459 chapter 17 Learning Objectives

459
chapter 17
Learning Objectives
● Describe revenue cycle management’s key phases
● Define and calculate key performance indicators
to compare performance among peers and with the
industry
● Identify critical points in the revenue cycle processes
● Understand the revenue life cycle from point-of-service
collections to claims adjudication
Revenue Cycle Management
Colleen Malmgren, MS, RHIA, and C. Jeanne Solberg, MA, RHIA
● Define the impact of a clinical documentation
improvement program on the revenue cycle
● Articulate case management’s and utilization review’s
impact on the revenue cycle
● Identify and correct issues at the source of denial
● Identify proper claims denial management tactics
● Create a successful denials management team
Key Terms
Insurance verification
Key performance indicator (KPI)
Local coverage determination (LCD)
MAP key
Medical necessity
National coverage determination (NCD)
Point-of-service (POS) collection
Preauthorization (or prior approval, authorization, or
predetermination)
Revenue cycle
Steerage
Utilization management
Utilization review
Accounts receivable (A/R) Days
Bill hold
Case management
Case mix index (CMI)
Charge capture
Charge Description Master (CDM)
Charity care
Claims scrubber software
Clean claim
Clinical documentation improvement (CDI)
Denial
Discharge, no final bill (DNFB)
Facility charge
Financial counselor
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460 Chapter 17
Introduction
There is significant financial pressure on healthcare organizations to manage their costs as consumers of services take on
an increased financial responsibility for their healthcare costs.
The revenue cycle is the process that begins when a patient
comes into the healthcare system and includes those activities
that have to occur in order for a provider of the care to bill at
the end of the patient’s service encounter. The healthcare revenue cycle encompasses people, tools, methodologies, and techniques that medical institutions use to manage their patients’
financial status. Revenue cycle management is a complex process that involves balancing people, processes, technology, and
the environment in which the processes take place.
The revenue management life cycle can be broken down
into three phases—the front-end, middle, and back-end
(see figure 17.1). The front-end of the revenue cycle includes
patient access functions such as scheduling of the patient for
services, registration of the patient, prior or preauthorization for
services, insurance verification, service estimates, and financial
counseling. During this phase, healthcare organizations need to
ascertain the source of payment for the service, follow requirements specified by the payer, accurately collect the patient’s
demographic information, and ensure a positive patient experience. Contract negotiations and re-negotiations with third-party
payers are also included in the front-end process. Specific terms
negotiated with payers drive patient services covered for reimbursement. These terms need to be defined and understood by
staff to properly support the front-end of the revenue cycle.
The middle process of the revenue cycle includes case
management, capture of charges for the services rendered,
and coding for those services based on clinical documentation. The key objectives in this phase are to manage clinical
practice according to accepted medical guidelines, identify
reimbursable services and ensure that documentation supports those services, and ensure coding of the documented
services is accurate and complete.
Figure 17.1. Revenue management life cycle
Front-End Process
Payor negotiation and renegotiation; patient access,
including scheduling, preauthorization, insurance
verification, point-of-service
collection, and financial
counseling
Back-End Process
Claims processing and
payment posting, follow-up,
customer service, collections,
and denial management
Middle Process
Charge capture, case
management, clinical
documentation, and coding
The back end of the revenue cycle is typically viewed as
the business office or patient financial service process and
includes claims processing and payment posting, followup, customer service, collections of unpaid bills, and denial
management (HIMSS 2009). In this phase, organizations
focus on releasing claims to the payers as quickly as possible after service is rendered and generating accurate and
complete claims resulting in reimbursement of the amount
expected by the payer.
Revenue Cycle Front-End Process
Scheduling and Registration
The scheduling of patient visits requires optimal assignment
of patients to the available healthcare resources. Accuracy of
information captured in this stage is vital to many of the processes occurring later in the revenue cycle, and the goal is to
continuously improve data collection and accuracy.
Staff responsible for scheduling and registration functions
requires a significant amount of knowledge regarding the
medical services provided, insurance carrier requirements,
provider preferences, and operational hours of services to
be rendered. The registration staff is tasked with gathering
and entering the required patient visit information. This staff
also takes an active role in promoting positive public relations with patients to increase community trust in the facility. Examples of demographic data collected include name,
date of birth, residence, sex, marital status, race and ethnicity, employer, insurance carrier, and guarantor. Incomplete or
inaccurate information can delay care and negatively impact
the revenue cycle (Corrigan 2009). When a patient arrives
for services, the registration staff is responsible for validating the patient’s identify, for example by photo identification; obtaining copies of insurance card(s); and obtaining
patient (responsible party) signatures for insurance payment
and release of medical information.
Initiating patient registration at the time of scheduling saves
time and is more user-friendly for patients when they arrive
for services. Each time a patient presents for clinical services,
the prior collected data need to be verified for accuracy and
updated with any changes.
The most common registration errors that affect the
revenue cycle are noted in table 17.1.
Insurance Verification
Insurance verification is a vital component of the prearrival process for scheduled patients. Verification of the
patient’s insurance for unscheduled patients occurs at the
time of their registration for clinical services or shortly
thereafter. The verification process entails validating that
the patient is a member of the insurance plan given and
is covered for the scheduled service date. It is also important to determine whether the patient’s insurance plan is
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Revenue Cycle Management 461
in-network vs. out-of-network, whether the scheduled
service expenses will be covered, whether a referral or an
authorization is required prior to the service being rendered,
and whether the patient will incur an out-of-pocket expense
(Langford et al. 2010).
Patient demographic and insurance information needs to
be complete and correct. In the absence of proper eligibility determination, payment for services may be delayed or
denied; claims may need to be reprocessed or reworked, adding delays in receiving payment for services; and patients
may become dissatisfied due to late statements and increased
financial responsibility for services (Anderson 2009).
Preauthorization
Preauthorization is also referred to as prior approval,
authorization, precertification, or predetermination and
is the requirement that a healthcare provider obtain permission from the health insurer prior to predefined services being
provided to the patients. Insurers have established more
• Incorrect insurance plan listed
• Policy number or group number missing or invalid
• Patient not eligible on date of service
• Patient with insurance listed as private pay
• Medicare listed when plan is Medicare health maintenance
organization (HMO)
• Medicare listed as primary when should be secondary
• Minors listed as guarantors
• More than one medical record number per patient
• Accident claims without occurrence codes
• Patient relationship to insurance subscriber code errors
• Failure to list medical necessity
• Missing guarantor or employer information
• Physician orders incomplete or missing
• Internal coding mismatches (for example, financial class to
patient type to stay type to service code to admit code)
• Missing prior authorization or precertification required for
service provided
• Transposed digits: Social Security number, date of birth,
policy number, group number
• Invalid punctuation in specified text fields
• Misspelled name
• Insurance eligibility verification failure
• Address verification failure (returned mail cost)
• Observation patient with inpatient stay type
• Point-of-service collection failure
• Incomplete or inaccurate Medicare secondary payer
questionnaire
Table 17.1. Most common registration errors
Source: Shorrosh 2011.
stringent guidelines with the increase in high-technology and
high- cost procedures and tests.
Scheduling or preauthorization teams need to understand
medical procedures and tests, initial diagnoses, and scheduled
treatments in order to obtain the necessary preauthorization
by the insurance company. There is a wide variation in
prior authorization requirements and criteria among payers
(HASC Summit 2009). It is important for healthcare providers to have current lists of procedures and tests requiring
prior authorization from all health insurers and have processes in place to obtain the authorization prior to services
being rendered. Reimbursement for services without preauthorization is often denied by insurers and results in significant negative financial impact to the healthcare organization.
