferred from one provider to another, often for specialty services; for example, when a CHALLENGE primary care physician (PCP) refers a patient with heart 1. Describe when the revenue cycle starts and 5. A patient is scheduled for an appointment disease to a cardiologist for more specific treatment. when it ends. tomorrow, and the CMAA notices the However, with some managed care plans, referrals may The revenue cycle begins with patient registration authorization number has expired and must require a UR component before the patient can receive and scheduling and ends when the claim is paid in be extended or a new authorization number full. The revenue cycle maintains the financial stability obtained. Which of the following steps of services somewhere other than at the primary care of the health care organization. the revenue cycle involves obtaining and level. verifying prior authorizations for certain 2. Briefly describe how practice management procedures? An insurance authorization is the process of obtaining systems impact the health care organization. A. Patient check-in approval from the patient’s payer. Authorizations are Practice management systems are an efficient way to B. Health care encounter and obtained in advance of the test, imaging, medical boost productivity and streamline with automation documentation equipment or device, procedure, or other service and are patient A/R controls, appointment scheduling, charge capture, generating financial reports and C. Utilization management review usually referred to as preauthorization. The patient statements. They are efficient examples of D. Payer adjudication how to utilize the PMS system to remain sustainable preauthorization request is submitted along with and improve patient outcomes. C is correct. Utilization review management is clinical information explaining why a particular service the process of verifying coverage and obtaining 3. Briefly describe charge capture and coding authorizations for certain services and procedures is needed. The purpose of a preauthorization request is prior to performing the service for insurance as it applies to the revenue cycle. reimbursement. to allow the payer to determine the medical Charge capture and coding is the process of entering appropriateness of the service. The payer will then the CPT, HCPCS, and ICD-10-CM codes associated 6. Describe when a referral would be needed approve, modify, or deny the request. Authorization with the patient encounter to prepare the claim for for patient care. submission to the insurance payer. Reimbursement numbers, any specified CPT and/or HCPCS codes, or any for services rendered are not paid unless charges A referral may be needed for patient care when other specifications such as the number of visits, along are entered into the PMS, coded correctly, and a patient is in need of more specialized care and submitted to the insurance payer. treatment. For example, when a primary care with the authorization expiration date, must be provider refers a patient to the cardiologist for 4. Why might a preauthorization be necessary management of heart disease. documented in the patient’s medical record for future reference. prior to performing a procedure? Preauthorization may be necessary prior to a service because the insurance payer does not want to be responsible for reimbursement on services they consider not medically necessary. The CMAA will contact the payer and provide patient health history information to describe the medical necessity of the service. National Healthcareer Association Certified Medical Administrative Assistant (CMAA) Study Guide Focused Review