1. Revenue Cycle Management
April 08, 2011
WSOPP
Presented by:
Carrie Romandine
Chris Duprey

2. Agenda Revenue Cycle Management Business Processes
Behind the Scenes at the Insurance Carrier
Estimating Coverage
Explanation of Remittances
Summary

3. Revenue Cycle Management
Coding & Billing
Receivable
Accounts
Patient Demographics,
Financial Verification
Insurance &

4. Business Processes

5. Registration
Collecting Patient Demographics and Financial Responsibility
Obtaining a clear and legible copy of the patient’s insurance card (front and back)
Documentation of each insurance the patient has (Primary, Secondary, Tertiary, etc.)
Having the appropriate forms signed

6. Verifying Benefits Verifies eligibility
The insured benefit is the coverage they have for allowable services provided.
Verifying benefits:
Verifies eligibility
Verifies whether you are an in-plan provider or not
Verifies whether pre-certification is needed for the services
Allows estimation of benefit payment
Allows pre-calculation estimation of insured responsibility
Does not guarantee payment of the claim
Verify benefits on every patient for every service that will be provided!

7. Calling for Verification
Verification is critical to the process.
Correct verification can:
Decrease the amount of refunds that are issued due to incorrect dollars being collected for co-pays and coinsurance.
Decrease the patient dollars outstanding.
Decrease the revenue cycle timeframe by ensuring all appropriate information is on the bill for timely adjudication.
Increase the amount of first pass or clean claims going to the insurance company.

8. Eligibility Vs. Benefits
Eligibility verification indicates whether or not the patient is eligible for coverage, do they have insurance that is active at this time.
Eligibility should be checked on all patients as close to the service date as possible
Realize eligibility changes frequently (Medicaid - 1st of the month; group insurance – July 1st and January 1st)
Benefits refers to the services that are covered under the current active insurance plan.
Always verify the benefits with the specific HCPCS code or service description (DME vs. O&P)

9. Authorizations
An authorization is a “permission of service” from the payer that informs the
provider whether or not the benefits will cover the service they are performing.
Many plans require prior authorization prior to treatment or no benefits may apply
Payers may assess a penalty if the prior authorization requirements have not been met
Payers may require the claim be submitted with the approval or authorization number in order for the claim to be paid

10. Timely Filing Requirements
Some states have a mandated timeframe that indicates how long after the date of service that a provider can bill for a claim.
In states where no mandate exists, payers may institute timely filing policies.
No payment can be received if you did not bill within this timeframe
Typically government and commercial carriers will not allow you to bill the patient if you as the provider missed the timely filing period.

11. Super Bill
Purpose of a super bill is to enable the Practitioner to indicate what services were performed for what diagnosis.
Ensures consistent coding is used throughout the practice
Serves as a communication tool to the Billing staff
Reflects what the record contains for documentation
If your organization does not utilize a Super Bill today, it is recommended that you think about introducing one as a first step to better billing.

12. Behind the Scenes at the Insurance Carriers

13. Insurance Knowledge? Why?
To ensure you:
Ask and receive correct benefits
Understand what the insured owes
Bill properly
To help you:
Problem solve when incorrect benefits are paid
Read the Explanation of Remittances
Position an appeal when necessary

14. Insurance Plan Designs
PPO
POS
HSA
Indemnity
HMO
Plan designs determine:
What benefits are available
How the benefits will be paid
How much the patient will owe
What type of questions to ask prior to performing the service
Network participation
Provider Referrals

15. Insurance Definitions
Insured - A person or organization that receives insurance coverage.
Insurer - An organization that sells an insurance coverage.
Deductible – The amount of covered expenses that must be incurred and paid by the insured before benefits become payable by the insurer.
Co-payment – A flat dollar amount that the insured pays each time a certain kind of service is received.
Co-insurance – The arrangement by which the insurer and the insured each pay a percentage of covered losses.
Out-of-pocket Maximum – Maximum cost the insured will pay in a calendar year (normally excludes co-pays, non-covered items, and over U&C charges). Can sometimes exclude deductible as well. Once the insured has met the out-of-pocket amount, the plan pays at 100%.
Premiums - Payments made by the insured to the insurer in exchange for coverage.

16. Insurance Definitions (cont.)
Benefit - A payment made by an insurer to an insured to compensate for a loss covered by their contractual agreement.
Claim - A demand by an insured for payment of a benefit.
Coverage - A contractual arrangement that states that the insurer will make a payment to the insured if a certain event occurs.
Limitations- An expense that may be limited due to certain conditions or circumstances which will allow benefits at a reduced rate, up to a specific dollar amount or limited to the number of services/items allowed p/yr.
Exclusions- An expense the insurer will not reimburse and under what circumstances it will not pay benefits for expenses that would usually be reimbursed.

