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The Revenue Cycle

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UVa and HSF Revenue Cycle

Presentation

•PRESENTATION GOALSTo illustrate and explain the Billing and Collection Revenue Cycle.

To identify who is responsible for each Functional Activity.

•UNDERSTANDING THE PROCESSOn the slides we will represent each of the major Functional Activities with

an icon. We have color coded each Functional Activity to illustrate who hasownership of this activity (e.g. Medical Center, Clinical Department, HSF).

These Functional Activities will be briefly described in the presentation.

•SPECIAL EXPLANATIONSSome Functional Activities can be the responsibility of two of the partners in

the Health System.

Orange indicates MedicalCenter OwnedResponsibility

Blue indicates HSF ClinicalDepartment Owned

Responsibility

Green indicates HSF AdminOwned Responsibility

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Revenue CycleScheduling

Payment Processing

Charge ProcessingRegistration

Secondary Claims

A/R Follow-up

Claim & StatementProduction

Legal Collections

Documentation & Coding

Resubmission & Appeals

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UVa and HSF Revenue Cycle

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It all begins with the patient

entering the UVa Health Systemneeding services

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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Appointment Scheduling Process

 –  Begin Revenue Cycle 

• Verification of insurance

• Authorizations and certifications

• Pre-registration gathering demographics

• Identify the referring physician

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Appointment Scheduling: Goals

Goals are those of Clinical Dept and Patient Services

• Get appointment within time desired by patient

• Patient is informed of referral process

• Inform patient to bring insurance card and

co-payment

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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Patient Registration Process

 –  Begin Revenue Cycle 

• Verification of insurance

• Authorization and certifications

• Registration gathering demographics

• Identify referring physician

• Initial review of financial requirements

• Co-pay collection for all appropriate patients

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Patient Registration: Goals

• Insure Pre-authorization received

• Insure verification of insurance and PCP validated

• For all appropriate patients collect co-pay andverify demographic information

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Patient Exam

• Patient identifies concern/problem

• Procedures performed and/or treatment

provided

• Discharge diagnosis

• Physician documentation initially recorded

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Patient Exam: Goals

• Reasonable/timely access

• Complete clinical service

• Informative to patient

• Appropriate documentation for patient care and for 

correct billing to third party

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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• Physician documents services

• Services coded by Physicians and/or coders:

CPT codes (procedures), ICD-9 (diagnosis),

HCPC (supplies, drugs, etc.)

Documentation & Coding Process

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• Documentation complete and signed by provider 

• Codes accurately reflect patient service(s)

• Coding reviewed to insure it reflectsdocumentation

Documentation & Coding: Goals

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• Accuracy of service and charge

• Appropriate edits to scrub data

• Charges entered timely for prompt payment

Charge Processing: Goals

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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Claim & Statement Production

• Claims edited to insure completeness and correctness

• Claims sent daily to carriers for processing

• Claims flow 70% electronic and 30% paper 

• Billing statements sent to patients for self-pay balances

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Claim & Statement Production: Goals

• Get accurate claims out daily

• Increase % of electronic claims

• Keep average cost per claim better than benchmark 

• Get statements out to patients for self-pay balances everyMonday within the current billing cycle (30 days)

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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Payment Processing

• Electronically or manually post remittances from payers and patients

 – Payments

 –  Denials or rejections

 – Adjustments

• Refunds

• Reconciliation of charges, payments and adjustments

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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Resubmission & Appeals

• Invalid registration

• Medical Documentation required

•Correct coding /charge corrections

• Missing referral/pre-authorizations

• Payments included in primary service

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Resubmission & Appeals: Goals

• All invoices requiring an HSF appeal processed are

completed within one week of receiving rejection

• Process all responses from clinical departmentswithin one day of receiving information

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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Secondary Claims/

Guarantor Billing• Claims edited to insure completeness

and correctness

• Secondary claims and patientstatement production

• Resubmission & appeals, if necessary

2

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Secondary Claims/

Guarantor Billing: Goals• All secondary claims submitted within 2 days of 

receiving primary payment, e.g. Medigap Plans

• Follow up on all outstanding self-pay balances within 10

days of statement submission• Additional “120 day” follow-up on all outstanding self-

 pay balances prior to bad debt transfer 

2

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

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A/R Follow-up

• Third party collection on appeals

• Self pay follow-up (Dunning cycles)

• Payment arrangements (Budget plans)• Improve claim edits as an outcome

• Bad debt transfer 

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A/R Follow-up: Goals

• Process all denials requiring departmental involvementwithin one week receipt of reject

• Daily follow-up on all outstanding requests with

clinical departments within one week of initial request

• Follow-up on all “no response” invoices within 45 daysof submission of claim

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Legal Collections

FOCUS IS ON THE LEGAL SYSTEM

• Warrant in debt

• Garnishments• Liens

• Payment arrangements (Legal budget plans)

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The

RevenueCycle

PatientRegistration

Patient ExamAppointmentScheduling

Resubmission

& Appeals

Charge

Processing

Claim &

Statement

Production

Legal Collections

A/R Follow-up

Payment

Processing

Documentation

& Coding

2

Secondary Claims/

Guarantor Billing

* *

*

*

****

*

*

* Measured

againstBenchmark s

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A successful Revenue Cycle depends on…

• Accurate data

• Working together 

• Effective communication

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Revenue Cycle Goals

• Improve the process

• Increase collections

• Let doctors practice medicine

• Enhance patient satisfaction

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