The following online training module will provide a general overview of the Vanderbilt University Medical Center s (VUMC) technical revenue cycle.

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1 The following online training module will provide a general overview of the Vanderbilt University Medical Center s (VUMC) technical revenue cycle. This Revenue Cycle Overview training will establish a foundation for upcoming process trainings, which describe the future state processes for your specific functional area. You are registered to participate in at least one of these upcoming process trainings, most of which will take place in person. Please listen to the audio on each slide, review the text and click the green arrow when you are ready to proceed to the next slide. If you wish to go back and review previously viewed slides, please use the navigation bar at the bottom of this presentation. 1

2 We will begin with the Learning Objectives of this online training. 2

3 The objective is to learn the end to end processes of the Revenue Cycle, along with your role and its impact on VUMC. 3

4 The next two slides will review common concepts and terms in the Revenue Cycle. 4

5 This section provides a list of common terms that you will encounter throughout this online training module. Please refer back to these slides as necessary, to familiarize yourself with key concepts and terminology. 5

6 This section provides a list of common terms that you will encounter throughout this online training module. Please refer back to these slides as necessary, to familiarize yourself with key concepts and terminology. 6

7 The next slide will illustrate how the individual functional areas in the Revenue Cycle are connected to each other, culminating in maximum reimbursements from various payors. 7

8 This diagram should help you understand how these functional areas span the technical revenue cycle from end to end. Each functional area is connected to another and is essential to successful reimbursement for services that VUMC provides. The revenue cycle is composed of three main sections of processes, often referred to as the Front, Middle, and Back End: Front End Revenue Cycle is more formally called Patient Access, which describes the processes before a patient receives services from VUMC. Patient Access begins before a patient arrives at the hospital with Scheduling and obtaining Pre registration information, which leads to verification of Insurance and Benefits. Next staff must obtain any Authorizations, Referrals, and Advanced Beneficiary Notice (ABN) forms required by payors. When the patient arrives at the medical center, Registration staff obtain any missing information, collect monies due, or gather needed signatures from the patient. The next step in Patient Access is Financial Counseling, which proactively addresses potential issues with payment for medical services, particularly for under or uninsured patients. Middle Revenue Cycle is more formally called Charge Integrity, which describes the processes required to document services and the associated fees that a patient receives during a visit. These processes begin with clinical documentation in Medical Records which, if done electronically, can automate the Charge Entry and Coding of each service. When medical records are documented manually, services are translated during Charge Entry and Coding into a diagnosis and procedure code for billing. Back End Revenue Cycle is more formally called Patient Financial Services, which 8

9 describes the processes involved in pursuing payment for the services that VUMC provides. Charges are processed during Billing into paper or electronic claim forms, which are sent to the Payor. Payment that VUMC expects are called accounts receivable or A/R. Sometimes, these payments require A/R Follow Up in order to seek underpaid or unpaid claims. Staff may also need to follow up on or resolve payors Denials of claims. Ultimately, the goal is to obtain complete or maximum Reimbursement. 8

10 The next few slides will examine the Front End: Patient Access concepts in more depth. 9

11 The majority of the Front End processes occur before a patient arrives at the hospital, beginning with Patient Scheduling and Pre registration, then Financial Clearance and Financial Counseling, and ending with arrival of the patient for Onsite Registration. More details on these functions on the next slides. 10

12 The next few slides will detail each function in Patient Access Services. 11

13 Patient Scheduling and Pre registration involve scheduling procedures or services for treatment, along with gathering demographic and financial information required by payors. Pre registration is also an opportunity for staff to attempt collecting patient liabilities (i.e. co pays and deductibles). 12

14 Financial Clearance involves validating that the patient has active insurance coverage for the type and time of service scheduled. Staff also confirm benefits for the specific services to be provided, including exact coverage levels and limitations as well as the estimated patient liability. Financial Clearance also involves determining that all necessary authorizations and referrals have been obtained in accordance with the patient s insurance requirements. 13

15 Financial Counseling involves addressing potential balances in upcoming inpatient and outpatient visits, requesting payment in full, determining potential eligibility for financial assistance programs, including Medicaid or charity care through use of automated tools and application processes, and establishing payment plans. 14

16 Onsite Registration involves activating the registration, verifying any missing data elements with the patient, and obtaining necessary patient/responsible party signatures on relevant financial forms (e.g., assignment of benefits, statement of financial responsibility, ABN, HIPAA release of information, etc.), and collecting outstanding liabilities. 15

17 For this quick knowledge check, think broadly about all the elements required for obtaining and checking for accurate insurance information. 16

18 Every function in the end to end revenue cycle works together to ensure insurance information is accurate. 17

19 The next few slides will examine the Middle Revenue Cycle: Charge Integrity concepts in more depth. 18

20 The middle functions include Medical Records, the Charge Description Master (CDM), and Charge Integrity; they seek to gather accurate clinical information about the patient s visit and the charges incurred during the visit, all of which are then captured in HealthQuest to support billing. More details on these functions are on the next slides. 19

