Revenue Cycle Case Studies

1. Revenue Cycle Case Studies HFMA Certification Exam Preparation

2. Case Study A Micro Case: Revenue Cycle Overview You have been assigned to provide an overview of the revenue cycle for new employees from different departments. In your overview, you are to identify the role each department plays in revenue generation and payment. Particular stress is to be given to a financial perspective for each department. • Draft the outline for your presentation: ·Identify the revenue cycle components and departments/groups within the revenue cycle · Identify the role each department/group has in getting paid · Identify what questions you can anticipate from those listening to your presentation

3. Discussion Points – Case Study A • The revenue cycle is the series of events and services provided prior to, during, and after the course of treatment that result in charges and create the potential for revenue • Occur before, during, and after patient care. • Pre‐admission: example‐preadmission testing • During: Any billable treatment or service • Post‐treatment: example‐coding and processing the claim • There are several dominant departments that contribute to the revenue cycle: • Access (also known as Admitting or Registration, including Pre‐registration) • Case Management (including Pre‐authorization activities) • Patient Care Services (including all departments that serve the patient) • Health Information Management (also known as Medical Records) • Patient Financial Services (also known as Patient Accounting or Billing Office)

4. Case Study B Micro Case: Financial Counseling‐Explain the Bill A patient calls you to discuss their bill. The patient does not understand what the charges are and notes that there are names of doctors and medical services groups that the patient does not know. • How would you explain: · How charges originate, are captured and aggregated? · The role of the doctors and medical services groups on the bill?

5. Discussion Points – Case Study B Discussion Points Patient access activity • Accurate charge capture beings with patient access gathering appropriate patient information, e.g.: • o Name and other identifiers such as sex, date of birth, race, social security number, and marital status • Address, home telephone number, occupation, and employer of patient • Type of accommodation requested or required • Resident status for all foreign‐born patients • Name, address, and telephone number of next‐of‐kin or spouse • Name of admitting physician • Name of attending physician • Admission diagnosis given by admitting physician • Date of most recent previous admission or outpatient services for the patient • Accident information • Financial resources and disclosure of guarantor • In addition to gathering the demographic/insurance information listed above, the pre‐care function is also the time to communicate to the patient about their financial obligations. • The provider should let the patient know if there is a deductible or co‐pay required and the organization’s expectations of payment for services rendered. • Insurance verification, ABN’s, MSPs if applicable to identify patient portion

6. Discussion Points – Case Study B Cont HIM Activity • The medical records department (also called Health Information Management or HIM) is the primary source for the clinical data required for reimbursement by Medicare, private insurance, or other payers. • Clinical data abstracted from medical records and coded in the medical records department are submitted to the patient financial services area for placement on the claim; submission is typically accomplished with some type of electronic transfer from the abstracting system in the HIM department to the financial system. • HIM employs specially educated individuals whose responsibility it is to convert the physician’s written diagnoses and procedures to codes. These codes are then entered into the claim system and drive the reimbursement that the organization will receive for the services provided. Providing Services • Contracted medical services: the reality that the hospital doesn’t own all the services it provides nor employs all of the service providers

7. Discussion Points – Case Study B Cont As you address the patient’s concerns you are aware that creating a dissatisfied patient‐customer carries the risk of future costs both “hard” and “soft.” Name the potential “hard” and “soft” costs. Discussion Points The cost of dissatisfied customers can be summarized in terms of “hard” and “soft” costs. The hard cost is the loss of future revenue. The soft cost, which is less easily defined and quantified, is the customer’s negative word‐of‐mouth advertising. This may influence others not to use the hospital. After the call has ended, you conclude that the patient’s lack of understanding regarding billing and financial procedures sets wrong expectations regarding payments. You believe that better orientation to financial procedures should be provided to patients. • Specify precisely what you would want the patient to know and understand? • How do you think the financial orientation should be executed? Discussion Points What the patient should know: • How the hospital/provider gets paid • Why payment is structured as it is? • The role of commercial/government insurance • The patient’s obligation

8. Case Study C Micro Case: The Importance of Data –to a Patient You are unexpectedly asked to assist registration with a seemingly “uncooperative” patient. You go to the patient reception area to meet the registrar and the patient. The patient is an elderly woman who does not want to provide much personal information. She is unsure why the facility wants that information and wonders how her personal information will be used. You pull a chair up to sit down next to the patient. What do you say to her?

