Training. IHS & RPMS Revenue Cycle Overview. Basic Third Party Billing/Accounts Receivable

Transcription

1 Training IHS & RPMS Revenue Cycle Overview Basic Third Party Billing/Accounts Receivable

2 Agenda IHS Overview RPMS Definition Patient Registration/Admitting Benefits Coordinator Roles Provider/Coder/PCC Data Entry Roles Third Party Billing Accounts Receivable Site Manager and Management Roles 2

3 What is Indian Health Service? An agency within the Department of Health & Human Services that provides healthcare to federally recognized American Indian and Alaska Natives. The mission of IHS is to raise the physical, mental, social and spiritual health American Indians and Alaska Natives to the highest possible level. The goal of IHS is to assure that comprehensive, culturally acceptable, personal and public health services are available and accessible to American Indian and Alaska Native people. 3

4 Who does IHS serve? Members of more than 562 federally recognized Tribes Primary source of healthcare for 1.9 million Indian people of the nation s estimated 3.3 million American Indian and Alaska Natives Majority reside on or near the reservation Over 600,000 Indians in urban areas Urban Indian health programs 34 cities throughout the United States 4

5 Area Offices 12 Area Offices throughout the US 162 Service Units 540 Healthcare delivery facilities 34 Urban Programs 5

6 Aberdeen Area Billings Area Oklahoma Area Alaska Area California Area Phoenix Area Albuquerque Area Nashville Area Portland Area Bemidji Area Navajo Area Tucson Area 6

7 RPMS Definition A set of integrated computer applications designed to support the clinical and administrative functions of a health care program 7

8 RPMS Integrates Multiple Clinical Systems PCC Data Entry Dental Pharmacy RCIS Radiology Laboratory Women s Health Behavioral Health Others PIMS Scheduling 8

9 Patient Registration Data Flow 9

10 Patient Registration Responsibilities Photo Courtesy of the Indian Health Service/U.S. Department of Health and Human Services. 10

11 Patient Interview The Interviewer: Provides positive initial point of contact Demonstrates a pleasant attitude Collects accurate data Ensures timely interview Obtains necessary signatures 11

12 Documents Requiring Signature 12

13 Copying, Printing, and Filing Third Party eligibility cards Change of name documents Legal Documents Face sheet Files 13

14 Importance of Data 14

15 Data Uses PCC health summaries Scheduling application Emergency situations Outside facilities Photo Courtesy of the Indian Health Service/U.S. Department of Health and Human Services. 15

16 Third Party Revenue Generation Cycle 16

17 Patient Registration/Admitting Roles Interview patients Enter/edit patient registration info Update third party eligibility Obtain signatures Refer to the Benefits Coordinator Obtain precertification/ pre-authorization 17

18 Benefits Coordinator Roles Act as the expert on Medicaid, Medicare, and private insurance eligibility guidelines Serves as a patient advocate Serves CHS Serves the Business Office 18

19 Clinical Provider Roles Document visit information Medical necessity of visit Completed procedures Issuance of supplies Provide necessary signatures Complete required training Understand CPT Evaluation and Management coding Understand ICD 9 Coding guidelines Understand Medicare billing guidelines 19

20 Coder Roles Require certification Demonstrate ICD 9, CPT-4, modifiers, HCPCs knowledge Ensure data integrity Know updated codes/guidelines 20

21 PCC Data Entry Roles Enter information into the RPMS Patient Care Component Accurately enter information Complete additional requests as necessary Review staffing levels Review office equipment ergonomics 21

22 Billing Staff Roles Review PCC visit within RPMS Third Party Billing System Review the Flagged as Billable report on a daily basis Approve claims Export/print claims Identify problems with process 22

23 Accounts Receivables Roles - Posting of Payments/Adjustments Receive Remittance Advice or Explanation of Benefits forms Post payments, adjustments, and Zero pays (no payment at all and reason for) to individual bills Analyze aging reports (by payer) File documents 23

24 Accounts Receivables Roles - Posting of Payments/Adjustments Follow up of unpaid claims Establish filing deadlines Work to change negative payer behavior Post to RPMS timely and accurately Follow-up patient files ( days) Correspond with patients/third party insurers to obtain necessary information 24

25 Other Staff Member Roles 25

26 Health Information Management Director Roles Ensure timely completion of medical records Facilitate coding updates and audits Conduct PCC data entry accuracy audits Analyze staffing levels 26

27 Business Office Manager Roles Work closely with front end staff, back end staff, and administration Serve as liaison between all disciplines Work with Primary Insurers Provide feedback to all disciplines Serve in an active role 27

28 IT Systems Manager Roles Ensure that the RPMS system is functioning correctly Ensure that the hardware is functioning Update RPMS Patient Registration, PCC, 3rd Party, and AR versions and patches Update required codes 28

29 Clinical Director Roles Ensure timely completion of medical records Address documentation issues Support medical necessity documentation Manage training initiatives 29

30 Director of Nursing Roles Ensure timely completion of medical records Ensure Medical Necessity Support documentation guidelines Ensure the documentation of issued supplies 30

31 Compliance Officer Roles Provide training and education Defuse fraud and abuse practices Respond to staff concerns 31

32 Administration Staff Administrative Officer Chief Executive Officer 32

33 Questions? 33