Financial Counseling
A healthcare organization needs to ensure the patient understands the financial aspects of his or her encounter of care and
the process for resolving any fiscal responsibility. Financial
counselors are staff dedicated to helping patients and physicians determine sources of reimbursement for healthcare
services. The counselors are responsible for identifying and
verifying the method of payment and debt resolution for services rendered to patients. Counselors need to understand a
patient’s financial assets and discuss payment alternatives
with patients. Some patients are eligible for charity care,
which is defined as healthcare services that have been or will
be provided but are never expected to result in cash inflows.
Charity care results from a provider’s policy to provide
healthcare services free or at a discount to individuals who
meet the established criteria (HFMA 2010). The counselors can establish payment arrangements such as credit card
payments, bank loans, and interest-bearing, hospital-funded
payment arrangements as necessary.
Strategies for financial counselors can include the ability to provide discounts on hospital bills for patients who do
not have health insurance and who meet certain eligibility
criteria. The amount of the discount is determined after an
assessment of the patient’s or a family’s financial need and
is typically based on current federal poverty guidelines.
Incentives for prompt-payment discounts can also be offered
to patients. Healthcare facilities need to follow consistent
procedures and steps to obtain appropriate payment and to
enhance revenue cycle processes (Guyton et al. 2005).
Point of Service Collection
Patients have taken on an increasing amount of financial
responsibility for their healthcare costs. Insurance companies determine that the annual copayments and deductibles
for which the patient is responsible account for 5 to 6 percent of total net revenue and 16 to 17 percent of outstanding
receivables (Page 2010). Point-of-service (POS) collection
is defined as the collection of the portion of the bill that is
likely the responsibility of the patient prior to the provision
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462 Chapter 17
of service (Goudzwaard 2007). POS collection works well
with scheduled and nonemergent patient visits. Access to
billing data from both payers and the healthcare’s own system is needed to be able to estimate what a patient owes at
the point of service. Healthcare staff needs to communicate
with the patient to set expectations regarding the cost of the
services, insurance coverage, and the expected payment at
the time of service (Yarbrough 2007). It is also important
that the healthcare providers be educated about the POS policy and procedures within the hospital so they may support
the process.
Medical Necessity Coverage Issues
Health insurance companies provide coverage only for
health-related services that they define or determine to be
medically necessary. Medicare defines medical necessity as
a determination that a service is reasonable and necessary for
the related diagnosis or treatment of illness or injury.
The American College of Medical Quality (ACMQ)
further defines the application of appropriate services and
supplies as those that are neither more nor less than what
the patient requires at a specific point in time. The ACMQ
(2010) has also adopted the following nine principles as
part of their policy related to the application of medical
necessity:
1. Determinations of medical necessity must adhere to the
standard of care that applies to the actual direct care and
treatment of the patient.
2. Medical necessity is the standard terminology that all
healthcare professionals and entities will use in the
review process when determining if medical care is
appropriate and essential.
3. Determinations of medical necessity must reflect the
efficient and cost-effective application of patient care
including, but not limited to, diagnostic testing, therapies (including activity restriction, after-care instructions, and prescriptions), disability ratings, rehabilitating
an illness, injury, disease or its associated symptoms,
impairments or functional limitations, procedures, psychiatric care, levels of hospital care, extended care,
long-term care, hospice care, and home healthcare.
4. Determinations of medical necessity made in a concurrent review should include discussions with the
attending provider as to the current medical condition
of the patient whenever possible. A physician advisor
or reviewer can make a positive determination regarding medical necessity without necessarily speaking with
the treating provider if the advisor has enough available information to make an appropriate medical decision. A physician advisor cannot decide to deny care
as not medically necessary without speaking to the
treating provider and these discussions must be clearly
documented.
5. Determinations of medical necessity must be unrelated
to payors’ monetary benefit.
6. Determinations of medical necessity must always be
made on a case-by-case basis consistent with the applicable standard of care and must be available for peer
review.
7. Recommendations approving medical necessity may be
made by a non-physician reviewer. Negative determinations for the initial review regarding medical necessity must be made by a physician advisor who has the
clinical training to review the particular clinical problem
(clinically matched) under review. A physician reviewer
or advisor must not delegate his or her review decisions
to a non-physician reviewer.
8. The process to be used in evaluating medical necessity
should be made known to the patient.
9. All medical review organizations involved in determining medical necessity shall have uniform, written
procedures for appeals of negative determinations that
services or supplies are not medically necessary.
Medicare’s national coverage policies are known as
national coverage determinations (NCDs), and local
fiscal intermediary policies are known as local coverage
determinations (LCDs). These policies define the specific
International Classification of Diseases (ICD) diagnosis
codes that support medical necessity for many services provided. There are not NCD or LCD policies for every type
of procedure or service that could be provided for a patient,
so healthcare organizations must stay current with the regulatory requirements and revisions that are contained in the
following documents in order to reduce billing denials and
ensure that payment is received for the services rendered.
● Payer billing manuals
● Medicare billing manuals
● Local fiscal intermediary policies
● Local Part B carrier policies
Pre-encounter Services
Many healthcare facilities have combined staff resources
related to the revenue cycle front-end process and developed
pre-encounter service centers for patients. The centers handle
preregistration, insurance eligibility and benefit verification,
payer authorizations, and preservice collections for all scheduled diagnostic testing and surgery patients. Organizations
have developed the following operating characteristics to support the front-end processes.
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Revenue Cycle Management 463
● Ninety-five percent of all scheduled services will be
preregistered.
● All areas performing registration functions will be
guided by the same operating characteristics.
● Procedures will be standardized and all staff trained
accordingly.
● Lack of preregistration will not contribute to treatment
delays.
● Insurance clearance processes will drive a decrease in
payer denials.
● Patient payment expectations will be communicated
to the patients and (except for emergency department
services) will be collected prior to or at the time of
service.
● All uninsured patients will be offered a self-pay discount package or will be screened for either medical
assistance or charity care, or both.
● Quality monitoring will be performed on a monthly
basis with feedback to the employees.
● Physician offices will be notified of any noncovered
services to make decisions regarding continuing with
services.
● Denials will be work-listed for identification and
resolution.
● Preregistration and financial clearance of scheduled services will be completed five days before the
patient’s appointment.
● Staff will use automated credit-scoring and addresschecking software to identify a patient’s potential to pay
and potential eligibility for charity care (Butcher 2012).
Results from combining the front-end processes have
eliminated last-minute cancellations of scheduled services,
improved patient flow, and increased patient satisfaction.
Contract Management
The management of contracts is an integral part of the revenue life cycle. Healthcare facilities negotiate contract terms
with third-party insurers for payment of services rendered to
patients. This is where allowable costs or chargeable services
or supplies provided by a hospital or physician that qualify
as covered expenses are defined. The contract terms need to
benefit and be cost-effective for the facility, its patients, and
the insurer.
Contract management has its own life cycle. Persons
responsible for contract management must first understand
service lines provided within their facility and then analyze the financial needs to provide the services. Contract
managers need to be able to analyze steerage vs. discounts.
Steerage is when an insurer provides financial incentive or
discounted rates to a facility to obtain a flow of patients it
would not otherwise receive. Contract management also
includes a comprehensive understanding of competitors and
the local market rates, for instance, what other providers of
services are charging. Managers need to negotiate contract
language and rates and be able to define payers’ and providers’ duties. Additional steps in the contract life cycle include
claims submission and follow-up; denial management; analysis of payment variances; the collection of accounts and
posting of payments; and, finally, analysis of the contract
performance (Hammer 2009).