17. Insurance - Points to Remember
Non-covered items do not apply to deductible, coinsurance limits, or out-of-pocket limits.
Some plans may have a combination of a co-pay, deductible and coinsurance on the same benefit.
Co-pay may still apply even after out-of-pocket limits are met.

18. Overall Issues
Many payers have many different claims payment systems adding confusion and complexity
Provider file accuracy is a major concern for payers
Inaccurate benefits can be given based on what questions are asked during the verification of benefits process

19. Claims Payment
Claims are paid based on how a benefit plan is loaded into the payer system
CPT, HCPC’s, Revenue and ICD-9 codes are used to determine level of payment for a service
Place of service can change the way a benefit will pay
Every code combination means a particular payment

20. Quoting Benefits
Benefits are quoted by determining how the system will pay for the services requested
Payers need place of service, type of service (by HCPCS code if possible), and diagnosis to quote the benefits
Errors occur when the quoted benefits are actually a different “code combination” than what is actually billed for

21. Electronic versus Paper
Submitting claims electronically means to pass the data needed to process a claim. electronically from the provider to the payer.
Use a clearinghouse to handle this transmission to ensure it is in the proper format needed and all data has been captured.
The claim is paid electronically by the payer without a paper bill needed.
Electronic claims are paid within a few days by most payers. Paper claims normally have a 3-4 week cycle.

22. Estimating Coverage

23. Estimating Coverage
The proper codes outline what service was done, where it was done, and for what diagnosis.
The contract that is in place outlines what the allowed amount will be for services provided.
The insured’s benefit plan outlines what level of payment will be paid for the eligible service.

24. Determination of Insurer and Patient Payment Responsibility
First calculate the total allowed amount possible to collect based on the contracted amounts in place (deal amounts).
Second take the allowed amounts and apply the benefit calculations to determine what the insurer/insured will pay.
Understand that the proper codes must be used to bill for services to ensure the benefits are applied correctly.

25. Calculation Worksheet
Built to assist the staff with the calculations so up front communication can be given to the customers for their responsibility portion
Determines what to collect from the patient at the point of service
Will be used to review the Explanation of Remittance when received if the amounts do not match

26. Coordination of Benefits
Many individuals have a Primary and Secondary carrier some even have a third or tertiary carrier
Medicare in some cases can be the primary carrier and in others be secondary, it is important to understand the Medicare COB rules to determine primary carrier appropriately
Medicaid is always the last payer when more than one carrier is present
If there are two commercial carriers, generally the patient’s coverage (where they are the employee) is first, their spouse’s is secondary

27. Explanation of Remittances

28. EOR’s
EOR’s are sent from the payer to the provider to explain what was paid on the claim.
EOR’s will indicate reason code(s) for the denial when a service was not paid.
Understanding the terminology will ensure you understand how a claim was processed and what your next steps will be.
The reason codes will provide you with the information you need to appeal or re- submit the claim.

29. EOR’s
Which reason codes listed would a provider have the ability to collect from the insured/patient?
Deductible
Co-payment
Co-insurance
Not covered
Provider discount

30. EOR’s
Answer: Deductible, Co-payments, Co-insurance, and Not Covered items
You cannot bill the insured for the provider discount amount per your contract with the payer.
For Medicare patients – special rules apply to services typically covered but not covered for a particular patient because they did not meet the criteria – An ABN form must be on file to collect dollars from the patient.

31. Steps to Review the EOR’s
Determine what the contract states is the allowable amount for the service provided.
Using the plan benefits, determine what the insurer/insured should pay off of the contract allowed amount.
Review the EOR to ensure the claim was paid according to your calculations.

32. Incorrect EOR’s If the EOR is incorrect:
“Don’t be left with empty pockets”
If the EOR is incorrect:
Determine what was different from your calculations.
Review any denial codes.
Determine if maximums or deductibles were met prior to your claim that you were unaware of.
Determine if it was a contract issue or a benefit payment issue.
If benefit payment issue, call insurer’s claim customer service to discuss.
If it was a contract issue, call the contract provider representative to ensure the contract has been loaded and interpreted correctly.

33. EOR’s (cont.) YES! Should you call if it is only a couple of dollars?
Those couple of dollars add up fast!
Contracting issues mean that something is wrong with how the contract is loaded and you will see errors on every claim potentially.

34. EOR’s that are Correct
With the right process in place a correct calculation leads to happy customers, they understand what they are paying for and how much they are responsible for prior to the service being completed.
If the EOR indicates what you previously collected and all dollars are accounted for; transaction is complete.
If the EOR indicates the insured owes more than what you anticipated, and after review it is correct, you must bill the insured the remaining amount.

35. Summary
Revenue cycle begins with registration and follows through to receiving payment
Understanding insurance will assist you in verifying benefits and estimating payment.
Having a solid process upfront will increase payment accuracy and timing
Reviewing EOR’s is essential to ensuring all dollars are collected.
Using the knowledge you learned throughout this training in your day to day functions is the true test.

36. Questions