9. Discussion Points – Case Study C Discussion Points • The importance of data for proper clinical treatment and payment • HIPAA‐ information is safe and secure As you continue to talk with the patient, she states that she does not know for certain what Medicare and her “other insurance” pays for. She expresses concern about having to pay “a huge bill” on a fixed income. What do you say to her and what is your next step? Discussion points • Medicare eligibility • ABNs and MSPs; coordination of benefits • Financial counseling and charity care

10. Case Study D Micro Case: HIM and QA As a member of the quality assessment and improvement team in your facility you are assigned to lead a review of the Health Information Management (HIM) function. You know that HIM is vital to the proper functioning of the revenue cycle. It is recommended to you to focus on the critical HIM tasks and responsibilities. • Identify what are the critical tasks and why they are so critical • What are the indicators of quality you will be looking for?

11. Discussion Points Case Study D Discussion Points • This department contributes to the revenue cycle in several ways. • Documentation Improvement • Data Integrity • Coding claims • Releasing patient information • Documentation Improvement: Clinical documentation drives what the HIM coding professional is able to code for the claim. • A coding professional is an individual who through formal or on‐the‐job training has the competency to accurately assign diagnostic and procedure codes according to an extensive set of rules established by the Centers for Medicare and Medicaid Services (CMS) • HIM Departments have implemented, often in collaboration with Case or Care Management, clinical documentation improvement (CDI) programs.

12. Discussion Points Case Study D Cont • Data Integrity: In this role, the HIM department interacts with many others including: Access: To ensure the patient’s social security number, date of birth, and medical record number are accurately assigned at the time of admission • Coding Claims: HIM employs specially educated individuals whose responsibility it is to convert the physician’s written diagnoses and procedures to codes. These codes are then entered into the claim system and drive the reimbursement that the organization will receive for the services provided. • Releasing patient information: This HIM function is involved with ensuring that only authorized releases of patient information occur. Quality indicators: correct coding and clean claims; CDI results, complete medical records, etc

13. Case Study E Micro Case Study: Generating the Bill for Third Party Payers Describe the processes involved in generating a patient’s bill and receiving payment from a third‐party payer.

14. Discussion Points Case Study E Discussion Points • Patient Access Responsibility • Obtain all necessary patient information necessary to submit a claim. Check eligibility, e.g., any preauthorization’s, co‐pays, etc • Data entered into hospital information system to create medical record and financial records • Allows for accurate processing of bills the first time • Clinical services provided and documented accurately and completely

15. Discussion Points Case Study E Cont HIM Responsibility • Ensure that complete data are obtained from physicians on a timely basis and its staff accurately codes and abstracts data needed for submission of claims • The medical record affects the potential reimbursement to the hospital since the clinical information serves as the basis of payment for DRG and case‐based payers. This information is used to substantiate insurance claims filed by the patient, physician, and hospital • HIM employs specially educated individuals whose responsibility it is to convert the physician’s written diagnoses and procedures to codes. These codes are then entered into the claim system and drive the reimbursement that the organization will receive for the services provided. • Claims cannot be coded from incomplete medical record information. Therefore, there are other staff in the HIM department that pursue missing documentation from treating departments as well as from the physicians. • Coding timeliness is a common focus point in revenue cycle reviews. Like PFS, HIM relies on others to generate the information it needs to code. Hastily coding without complete information could result in lost reimbursement

16. Discussion Points Case Study E Cont PFS Responsibility This department is often responsible for managing the master listing of charges, collecting the charges for services rendered, assembling those charges in the proper format on the claim, submitting a timely claim to the payer, collecting balances due, and effectively managing the organization’s accounts receivable. •  In the bill print phase, a claim form (UB‐04 or HCFA 1500) is generated in either paper or electronic form. • Although these billing formats are supposedly “uniform,” many payers demand additional information before paying a claim. Such documentation might include the following: • ER report • History and physical • Therapy notes • Operative • Payers generally impose time limits in which claims must be billed • In the bill submission phase, medical claims or bills leave the patient accounting department with all necessary documentation attached, and are sent to the payer in either paper or electronic format

17. Case Study F Micro Case Study: The Charge Master The Chargemaster or Charge Description Master (CDM) • What is it? • What is its role?

18. Discussion Points Case Study F Discussion Points: • Patient Financial Services often manages a document that lists all services a patient may be charge for in a healthcare facility. This document is known as the Chargemaster or Charge Description Master (CDM). • The CDM: • Lists all services, supplies, room and board, etc. • Contains the description for each charge • Contains the appropriate HCPCS and revenue codes for the charges listed • Lists the current charge for each service. • If services are provided, but there is no charge in the charge description master for that service, then no charge will be generated. • Since the HCPCS codes can change from time to time, it is important that the charge description master be reviewed at least quarterly and all updates entered. § If these updates do not occur, inappropriate billing can occur, which can affect both reimbursement and compliance with billing regulations. An out-of-date chargemaster can result in inappropriate reimbursement, poor data quality for results and trend monitoring and billing compliance issues.