Technology Tools
Hospitals and healthcare systems need to accurately forecast,
calculate, and capture all net revenue contractually owed
to them. Contract management technology can assist with
understanding the expected net revenue of every patient at
discharge regardless of payer. Contract management software systems enable organizations to coordinate all phases
of contracted payer business (negotiations, payment compliance, performance review); recover prior contract management underpayments by identifying payment variances;
ensure proper payments on all subsequent claims as the system accurately calculates expected reimbursement; model
complex contracts with multiple reimbursement formulas in a
simple and timely manner; and take appropriate action when
expected results are not achieved.
Technology tools to support the patient access workflows
are important to support quality of work and productivity of
staff. Tools identified by the 2008–2009 HIMSS Revenue
Cycle Improvement Task Force (2009) to support the frontend process include
● Enterprise-wide scheduling system
● Order tracking and management system
● Telephony system in order to measure call activity
● Registration quality assurance tools
● Online third-party eligibility and coverage limitations
● Workflow drivers to ensure all financial clearance
functions are completed
● Estimation tools for patient out-of-pocket financial
responsibility
● Electronic financial assistance applications
Check Your Understanding 17.1
Instructions: Answer the following questions on a separate piece
of paper
1. List five common registration errors that affect the revenue
cycle.
2. Name the Medicare coverage policies that list diagnoses
supporting medical necessity?
3. What information does the scheduling staff need in order to
obtain authorization prior to services being rendered?
4. What strategies are employed by the financial counseling
staff to obtain appropriate payment for services provided to
the patient?
5. Identify five steps of the contract life cycle.
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464 Chapter 17
Revenue Cycle Middle Process
Case and Utilization Management
The Case Management Society of America (CMSA) defines
case management as “…a collaborative process of assessment, planning, facilitation, care coordination, evaluation,
and advocacy for options and services to meet an individual’s
and family’s comprehensive health needs through communication and available resources to promote quality
cost effective outcomes” (CMSA 2012). The American
Case Management Association (ACMA) defines case management as “…a collaborative practice model including
patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The case management
process encompasses communication and facilitates care
along a continuum through effective resource coordination.
The goals of case management include the achievement of
optimal health, access to care, and appropriate utilization of
resources, balanced with the patient’s right to self-determination” (ACMA 2012). Both organizations support professionals who evaluate the appropriateness of hospital admissions
according to pre-established criteria.
Case managers’ responsibilities were initially to manage
and ensure the appropriate utilization of acute care resources
with a focus on improving quality and reducing costs.
Today’s case manager role has evolved further and involves:
● Partnering with physicians during rounds to participate in treatment plan progress reporting
● Questioning duplicative interventions or interventions
that may be contrary to evidence-based protocols
● Collaborating with the nurses to identify any obstacles to move the treatment plan forward and bring
that information to the bedside to resolve with the
physician
● Facilitating communication among attending physicians and consultants
● Advocating for the patient and family to ensure
that prescribed interventions are suitable to the
patient’s preferences and economic circumstances
● Prompting a planning discussion for transitioning
patients from one level of care to another—whether
from a critical care area to a medical unit or from
a medical unit to the patient’s home (Daniels and
Frater 2011).
These responsibilities allow the case managers to
quickly identify barriers that may impede the efficient
progression of the patient through the healthcare service
process. Unexpected delays in care or discharge can be
prevented, and unnecessary consumption of resources such
as additional patient days can be avoided (Daniels 2007).
The case manager can have a positive impact on the revenue cycle by avoiding the delays, navigating the patient
through the healthcare process, and acting as an advocate
for the patient resulting in higher patient satisfaction with
the healthcare facility (Miodonski 2011).
Utilization management works in conjunction with case
management, and, at times, the terms and responsibilities are
used interchangeably. Utilization management is the evaluation of the medical necessity, appropriateness, and efficiency
of the use of healthcare services, procedures, and facilities
under the provisions of the applicable health benefits plan; it
is sometimes called utilization review (URAC 2012). The
utilization review (UR) staff is responsible for the day-to-day
provisions of the hospital’s utilization plan as required by the
Medicare Conditions of Participation. Utilization personnel are
required to perform the following functions:
● Review the medical record thoroughly to obtain information necessary to make UR decisions
● Apply criteria objectively for admissions, continued
stay, level of care, and discharge readiness
● Provide services 24 hours a day, 7 days a week, to all
relevant hospital departments, acting as a resource
● Review, within 24 hours, all patients placed in a bed
● Screen and coordinate elective and emergency admissions and transfers, outpatient observations, and conversions of status as appropriate and compliant
● Provide UR to all admissions, regardless of payer
status
● Review all continued stays at a scheduled frequency,
but not less than every three days or sooner
● Screen for timeliness, safety, and appropriateness of
the rendering or use of hospital services or resources
● Meet weekly for complex case (high-dollar or long
length of stay) problem solving
● Complete retrospective or focused reviews as directed
by the UR committee. (McLean 2011a)
The staff works with external review organizations and
should establish working relations with third-party reviewers, provide requested clinical information as required,
facilitate medical record access and supervision of insurance reviewers, and ensure communication to patients and
their families resulting from the external review organization
communications.
According to the Centers for Medicare and Medicaid Services (CMS 2012), hospitals have the responsibility to issue
Hospital-Issued Notices of Noncoverage (HINNs) to Medicare beneficiaries prior to admission, at admission, or at any
point during an inpatient stay if the hospital determines that
the care the beneficiary is receiving, or is about to receive, is
not covered because it:
● is not medically necessary,
● is not delivered in the most appropriate setting, or
● is custodial in nature.
Medicaid requirements vary from state to state for notification of denial of care or termination of benefits. The
healthcare facility’s utilization plan should include the state’s
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Revenue Cycle Management 465
specific requirements associated with denial or termination
of benefits coverage (McLean 2011b).
Commercial payers are responsible for informing the
patient or the patient’s family, attending physician, and facility department responsible for utilization review of adverse
determinations. Utilization personnel take an active role in
monitoring, reporting, and communicating adverse determination to patients and their families and ensuring all procedures are followed in rendering the communication. These
procedures are important to ensure financial responsibility
of services provided and are important in a well-managed
revenue cycle process.
Charge Capture
Charge capture is a method of recording services and supplies or items delivered to the patient and directing them to
be billed on a claim form. It is the process of documenting,
posting, and reconciling the charges for services rendered
to patients. Organizational success is directly dependent
upon accurately documenting and reporting charges in a
timely manner, and the aim is to have policies, procedures,
and resources in place to ensure quality charge capture that
enhances revenue and adheres to compliance and other
standards.
Quality charge capture is critical for the following
reasons:
● Payments are often related to charges; reimbursement
for outpatient services is often driven by the specific
charges along with Current Procedural Terminology
(CPT) and Healthcare Common Procedure Coding
System (HCPCS) codes listed on the claim.
● Charges drive prices and rates for reimbursement;
payment rates established for diagnosis-related groups
(DRGs) and ambulatory patient classifications (APCs)
is determined by analyzing historical cost data, and if
true costs are not being reflected, reimbursement rates
are set too low.
● Charges reflect resource utilization; this allows analysis and comparison of the resources used for patients
with similar diagnoses treated in similar service lines
or receiving similar treatments.
● Charges help in the measurement of labor cost and productivity; this assists the organization in monitoring the
cost of doing business and determining staffing needs.
● Errors in charge capture create significant rework
and billing delays; errors may also go undetected and
result in loss of revenue or put the organization at risk
by not meeting regulatory requirements.