21 The Middle Revenue Cycle links VUMC s clinical system (applications such as Radiology, Pharmacy, etc.) to Charge Capture Processes via Medical Records, and finally to the Patient Accounting System, HealthQuest, via the CDM. Medical Records refers to clinical documentation of all services, supplies, and medications into a paper or electronic medical record (VUMC s Starpanel) by clinical staff such as nurses. Payors may sometimes require detailed medical records to support the payors reimbursement for the level of care provided to a patient. The Charge Description Master (CDM) is the menu of services that hospitals provide and their prices. The CDM requires periodic maintenance by revenue integrity specialists so that prices and services are accurate, and billing is compliant and appropriate. Both Medical Records and the CDM are linked to Charge Integrity, which refers to charge entry & charge reconciliation, or entering billable services into the patient accounting system within the required timeframe so that insurance companies can be billed. The reconciliation aspect establishes that all billable services are captured for reimbursement purposes. Charge entry may be automated or it may be completed manually by a charge nurse or medical records coder. 20

22 A poorly maintained CDM results in incomplete or inaccurate charge capture, claim denials, exposure to compliance risks, and lost reimbursement. Each service listed in a CDM is associated with 1 3 billing codes, such as CPT, APC, and/or Revenue codes. More details on billing codes are provided on upcoming slides. 21

23 The typical flow of the Medical Record functions is shown here, starting when the patient record is received at discharge and ending with coding of the services for a final bill. 22

24 Current Procedural Terminology (CPT) codes are used by insurers to identify what services/procedures were provided to the patient. 23

25 The Healthcare Common Procedure Coding System (HCPCS) is based on CPT codes and is used by Medicare to identify products, services, and supplies that are not described by CPTs. 24

26 Revenue Codes are used for hospital billing on the UB 04 billing form. More details on the UB 04 will be provided on upcoming slides. ICD 9 Codes are an internationally recognized set of standard diagnosis codes for diseases. In October 2014, hospitals will be required to upgrade to ICD 10 Codes, which is an updated system that includes more specific and detailed diagnoses and their variants. The next slide will explain the changes in ICD coding. 25

27 VUMC will be upgrading the ICD coding system to the new standards by October The number of unique codes will increase to accommodate more specific descriptions of diagnoses and procedures. ICD 10 codes will be 7 digit alphanumeric characters, instead of the 5 digit numeric characters in ICD 9. 26

28 For this quick knowledge check, think about what CPT stands for. 27

29 CPT is an acronym for Current Procedural Terminology. They are used by insurers to identify what procedures or services were provided to the patient. 28

30 The next few slides will examine the Back End Revenue Cycle: Patient Financial Services concepts in more depth. 29

31 The Back End functions include processes associated with release of accurate claims for Billing insurers and patients, editing incorrect claims through a Claim Scrubber before transmission to the payor, then Collections, with Follow Up and Denials Management if payment discrepancies exist, and finally Payment Posting of funds from payors or patients. The timely filing of claims and collections is essential to improving VUMC s revenue and the patient experience. 30

32 Billing for charges must be accurate and timely. Staff should be aware of the specific timely filing deadlines for various payors. Incomplete, inaccurate, or late claims may be denied by the payor, thereby prolonging the payment cycle time. Hospital/technical billing typically occurs on the Universal Billing (UB 04) form, while Physician/professional billing typically occurs on the CMS 1500 form. 31

33 A claim scrubber is a claims processing software that identifies corrections needed on a claim. A claim that is not clean will hit an edit in the claim scrubber and must be corrected before releasing the claim to a payor. 32

34 For this quick knowledge check, think about the definition of a clean claim. 33

35 Remember that clean claims are those that do not require any additional corrections. A claim that is not clean will hit an edit in the claim scrubber and require additional time and attention to correct before submitting to a payor. 34

36 Collections and follow up are processes in pursuing payment on unpaid claims. Review the ideal model for effective follow up on this slide. 35

37 Payment posting refers to the process of recording payments received from payors or patients. This slide describes the responsibilities of the Payment Posting team, as well as the role of the EOB statement. The EOB plays a significant part in many of the procedures in the Back End Revenue Cycle. 36

38 Afew reasons why a payor might deny a claim include: billing for a service that was not authorized, billing for a procedure that was not medically necessary, or filing the claim late. A denial may result in no payment at all, or it may result in some payment if the claim was partially denied (also known as an underpayment). The ideal outcome of a denied or underpaid claim is to fix the reason for the denial or underpayment in order to receive correct reimbursement and prevent future denials. 37

39 The next few slides will describe the purpose of a Customer Service functional area within the Revenue Cycle and the patient experience. 38

40 Improving VUMC s patient experience relies greatly on Customer Service staff to provide support and explanations to various parties including patients, guarantors, and other stakeholders. 39

41 Privacy and patient confidentiality are required in providing Customer Services. All VUMC staff must abide by HIPAA privacy rules regarding disclosure of Protected Health Information (PHI). 40

42 For this Final Knowledge Check, do you remember some of the discussion points related to these questions? 41

43 Check your answers to the Final Knowledge Check questions. These points are important for understanding the impact of various Revenue Cycle functions on VUMC s business operations. 42

44 If you would like a printed version of this material for reference, please click the link on this slide. 43

45 Thank you. You have completed this online module. You may now close your browser and log out of The Learning Exchange. 44

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