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RCMS (Revenue Cycle Management System) Flow chart model
By Veeresh Bikkaneti C.M.R.S) Blog: 10/28/2009 info compiled by veeresh C.M.R.S
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Patient Employer Payer Bank Medical Group Analysis & Reporting
Actual Vs. target reports coding accuracy payer performance New Employee employee selects insurance payer employer collects premium employer pays premium to payer Contract Finalize contract educate practice on contract Physician credentialing Pre-Visit Patient makes appointment Registration completed in system Patient given office policies insurance verified with payer referrals & authorizations obtained. Patient Employer Payer Bank Medical Group Insurance & Patient Follow-Up Account Follow-Up Patient referred to collection agency Credit balances resolved. Payments payer pays claims Check and EOB received by Bank Money deposited Deposit reconciled at practice Denials claim denied by payer EOB received and posted claim corrected claim reset to payer Check -IN/Visit Patient pays co pays/ Deductible Insurance card copied physician sees patient payment posted to account physician documents medical record physician completes encounter form Charge Entry Encounter Forms Audited Charge entered into system Charges scrubbed Claims claim Created claim sent to payer acknowledgment received.
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RCMS : Responsibility and Functionality
Administration Practice Responsibility Registration coding Charge capture Reimbursement, Fees and credentialing Functionality Revenue cycle 10/28/2009 info compiled by veeresh C.M.R.S
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RCMS : Responsibility and Functionality
Billing Office Billing Office Collection agency Responsibility Claims transmission payment posting Insurance Follow- Up Patient Follow- UP Patient Collections Functionality Traditional “billing Office” Revenue cycle 10/28/2009 info compiled by Bikkaneti Veeresh C.M.R.S
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RCMS : Responsibility and Functionality
Accounting finance Responsibility reporting Functionality Revenue cycle 10/28/2009 info compiled by veeresh C.M.R.S
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The Revenue Cycle: Billing Tasks
Payer contracts Front Desk Visit Post the Visits & charge entry Reports & analysis Edits Billing & collections Payer Rejections Patient services and satisfaction Compliance Pre visit or Benefits determination 10/28/2009 info compiled by veeresh C.M.R.S
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info compiled by veeresh C.M.R.S
Practices Need to Attend to Compliance issues though out the revenue cycle. Billing process is often described as having both front End and back end. As more care became “managed”, however, the End-to- End process evolved so that billing now starts, When the Patient calls to make an appointment. All functions outlined below represent Reimbursement functions for the medical practice. Now this is clear that billing and collection is no longer only a back office responsibility. 10/28/2009 info compiled by veeresh C.M.R.S
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Front end and back end billing functions
Front End Functions Back End Functions Appointment scheduling Billing edits Registration(demographic and insurance) Claims to payers Check – in Process Account receivable follow-Up (by payer type) Check – Out Process Referrals and Pre-Authorizations Statement s to patients Coding Payment posting Charges Capture and entry Payment Variance Analysis Financial counseling Denials posting and resolution Cash at time of service Reporting results and analysis 10/28/2009 info compiled by veeresh C.M.R.S
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Service capture -Inpatient Service capture –outpatient
Revenue cycle Business Pre-visit Registration Insurance verification authorization Step1. Pre Visit Patient Check -in Time-of-service payments Real time system updates Provide service Inpatient Outpatient Service capture -Inpatient Inpatient charge report Hospital face sheet Step2. Check-In Step3. Charge Capture and Charge entry Provider documents services Provider identifies procedure and Diagnosis codes Service capture –outpatient Outpatient charge report Review Compare with provider schedule/contract with the payer Missing charge reports Hospital reports and logs Audit coding to documentation 10/28/2009 info compiled by veeresh C.M.R.S
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info compiled by veeresh C.M.R.S
review Review edit report Correct claim yes no Are claims clean? Charge entry At site or central billing office Daily recap balance Generate and submit claim Electronic or manual Step4. claims process 10/28/2009 info compiled by veeresh C.M.R.S
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info compiled by veeresh C.M.R.S
Step 6&8 Follow –up and collections Transmit/mail claim Electronic claim submission Paper claim mailing Print confirmation report Claims#, $ amount Accepted , Yes/ No Account – Up and collections Reviews outstanding A/R Research /review Request additional information Resubmit/update claim No Step7. Denial Management Claim paid? Yes Open mail Prepare batch. Endorse checks Prepare deposit. 10/28/2009 info compiled by veeresh C.M.R.S
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info compiled by veeresh C.M.R.S
Research /review Call provider relations Follow instructions for appeal Process refund Continue to follow account Payment posting Post batch. Prepare secondary claims Flag appeals, rejections, refunds. Balance batch Step5. payment posting Payment accurate? Spend $$$$$$ Yes No 10/28/2009 info compiled by veeresh C.M.R.S
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Thank you For more info contact me : galaxyblackhole1@gmail.com
10/28/2009 info compiled by veeresh C.M.R.S
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