A variety of charge capture mechanisms may be in place
to get charges entered into the billing system. Charges may
be entered from paper or electronic charge tickets or encounter forms, or they may be interfaced from source systems
used in areas, such as a lab or pharmacy, that submit large
volumes of charges. Electronic health record systems may
also be configured to apply charges to patient accounts,
and health information management coding staff often has
responsibility for some charge entry based on clinical documentation. Regardless of the mechanism for charge entry, it
is important to verify the accuracy of the charge codes being
entered and to ensure they are posted to the correct patient
accounts for the correct dates of service.
The primary responsibility for charge capture is assigned
to staff in the departments providing the services, but there
are complex regulatory requirements surrounding compliant
charge capture, so ongoing charge capture education with
well-documented policies and procedures is vital.
Organizations may utilize internal billing system edits
designed to detect and correct charge capture errors before
claims are submitted to the third-party payers. They may also
utilize APC grouper software or Medicare claims scrubber
software designed to detect errors that would result in payer
denials. As errors are detected, they should appear on reports
and be reviewed by the appropriate departments so corrections can be made and issues or problems can be detected
and resolved.
Timely submission of charges is also critical for revenue
cycle success. Each facility has a defined number of bill
hold days. These are the number of days in which accounts
will be held from billing so charges can be entered after the
patient is discharged. Bill hold assumes that there will be a
delay in accumulating the charges incurred by a patient. By
incorporating this predicted delay into normal operations,
the facility creates a preventive control to avoid underbilling or having to submit late charges to the payer. Charges
added after this suspense period (typically two to five days)
are considered late charges.
Third-party payers generally will not reimburse a claim
that does not include the clinical diagnostic and procedural
codes. This is true whether the reimbursement is based on a
prospective payment system (PPS), actual charges, or some
other method. For this reason, the patient accounts department cannot drop a bill until the patient record has been
coded. Therefore, timely, accurate coding is critical to the
reimbursement process and directly affects the facility’s cash
flow.
An additional responsibility in revenue cycle management is determining items or services that are not separately
billable. Routine supplies are commonly defined as a supply used as part of the normal course of service where the
care is delivered, given to most patients treated in a particular setting or incidental to the procedure, or inherent to a
procedure. These supplies are not billable and are considered part of the room and board charge for a hospital or an
overhead cost for the healthcare facility. Examples of routine
supplies include specimen collection containers, syringes,
needles, gloves, pillows, sponges, heating pads, and irrigation solutions. Equipment available to all patients in an area
or commonly used during a procedure is also considered not
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466 Chapter 17
separately billable. Examples of equipment not separately
billable include cardiac monitors, blood pressure monitors,
wall suction units, and intravenous pumps.
Another important aspect of charge capture includes
facility charge capture. Since April 7, 2000, CMS has
instructed hospitals to report facility resources for clinic hospital outpatient visits using the CPT evaluation and management (E/M) codes (CMS 2008). The facility charge allows
capture of an E/M charge that represents those resources
not included with the CPT code for the clinic environment.
Hospitals were also instructed to develop internal hospital
guidelines for reporting the appropriate visit level. Three
options are allowed for capture of the facility evaluation and
management charge:
● Guidelines based on the number or type of staff
interventions
— Number and type of interventions
— Based upon diagnosis—evaluating most common
vs. extreme trauma
— Interventions not identified by CPT
● Guidelines based on the time staff spent with the
patient
— Nursing time spent with patient
● Guidelines based on a point system
— Resource intensity points
— Severity acuity based upon patient complexity
CMS does not provide national guidelines but expects a
hospital’s internal guidelines to follow the principles listed
here.
1. The coding guidelines should follow the intent of the
CPT code descriptor in that the guidelines should be
designed to reasonably relate the intensity of hospital
resources to the different levels of effort represented by
the code (65 FR 18451).
2. The coding guidelines should be based on hospital facility resources. The guidelines should not be based on
physician resources (67 FR 66792).
3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes
and audits (67 FR 66792).
4. The coding guidelines should meet the Health Insurance
Portability and Accountability Act (HIPAA) requirements (67 FR 66792).
5. The coding guidelines should only require documentation that is clinically necessary for patient care.
6. The coding guidelines should not facilitate upcoding or
gaming (67 FR 66792).
7. The coding guidelines should be written or recorded, be
well documented, and provide the basis for selection of
a specific code.
8. The coding guidelines should be applied consistently
across patients in the clinic or emergency department to
which they apply.
9. The coding guidelines should not change with great
frequency.
10. The coding guidelines should be readily available for
fiscal intermediary (or, if applicable, medicare administrative contractor) review.
11. The coding guidelines should result in coding decisions
that could be verified by other hospital staff as well as
outside sources.
CMS provided additional clarification surrounding some
of the principles.
● The first principle states coding guidelines should
follow the intent of the CPT code descriptor to relate
to the intensity of resources to different levels of
effort represented by the code, not that the hospital’s
guidelines need to specifically consider the three factors included in the CPT E/M codes for consideration
regarding physician visit reporting.
● Regarding principle two, hospitals are responsible for
reporting the CPT E/M visit code that appropriately
represents the resources utilized by the hospital rather
than the resources utilized by the physician. This does
not preclude the hospital from using or adapting the
physician guidelines if the hospital believes that such
guidelines adequately describe hospital resources.
● In principle eight, a hospital with multiple clinics (for
example, primary care, oncology, wound care, and
such) may have different coding guidelines for each
clinic, but the guidelines must be applied uniformly
within each separate clinic. The hospital’s various sets
of internal guidelines must measure resource use in a
relative manner in relation to each other. For example,
resources required for a Level 3 established patient
visit under one set of guidelines should be comparable
to the resources required for a Level 3 established
patient visit under all other sets of clinic visit guidelines used by the hospital.
● Regarding principle nine, CMS would generally expect
hospitals to adjust their guidelines less frequently
than every few months, and CMS believes it would be
reasonable for hospitals to adjust their guidelines annually, if necessary.
● Regarding the tenth principle, hospitals should use
their judgment to ensure that coding guidelines are
readily available in an appropriate and reasonable
format. CMS would encourage fiscal intermediaries
and medicare administrative contractors to review a
hospital’s internal guidelines when an audit occurs.
● Regarding the 11th principle, hospitals should use
their judgment to ensure that their coding guidelines
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Revenue Cycle Management 467
can produce results that are reproducible by others. In
the absence of national visit guidelines, hospitals have
the flexibility to determine whether or not to include
separately payable services as a proxy to measure
hospital resource use that is not associated with those
separately payable services. The costs of hospital
resource use associated with those separately payable
services would be paid through separate outpatient
PPS payment for the other services (Bowman 2008).
CMS also noted that facilities must also make the determination as to whether the patient is “new” or “established.”
CMS stated, “effective January 1, 2009, as stated in the
November 24, 2008 OPPS Final Rule (73 FR 68679), under
the OPPS, the meanings of ‘new’ and ‘established’ pertain
to whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past 3 years. If
a patient has been registered as an outpatient in a hospital’s
off-campus provider-based clinic or emergency department
within the past 3 years that patient would still be considered
an ‘established’ patient to the hospital for an on-campus
or off-campus clinic visit even if the medical record was
initially created by the hospital prior to the past 3 years”
(CMS 2008).
Charge Description Master
The Charge Description Master (CDM) is an electronic
file that represents a master list of all services, supplies,
devices, and medications charged for inpatient or outpatient
services (see table 17.2). The CDM contains the basic elements for identifying, coding, and billing items and services
provided to patients, and it is the mechanism for representing
captured charges on the billing claim.
Each billable service or supply is set up in the CDM
and assigned an internal charge code number, which
links it to the various data elements necessary for billing
and for tracking charge activity within the organization.
All charges that are set up in charging source systems or
charges that are listed on paper or electronic charge tickets
must be identical to those set up in the Charge Description
Master file in the billing system.
