RCMS (Revenue Cycle Management System ) Flow chart model

1. RCMS (Revenue Cycle Management System)Flow chart model • By Veeresh BikkanetiC.M.R.S) • Email: galaxyblackhole1@gmail.com • Blog: http://medicalbillingandcoding.blog.com/ • http://medicalbillingandcoding.blog.com/ info compiled by veeresh C.M.R.S

2. 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. • 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.

3. RCMS : Responsibility and Functionality Administration Practice Responsibility Registration coding Charge capture Reimbursement, Fees and credentialing Functionality Revenue cycle info compiled by veeresh C.M.R.S

4. 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 info compiled by BikkanetiVeeresh C.M.R.S

5. RCMS : Responsibility and Functionality Accounting finance Responsibility reporting Functionality Revenue cycle info compiled by veeresh C.M.R.S

6. The Revenue Cycle: Billing Tasks Payer contracts Payer Rejections Pre visit or Benefits determination Front Desk Visit Edits Post the Visits & charge entry Billing & collections Patient services and satisfaction Compliance Reports & analysis info compiled by veeresh C.M.R.S

7. 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. info compiled by veeresh C.M.R.S

8. Front end and back end billing functions info compiled by veeresh C.M.R.S

9. Revenue cycle Step1. Pre Visit • Business Pre-visit • Registration • Insurance verification • authorization Step3. Charge Capture and Charge entry • Service capture -Inpatient • Inpatient charge report • Hospital face sheet Step2. Check-In • Review • Compare with provider schedule/contract with the payer • Missing charge reports • Hospital reports and logs • Audit coding to documentation • Patient Check -in • Time-of-service payments • Real time system updates • Provider documents services • Provider identifies procedure and Diagnosis codes • Service capture –outpatient • Outpatient charge report • Provide service • Inpatient • Outpatient info compiled by veeresh C.M.R.S

10. Step4. claims process • Charge entry • At site or central billing office • Daily recap balance • Generate and submit claim • Electronic or manual Are claims clean? yes no • review • Review edit report • Correct claim info compiled by veeresh C.M.R.S

11. 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. info compiled by veeresh C.M.R.S

12. Step5. payment posting • Payment posting • Post batch. • Prepare secondary claims • Flag appeals, rejections, refunds. • Balance batch Payment accurate? Spend $$$$$$ Yes No • Research /review • Call provider relations • Follow instructions for appeal • Process refund • Continue to follow account info compiled by veeresh C.M.R.S

13. Thank you For more info contact me : galaxyblackhole1@gmail.com info compiled by veeresh C.M.R.S