The revenue cycle what is it
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The revenue cycle what is it

The Revenue CycleWhat is it?


Where does the revenue cycle start

Where does the Revenue Cycle Start?


Physician s office or emergency room

Physician’s Office Or Emergency Room

  • Physician writes an order

    • To admit patient

    • To observe patient

    • For tests, procedures, lab, radiology, etc

    • For surgery

      • SDS

      • Inpatient surgery


Scheduling

Scheduling

  • Referrals

  • Authorizations

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

    • Pre-cert or pre-auth number must be included on claim

  • Notifications

    • Some insurances do not require authorization.

    • Some insurance request to be notified.


Pre registration

Pre-Registration

  • Verify Insurance Coverage

  • Verify Authorization

  • Verify Patient Demographics

  • Determine Patient Responsibility

    • Co-pays, deductibles

    • Co-insurance

  • Obtain Patient Responsibility up front

  • Collect deposits


Financial counseling

Financial Counseling

  • Meet with patients to review their financial obligations

    • Scheduling / Pre-registration process

    • Registration

    • Prior to discharge – inpatients

    • During discharge process – in and out patients

  • Once they are out the door the

    chances of collecting diminish

    dramatically


Registration s turn

Registration’s Turn

  • Verify any missing data

  • Verify Identity

  • Scan Insurance Cards and documentation

  • Obtain co-pays & patient responsibility $$$

  • Patient Signs required documents

    • Permission to treat, guaranty of payment, assignment of benefits

    • Other consent forms


And more

And More ……

  • Advance Directives

  • Notice of Financial Responsibility

  • MSP Questionnaire

  • Rights as a Medicare patient

  • ABNs

  • HIPAA – Privacy Notice

  • Red Flag Regulations

  • Etc.


Bed management

Bed Management

  • Bed Accommodation

    • Private

    • Semiprivate

  • Verified at Midnight

  • Charged at Midnight

  • Patients holding in ED for a bed


Case management

Case Management

  • See every observation or inpatient

  • Case management monitors inpatient and observation patients’ care to ensure admission meets admission criteria

    • Interqual

    • Milliman 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 days

    • All others - daily


Discharge planning

Discharge Planning

  • Performed 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 resource

    • May arrange transfer to SNF, Home Health, contact family, etc.

    • Work with physician and family

    • Consider what insurance will pay for


Charges are entered

Charges are Entered

  • Charges are maintained in the charge master (CDM)

  • A unique charge code identifies each service and test performed or supply provided

  • Many charges have CPT-4 or HCPCS codes attached, required for billing

  • Charges connect to Revenue Codes, required for billing

  • Charges are billed on UB04 and HCFA 1500 claim forms


Services are documented

Services are Documented

  • Documentation 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 signed

  • Documentation must be complete and legible


Electronic medical record

Electronic Medical Record

  • Automate as much of the medical record as possible.

  • Eliminates filing issues

  • Allows for instantaneous access to medical record

  • Reduces storage space

  • Much of our medical record is electronic


Patient is discharged

Patient is Discharged

  • Financial Counseling

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

  • Discharge Planning

  • Discharge disposition – can affect reimbursement

    • Another facility

    • SNF

    • Home

    • Home health


Medical records him

Medical Records – “HIM”

  • Manages the medical record

    • Scans and files loose documentation

    • Verifies electronic records

  • Ensure physician, nurses and clinical staff have signed where necessary

  • Monitors, reports and obtains chart deficiencies

  • Coding and abstracting

  • DNFB management


Medical records coding

Medical Records Coding

  • Medical records chart reviewed by certified coder

  • Physician, nursing and ancillary documentation is critical

  • ICD- 9 codes: diagnoses, procedures

  • CPT-4 codes: procedures performed

  • Greatly impacts reimbursement

  • Heavily regulated


Insurance processes claim

Insurance Processes Claim

  • Pays claim

  • Denies claim

    • Immediately

    • After processing

  • Line item denials

  • Pends claim

    • Doesn’t notify hospital

    • Timely filing


Contact us

Contact Us

Futuristic Gigatech

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

E-mail : [email protected] Office: 0091 80 4093 4093India Mobile: 0091 903 500 4530


Futuristic gigatech pvt ltd 7155924

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