The CDM contains the following general data elements:
● Charge code—a unique identifier to identify and
represent each billable service or supply. The number
is meaningful only to the organization and does not
appear on the billing claim.
● Charge code description—a narrative description of
the service or supply. It does not appear on the billing
claim but would be available on an itemized patient
statement.
● CPT or HCPCS code—a nationally recognized fivedigit code. Not all CDM line items have a CPT or
HCPCS code because there are services and supplies
for which no code has been developed. These charges
are represented on the claim using only the revenue
code. When a CPT or HCPCS code does exist to
represent a chargemaster line item, it is reported on the
outpatient billing claim.
● Modifiers—two-digit numeric or alphanumeric extensions that are added to the CPT or HCPCS codes to
provide further information about the code. The claim
form allows room for one or two modifiers to be
attached to a CPT or HCPCS code.
● Revenue code—a nationally recognized four-digit code
that provides a general identification of what the line
item charge represents (that is, room and board, lab
services, radiology services, pharmacy items, supply
items, surgical procedures). The revenue code and its
description are required on each line item of a billing
claim for both inpatients and outpatients.
Charge
Code Charge Code Description
CPT/HCPCS
Code Modifier Revenue Code Price
2721159 CATHETER, DRAINAGE 272 79.00
2786337 CATHETER, HEMODIALYSIS LONG TERM C1750 278 438.00
3008423 DRUG SCREEN QUALITATIVE, SINGLE DRUG
CLASS
80101 300 41.00
3007215 CBC COMPLETE, WITH DIFFERENTIAL 85025 300 123.00
3207721 VENOGRAM EXTREMITY BILATERAL 75822 320 1,320.00
3406973 PARATHYROID SCAN 78070 340 798.00
3618306 DRAINAGE OF HEMATOMA/SEROMA 10140 361 1,517.00
3612905 INJECTION SACROILIAC JOINT 27096 361 786.00
4245986 PHYSICAL THERAPY EVALUATION 97001 GP 424 196.00
4302398 OCCUPATIONAL THERAPY RE-EVALUATION 97004 GO 430 134.00
4802563 ECHO TRANSTHORACIC, CONGENITAL
W/CONTRAST
93303 480 1,232.00
Table 17.2. Sample chargemaster description
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468 Chapter 17
● Price—the charge that is established for the line item
service, item, or supply. Factors that may determine the
price that is established include
— The Medicare and Medicaid reimbursement rates
(set by federal and state government agencies)
— Reimbursement provided by other third-party
payers (set by contract negotiations with the payers)
— Cost information that is calculated by the accounting or finance area (the cost to the organization to
provide that service, such as supplies, equipment,
and labor).
— Standard markup rates for services or supplies (to
factor in indirect costs to the organization or discount rates that are negotiated with the third-party
payers)
— Benchmark data on pricing in comparable
organizations
— Market competitive services.
Additional data elements may include the date the charge
code was created or made active; the date the charge code
was deactivated; a code that uniquely identifies the department cost center that uses the code; and payer-specific
requirements for reporting the charge, for example, a different CPT, HCPCS, or modifier that needs to be reported to the
payer for the charge submitted.
The chargemaster must continually be updated to ensure
that it represents all billable services and supplies and to
keep up with changes in CPT or HCPCS codes, revenue
code assignment, and payer-specific requirements. Any
number of events may trigger a need for CDM modifications.
Examples include
1. Regulatory changes such as CPT or HCPCS code
changes
2. Changes in CMS reimbursement guidelines
3. New department services
4. New product lines
5. Identification that the existing code does not match the
service being provided
6. Recurring claim scrubber or APC edits identifying
inappropriate setup in the CDM
7. Payer denials identifying inappropriate revenue code
or CPT or HCPCS code assignment in the CDM
(HFMA 2007).
A variety of resources are used to support the maintenance of the CDM. Internet resources are listed in table 17.3.
Many larger organizations use a software system to assist
with maintenance of the CDM and to view items that are set
up in a department or cost center’s chargemaster. The software is primarily designed to continuously apply edits that
point out compliance issues, validity of elements such as
CPT codes and revenue codes, and identification of items
priced below national reimbursement levels.
Maintenance of the CDM is a multidisciplinary activity. Proper chargemaster maintenance requires expertise in
coding, clinical procedures, health record or clinical documentation, and billing regulations. For example, the health
information management (HIM) department is knowledgeable of the codes, the patient accounts department knows
the general ledger codes, the pharmacy department is
familiar with the drugs and their costs, and the finance or
revenue integrity department knows the associated charge
formulas. Pharmacy cannot realistically update radiology’s
data nor can finance update charges without knowledge
of underlying costs and input from the specific department
(OptumInsight 2011).
Representatives from various areas that impact the revenue life cycle are critical to the success of the team. It is
equally beneficial to include representatives from those
departments that capture and generate charges; additional
representatives may be included depending upon the facility structure. Department representation typically includes
the chargemaster coordinator; patient access including
admitting, registration, and scheduling; compliance; revenue integrity; patient financial service (billing department);
contracting; finance; information services; HIM; ancillary
departments such as radiology, laboratory, surgery, or pharmacy; and physicians as needed.
• Medicare contractor bulletins and advisories
• Medicare manuals
— Claims Processing Manual (combination of the old hospital,
intermediary, and carrier manuals)
— Benefit Policy Manual
— Provider Reimbursement Manual
— National Coverage Determinations Manual
• Transmittals related to
— Hospital OPPS
— Fraud and abuse
— Coverage determinations
— Durable medical equipment regional carriers (DMERCs)
— Orthotics, prosthetics, and supplies
— Ambulance billing
— HIPAA
— Clarifications of previous transmittals
• Office of Inspector General
• National Correct Coding Initiative (NCCI) edits
• Medicare Addendum B
Table 17.3. CDM resources
Source: Shuler 2011.
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Revenue Cycle Management 469
Responsibilities of the chargemaster committee include:
● Developing policies and procedures for the chargemaster review process
● Performing chargemaster review at least annually when
new CPT and HCPCS codes are available or changes
are made throughout the year
● Attending to key elements of the annual chargemaster
review, including
— Reviewing all CPT and HCPCS codes for accuracy,
validity, and relationship to charge description
number
— Reviewing all charge descriptions for accuracy and
clinical appropriateness
— Reviewing all revenue codes for accuracy and linkage to charge description numbers
● Ensuring that the usage of all CPT, HCPCS, and revenue codes are in compliance with Medicare guidelines
or other existing payer contracts
● Reviewing all charge dollar amounts for appropriateness by payer
● Reviewing all charge codes for uniqueness and validity
● Reviewing all department code numbers for uniqueness and validity
● Performing ongoing chargemaster maintenance as the
facility adds or deletes new procedures, updates technology, or changes services provided
● Ensuring that all necessary maintenance to systems
affected by changes to the chargemaster (such as order
entry feeder systems, charge tickets, and interfaces)
is performed when chargemaster maintenance is
performed
● Performing tests to make sure that changes to the
chargemaster result in the desired outcome
● Educating all clinical department directors on the
chargemaster and the effect of the chargemaster on
corporate compliance
● Establishing a procedure to allow clinical department
directors to submit chargemaster change requests for
new, deleted, or revised procedures or services
● Ensuring there is no duplication of code assignment
by coders and chargemaster-assigned codes in any
department (for example, interventional radiology or
cardiology catheterization laboratory)
● Reviewing all charge ticket and order entry screens
for accuracy against the chargemaster and appropriate
mapping to CPT or HCPCS codes when required
● Reviewing and complying with directives in Medicare
transmittals, Medicare manual updates, and official
coding guidelines
● Complying with guidelines in the National Correct
Coding Initiative, Outpatient Code Editor edits, and
any other coding or bundling edits
● Considering carefully any application that involves one
charge description number that expands into more than
one CPT or HCPCS code to prevent inadvertent unbundling and unearned reimbursement for services
● Reviewing and taking action on all remittance advice
denials involving HCPCS or CPT coding rules and
guidelines or CMS payer rules
● Educating all staff affected by changes to the chargemaster in a timely fashion (AHIMA 2010b)
The CDM staff must also communicate with staff who
negotiates commercial and managed care contracts for the
hospital to ensure that data elements meet specific payer
requirements. Chargemaster maintenance also involves good
communication with the billing staff with regard to payment denials related to an incorrect revenue code or CPT
or HCPCS code, so that necessary changes get made to the
chargemaster.
