The Revenue Cycle

What is it?

Where does the Revenue Cycle Start?

Physician’s Office Or Emergency RoomPhysician writes an order

To admit patientTo observe patientFor tests, procedures, lab, radiology, etcFor surgery

SDS Inpatient surgery

SchedulingReferralsAuthorizations

Pre-cert or pre-auth must be obtained from insurance prior to treatment

Pre-cert or pre-auth number must be included on claimNotifications

Some insurances do not require authorization. Some insurance request to be notified.

Pre-RegistrationVerify Insurance CoverageVerify AuthorizationVerify Patient DemographicsDetermine Patient Responsibility

Co-pays, deductiblesCo-insurance

Obtain Patient Responsibility up frontCollect deposits

Financial CounselingMeet with patients to review their financial

obligationsScheduling / Pre-registration processRegistrationPrior to discharge – inpatientsDuring discharge process – in and out patients

Once they are out the door thechances of collecting diminish dramatically

Registration’s TurnVerify any missing dataVerify IdentityScan Insurance Cards and documentationObtain co-pays & patient responsibility $$$Patient Signs required documents

Permission to treat, guaranty of payment, assignment of benefits

Other consent forms

And More ……Advance DirectivesNotice of Financial ResponsibilityMSP QuestionnaireRights as a Medicare patientABNsHIPAA – Privacy NoticeRed Flag RegulationsEtc.

Bed ManagementBed Accommodation

PrivateSemiprivate

Verified at MidnightCharged at MidnightPatients holding in ED for a bed

Case ManagementSee every observation or inpatientCase management monitors inpatient and

observation patients’ care to ensure admission meets admission criteriaInterqualMilliman Care Standards - used by insurances

Works with physicians to discharge the patient in the appropriate amount of time or ensure patient still meets inpatient criteria.

Monitors and works on delays to recovery.Review patients status:

Medicare and Medicaid – every 3 daysAll others - daily

Discharge PlanningPerformed by case management.Begins when patient is admitted.Goal is to only keep patient in house as long as is

medically necessary to provide excellent quality of care while maximizing reimbursement.

Discharge to appropriate community resourceMay arrange transfer to SNF, Home Health, contact

family, etc.Work with physician and familyConsider what insurance will pay for

Charges are EnteredCharges are maintained in the charge master

(CDM)A unique charge code identifies each service and

test performed or supply providedMany charges have CPT-4 or HCPCS codes

attached, required for billingCharges connect to Revenue Codes, required for

billingCharges are billed on UB04 and HCFA 1500

claim forms

Services are DocumentedDocumentation must exist in the Medical

Record to support all procedures performed and supplies used.

Physician and Clinical staff signatures are critical

Verbal orders must be signedDocumentation must be complete and legible

Electronic Medical RecordAutomate as much of the medical record as

possible.Eliminates filing issuesAllows for instantaneous access to medical

recordReduces storage spaceMuch of our medical record is electronic

Patient is DischargedFinancial Counseling

Outstanding balances, co-pays, co-insurance, deductibles, bad debt, non-covered services

Discharge PlanningDischarge disposition – can affect

reimbursementAnother facilitySNFHomeHome health

Medical Records – “HIM”Manages the medical record

Scans and files loose documentationVerifies electronic records

Ensure physician, nurses and clinical staff have signed where necessary

Monitors, reports and obtains chart deficienciesCoding and abstractingDNFB management

Medical Records CodingMedical records chart reviewed by certified

coderPhysician, nursing and ancillary

documentation is criticalICD- 9 codes: diagnoses, proceduresCPT-4 codes: procedures performedGreatly impacts reimbursementHeavily regulated

Insurance Processes ClaimPays claimDenies claim

ImmediatelyAfter processing

Line item denialsPends claim

Doesn’t notify hospitalTimely filing

Contact Us

Futuristic Gigatech

46/4, Novel Tech Park,Garvebhavi Palya , Kudlu Gate,Hosur Main Road, Bangalore, Karnataka – 56 00 68.

E-mail : info@futuristicgigatech.comIndia Office: 0091 80 4093 4093India Mobile: 0091 903 500 4530

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