Consequences of improperly maintained or inaccurate
chargemaster are the following:
● Services are provided, but associated charges are not
set up in the CDM, so the organization is unable to
bill and is providing free service.
● If a charge is not set up in the CDM until after the
service is provided, the charge might not get posted to
the patient’s account during the bill hold time.
● When all services are not set up in the CDM, the
department is only capturing part of its charges, and
the result is reduced revenue.
● If charges are not set up in the CDM or if there are
errors in the way they are set up, billing edits and APC
edits may be generated, holding up processing of the
claim. All billing delays result in increased accounts
receivable (A/R) days.
● APC and billing edits result in multiple individuals investigating the issues and making necessary
changes, which results in increased cost to the
organization.
An up-to-date, complete, and well-maintained chargemaster is a significant financial, operational, and compliance
asset to a healthcare organization.
Clinical Documentation
Complete, accurate, and timely documentation of patient
history, assessment, surgical and procedure notes, and clinical plan are important aspects of the revenue cycle. Clinicians need to document the services that are performed and
the medical necessity of the services, and staff needs to
verify the charges are matching the services that are being
performed prior to bill submission. CMS regulations require
documentation to support the care provided to the patient. In
order to comply with these regulations, hospitals have placed
an increased focus on clinical documentation management
and coding practices due to their direct impact on the healthcare facility’s revenue.
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470 Chapter 17
Hospitals have invested in clinical documentation
improvement(CDI) programs to assure the health record accurately reflects the actual condition of the patient. The American
Health Information Management Association (AHIMA) developed a toolkit for clinical documentation improvement, stating
its purpose is to “…initiate concurrent and, as appropriate, retrospective reviews of inpatient health records for conflicting,
incomplete, or nonspecific provider documentation” and identified the following key goals for a CDI program:
● Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses
and procedures
● Support accurate diagnostic and procedural coding,
DRG assignment, severity of illness, and expected risk
of mortality, leading to appropriate reimbursement
● Promote health record completion during the patient’s
course of care
● Improve communication between physicians and other
members of the healthcare team
● Provide education
● Improve documentation to reflect quality and outcome
scores
● Improve coders’ clinical knowledge (AHIMA 2010a)
A focus on appropriate clinical documentation can reduce
the risks from incomplete and unclear documentation resulting
in lost revenue for the healthcare facility. Accurate and thorough clinical documentation that is properly coded and billed
to payers results in benefits such as increased third-party payer
billing compliance, improved quality reporting to external parties, and increased revenues by coding the most appropriate
DRG and minimizing denials.
Coding
The HIM department performs a variety of functions, but the
primary one related to the revenue cycle is code assignment.
Upon a patient’s discharge, the clinical documentation is
reviewed and ICD diagnosis codes are assigned for inpatient and
outpatient claims, and CPT or HCPCS codes are assigned only
for outpatient claims. It is very important to have experienced,
well-trained coders in order to ensure accurate and complete
code assignment and optimum reimbursement. Coders must be
skilled at reading through documentation on a variety of different forms and formats and interpreting that documentation to
arrive at the correct code assignment. When documentation is
vague or ambiguous, they may need to query the physician for
clarification. The physician query process can create significant
delays in the revenue cycle when the coder is waiting for the
physician response and cannot complete the coding until it is
received.
A bill cannot be generated until the coding is complete, so
organizations routinely monitor the discharged, no final bill
(DNFB) days. The goal for an efficient revenue cycle is to
eliminate any backlog of uncoded charts and to complete the
coding process within the time frame of the bill hold days that
have been established for the organization.
The hospital’s case mix index (CMI) is also measured
and analyzed. The case mix index allows an organization to
compare its cost of providing care to its DRG mix of patients
compared to other hospitals. Medicare determines DRG
weights by comparing the average cost of treating patients in
one DRG to the average cost of all patients receiving hospital
inpatient care. The DRG weights do not reflect an individual
hospital’s costs relative to another hospital or peer group. The
CMI is calculated by summing the Medicare DRG weight
for every inpatient discharge and dividing by the number of
discharges. Medicare DRG weights are used and applied to
patients within all payers. The accuracy of clinical documentation and of code assignment can influence a facility’s case
mix index. By missing diagnoses or procedures that should
be coded, or failing to assign the most specific coding possible, the coding staff can cause the case mix index to be lower
than it should be.
Technology Tools
Similar to the front-end process of the revenue cycle, technology tools play a vital role in the efficiency and quality
of work produced by healthcare staff. The following tools
and techniques were identified by the HIMSS Revenue
Cycle Improvement Task Force (2009) to support the middle
process:
● Clinical documentation may first originate as written
text, dictation, or text keyed directly to the system.
Ultimately, clinical documentation must result in
codified procedures and diagnoses to support billing.
● Charge capture may be completed with a mix of
forms, online entry (keyed or scanned), and automatic
triggering.
● Electronic or e-tools help with maintenance of chargemasters. Optimal software packages include online
reference tools that compile the latest coding and
regulatory information, have a complete and active
code book feature, and include a browser-based, crossreference toolkit enabling users to research coding,
regulations, and pricing information.
● HIM processes are dependent on access to all clinical documentation and any precoded data. Reference materials may be required to support the coding
process; once determined, coded values must be input
into systems for inclusion in claims processing. Automated edits may be imbedded in transactions systems
to identify discrepancies at the time of entry (prior to
submission into the claim cycle). Final coded records
must be submitted through DRG tools to calculate
and assign DRGs. Systems tools may include a mix
of health information system (HIS) applications or an
HIM-specific application that is integrated with other
HIS applications.
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Revenue Cycle Management 471
Check Your Understanding 17.2
Instructions: Answer the following questions on a separate piece
of paper.
1. To ensure appropriate and effective resource coordination,
what roles should be performed by the case management or
utilization review staff?
2. What effect does the charge capture process have on the
reimbursement received for services?
3. What is the relationship between charging source systems
and the CDM?
4. To ensure multidisciplinary representation, what areas
should be involved in the chargemaster committee?
5. What are the key goals of a clinical documentation
improvement program?
6. How is the hospital case mix index calculated?
Revenue Cycle Back-End Process
Claims Processing
Claims processing involves accumulating charges for services, submitting claims for reimbursement, and ensuring that claims are satisfied. The patient financial services
or billing area has the responsibility for the collection of
revenue for the patient encounter. Once a patient has been
discharged, the goal is to get a complete and accurate claim
generated and submitted for payment as quickly as possible. Organizations routinely measure accounts receivable
(A/R) days—the average number of days between the provision of services and the receipt of payment for those services as a measure of how successful their revenue cycle is.
An efficient revenue cycle helps the organization lower the
A/R days, which in turn improves cash flow.
Claims processing is sometimes outsourced in nonhospital ambulatory care because physician offices and other small
facilities often do not have the resources to perform this complex activity effectively. The activity of submitting a claim is
often called dropping a bill. Because reimbursement for clinical services provided is the healthcare facility’s largest source
of revenue, timely, accurate claims processing is necessary.
Most billing systems are programmed to automatically
submit claims to the payers (after the bill hold time frame) if
the account is not being held for any type of edit resolution,
and these are often referred to as clean claims. Because there
are so many complex rules and edits, manual intervention
is required for many claims, but the goal is to continually
increase the percentage of clean claims that can be billed with
no intervention. The sophistication level of the organization’s
billing system determines how much is able to be programmed
into the system vs. how much has to be handled manually by
the billing staff.
America’s Health Insurance Plans, Washington, D.C.,
released a study to show the percentage of claims received
electronically was 82 percent in 2009, up from 75 percent in
2006 and 44 percent in 2002 (AHIP 2009). The study also
showed a notable lag before health insurance plans receive
claims from healthcare providers. Twenty-two percent of
claims received from healthcare providers were greater than
30 days after the date of patient service, and 12 percent of
claims were received more than 60 days after the date of
the patient’s service. The 2009 survey also showed health
insurance plans processed nearly 99 percent of clean claims
within 60 days, and 97 percent within 30 days.
Payment Posting
Payment is received from third-party payers and patients in
various ways, and the payments must be posted to the correct
individual patient accounts. Internally, some allocation of
the revenue must be made to the various areas that provided
services. This process is established by the organization’s
financial accounting area, and the methods of allocation may
vary. Since payment received does not equal the amount
that was billed, it is a complex process to determine the correct allocations and to post the necessary payments, adjustments, and discounts to the correct accounts. Ultimately, the
account balance on each patient’s account must equal zero
(Nelson 2011). There are instances when too many payments
are posted to the accounts because there can be multiple payments from one or more insurance companies and copayment or coinsurance payments received from the patient. In
these cases, the account has a negative balance, and it must
be determined where the overpayments occurred, so funds
can be refunded to the correct payer or to the patient.
Follow-up
Once payment is received from third-party payers and the
discounts and adjustments are applied to the balance on
the account, there may still be a portion that is due from
the patient (related to deductibles, coinsurance, and copayments). The patient financial services staff works to collect this portion from the patient and to appropriately refer
patients to medical assistance or other programs or apply
charge discounts as applicable.
Organizations may also utilize third-party collection agencies to assist with collection of payment on problem accounts.
These engagements may also necessitate a relationship with
a third-party collection attorney and an internal legal review
team that reviews all accounts prior to legal collection.
Denial Management
Denials may simply be defined as a payer’s refusal to provide payment. According to the Advisory Board Company,
the nation’s largest hospital research organization, the cost of
denials to healthcare organizations ranges from 1 to 3 percent
of total revenue. Approximately 90 percent of denials are
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472 Chapter 17
preventable and 67 percent are recoverable (Fontaine n.d.).
The most common reasons for the denials include
● Beneficiary not covered
● Lack of medical necessity—not reasonable or necessary
● Lack of precertification
● Inappropriate utilization
● Noncovered services
● Incorrect charging—unbundled code
● Incorrect coding
— Procedure code does not match patient sex
— Diagnosis procedure code does not match service
provided
— Procedure code inconsistent with modifier used
— Procedure code inconsistent with place of service
— Diagnosis inconsistent with age, sex, and procedure
— Modifier not provided
● Late charges or untimely filing
A denial management program requires facilities to seek
both prevention and recovery. Denials management requires
a cross-functional team to evaluate reasons for the denials
and to facilitate changes in work processes to prevent further denials from occurring. Denial team stakeholders often
include staff or managers from departments such as patient
financial services or billing; HIM; compliance; revenue
integrity or chargemaster; patient access, including registration, admissions, and surgery scheduling; utilization or case
management; contracting; finance; and various ancillary services and clinics where the denials may be occurring. A successful denial management program includes the following:
● Focus on recovery of lost reimbursement and prevention of further denial
● Teamwork to manage the denials
● Need to appropriately value the staff and provide
appropriate and clear work guidelines, standards, and
expectations
● Investment in staff training and education
● Utilization of technology to assist with processes
● Creation of a departmental dashboard to monitor progress of team efforts used to
— Measure individual department against a benchmark
— Compare individual departments against the organization as a whole
— Trend success within a department
● Denial tracking by payer
● Identification, quantification, and sorting by carrier
● Identification of trends that are not “true” denials but
potential stall tactics
● Sharing of specific examples with managed care or
contracting departments (Dunn 2009)
Revenue Audit and Recovery
After payment has been received, it is audited against the
terms of the contract to determine whether the organization
has received the correct reimbursement. Since the terms of
payer contracts are usually very complex, the revenue audit
and recovery function is greatly enhanced by the use of software systems that model the contracts and produce reports of
accounts with variation to the expected reimbursement.
To achieve optimum benefit, audits should occur for all
payment relationships that can be modeled. The government
payers and most commercial payers have fairly straightforward terms of reimbursement without a lot of specific
language. Those payers that negotiate specific terms of a
contract with the organization’s contracting team usually
have more complex terms of payment and variations for various plans or products offered by their company. It is particularly helpful to model the specific terms of these contracts
in a software system in order to detect variation in payment.
In organizations utilizing modeling software, the information about expected reimbursement is calculated after
all charges have been posted to the account and the bill has
been submitted to the payer. The level of detail specified in
negotiated contracts requires the software modeling programs to create a hierarchy when there are multiple types of
services provided to the patient. Once payment is received
and the reimbursement amounts are posted to the account,
the software system generates a weekly or monthly report
of all accounts with payment variation. A threshold is usually established for the percentage of variation that must
exist in order for an account to be included on the variation
report. The number of accounts may be too high to enable a
100 percent review, so guidelines should be established to
determine which accounts will be reviewed. Reports can be
generated to allow review of accounts by a specific payer,
a payer plan, inpatients vs. outpatients, accounts with high
dollar amount, and such.
Payments are examined against the Explanation of Benefits
(EOB) to see if specific items were paid or if they were considered to be bundled services or were denied or returned to
the provider for correction. The audit may detect errors in the
modeling that was applied or errors in insurance assignment at
the time of registration. This provides an opportunity to provide feedback and further staff education. The audit may also
detect patterns of underpayments or overpayments, which can
initiate a focus on accounts with similar charges.
Technology Tools
Tools identified by the HIMSS Revenue Cycle Improvement
Task Force (2009) to support the back-end process include
● Workflow claims management system for follow-up
● Denial management system
● Contract management system
● Claims editing system
● Integration to payers for automated claims status and
cash posting
● Telephony system in order to measure call activity
● Electronic financial assistance application
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Revenue Cycle Management 473
Check Your Understanding 17.3
Instructions: Answer the following questions on a separate piece
of paper
1. How are an organization’s accounts receivable days
impacted by its bill hold days and its percentage of clean
claim submissions?
2. What factors can cause a patient account balance to display a
negative amount?
3. What are four of the most common reasons for billing
denials?
4. What criteria are used to select claims that should be audited
to determine whether proper reimbursement has been
received?
Strategies for Revenue Cycle Success
Quality Measures for Improvement
Increasing revenue cycle performance can have a positive
impact on a healthcare organization’s financial bottom line
(see table 17.4). Measuring the various processes of the
revenue cycle against established benchmarks provides an
opportunity for organizations to focus on areas to improve.
Influences such as geographical location, bed size, payer mix,
net patient revenue, and the mix of inpatient, outpatient, and
emergency room visits can impact the revenue cycle (HFMA
2011). The Healthcare Financial Management Association
(HFMA) defined key measures to evaluate revenue cycle performance. The tool allows hospitals to track its revenue cycle
performance using industry-standard metrics and compare
the results with peer groups based upon the aforementioned
influences (table 17.5).
Key performance indicators (KPIs) allow healthcare facilities to measure and benchmark their data against best practice.
The KPIs were developed by the HFMA based upon research
from HFMA publications, forums, and website; the American
Health Information Management Association publications and
website; accounting firms; vendor internal standards and client
data; and hospital accounts receivable analysis report standards
(Hammer 2007).
Table 17.4. Benchmarking
Use of Benchmarking Can Drive
Significant Improvements
Key Performance
Indicator Top Quartile Median Difference
Days in A/R 37.7 43.1 5.4
Point-of-Service
Cash Collection
46% 30% 16%
Source: Analysis of HFMA’s MAP AppSM, September 2010.
In addition to measuring key revenue cycle tasks, seven
additional strategies for success include the following:
● There needs to be an organization focus on revenue
cycle improvement, and a dedicated team should be
put into place to maintain the focus.
● Metrics need to be used to conduct root cause
analysis to facilitate changes throughout the
healthcare system.
● There needs to be a shared sense of accountability for
revenue cycle performance.
● Collaboration with other departments to enhance the
revenue cycle performance needs to become an organizational focus.
● A comprehensive approach needs to be developed to
address uncompensated care.
● The organization needs to find innovative ways to
enhance customer service.
● The organization must focus on improving the total
patient experience (Williams 2011).
Technology plays a key role in successful revenue cycle
management by supporting effective and efficient operational practices. Healthcare financial improvement can be
enhanced by employing the following tools and techniques:
● Enforce accountability.
● Monitor goals in a timely manner.
● Report results using a balanced scorecard technique.
● Establish a goal of overhead costs as a percentage of
total costs.
● Adopt flexible budgeting.
● Adopt benchmarking.
● Develop percentile goals.
● Determine labor ratio goals.
● Reduce resource consumption.
● Purchase and use effective cost-management tools.
(Berger 2007)
HFMA developed additional indicators to consistently
measure the key performance indicators known as MAP
keys. The purpose was to develop the standard for revenue
cycle excellence. Each MAP key measures a specific revenue cycle function and provides the purpose for the measurement, the value of the measure, and the specific equation
(numerator and denominator) to consistently calculate the
measure. Examples of MAP keys are found in table 17.6.
Check Your Understanding 17.4
Instructions: Answer the following questions on a separate piece
of paper
1. What is the purpose of MAP keys?
2. Name four key strategies of success for the revenue cycle.
3. How do you measure late charges as a percentage of total
charges?
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474 Chapter 17
Denial Type Percent
Overall initial denials rate (% of gross revenue) ≤ 4%
Clinical initial denials rate (% of gross revenue) ≤ 5%
Technical initial denials rate (% of gross revenue) ≤ 3%
Underpayments additional collection rate ≥ 75%
Appealed denials overturned rate 40–60%
Electronic eligibility rate ≥ 75%
Physician precertification double-check rate 100%
Case managers’ time spent securing authorization ≤ 20%
Total denial reason codes ≤ 25%
Scheduling Percent
Overall scheduling rate of potentially eligible patients 100%
• Scheduling rate for elective and urgent inpatients 100%
• Scheduling rate for ambulatory surgery patients 100%
• Scheduling rate for high-dollar outpatient diagnostic patients 100%
Scheduled patients’ preregistration rate 98%
Registration/Preregistration Percent
Overall preregistration rate of scheduled patients ≥ 98%
Overall insurance verification rate of preregistered patients ≥ 98%
Data quality compared with pre-established department standards ≥ 99%
Health Information Percent
Copies of medical records pursuant to payers’ requests ≥ 2 days
Potential “over codes” beyond 75th percentile ≥ 2%
Potential “under codes” below 10th percentile ≥ 2%
Data quality compared with pre-established department standards ≥ 99%
Chargemaster Percent
Chargemaster duplicate items 0%
Chargemaster incorrect or missing HCPCS/CPT-4 codes 0%
Chargemaster incorrect or invalid revenue codes 0%
Chargemaster revenue code lacks necessary HCPCS/CPT-4 code 0%
Chargemaster item has invalid or incorrect modifier 0%
Chargemaster item has missing modifier 0%
Chargemaster item description is “miscellaneous” 0%
Table 17.5. HFMA denial key performance indicators
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Revenue Cycle Management 475
Effective management of the revenue cycle is an important
piece of improving the net revenue for a facility. Successful
revenue cycle management requires streamlined workflow
processes throughout the life cycle. The goal is to get revenue to flow quickly and efficiently through all steps in the
cycle. To achieve that goal, it is necessary to understand
each of the steps and the detailed processes that take place
within them. It is also important to monitor and audit all the
steps to uncover processes that are inefficient or are in need
of improvement. Organizations should conduct research to
identify best practices in each area and attempt to model
those practices where possible. When conducting evaluation
Summary of processes, it is necessary to examine the flow of events
and the interrelationships among them, as opportunities for
improvement may exist there. Once improvement efforts are
initiated and efficiency of processes and workflow has been
achieved, there must be controls in place to sustain those
improvements.
2008–2009 Healthcare Information and Management Systems
Society Financial Systems Revenue Cycle Task Force. 2009.
Revenue cycle management: A life cycle approach. http://www
.himss.org/content/files/20090909RCMTFwhitepaper.pdf.
References
Measure Purpose Value Equation
Point-of-Service Cash
Collections
Trending indicator of point-ofservice collection efforts
Indicates revenue cycle efficiency
and effectiveness
N: Number of patient encounters
preregistered
D: Number of scheduled patient
encounters
Preregistration Rate Trending indicator that patient
access processes are timely,
accurate, and efficient
Indicates revenue cycle efficiency
and effectiveness
N: Number of patient encounters
preregistered
D: Number of scheduled patient
encounters
Insurance Verification
Rate
Trending indicator that patient
access functions are timely,
accurate, and efficient
Indicates revenue cycle process
efficiency and effectiveness
N: Total number of verified
encounters
D: Total number of registered
encounters
Service Authorization
Rate
Trending indicator that patient
access functions are timely,
accurate, and efficient
Indicates revenue cycle process
efficiency and effectiveness
N: Number of encounters
authorized
D: Number of encounters requiring
authorization
Days in Total
Discharged, No Final
Bill (DNFB)
Trending indicator of claims
generation process
Indicates revenue cycle performance
and can identify performance issues
impacting cash flow
N: Gross dollars in A/R (no final
billed)
D: Average daily gross revenue
Days in Total
Discharged, Not
Submitted to Payer
(DNSP)
Trending indicator of total
claims generation and
submission process
Indicates revenue cycle performance
and can identify performance issues
impacting cash flow
N: gross dollars in DNFB + gross
dollars in FBNS
D: Average daily gross revenue
Late Charges as % of
Total Charges
Measure of revenue capture
efficiency
Indicates revenue cycle performance
and can identify performance issues
impacting cash flow
N: Charges with post date greater
than 3 days from last service date
D: Total gross charges
Net Days Revenue in
Credit Balance
Trending indicator to accurately
report account values, ensure
compliance with regulatory
requirements, and monitor
overall payment system
effectiveness
Indicates whether credit balances are
being managed to appropriate levels
and are compliant with regulatory
requirements
N: Dollars in credit balance
D: Average daily net patient
services revenue
Source: HFMA 2012.
Table 17.6. Examples of MAP keys
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476 Chapter 17
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Revenue Cycle Management 477
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