Question

Cure All Hospital has received a number of payer denials for services billed with incorrect CPT codes and revenue codes. After investigating, Jane discovered that several departments were submitting their charges using electronic source systems or paper charge tickets that had not been updated to match the billing system’s charge master.
  

Discuss what Jane should do to correct this problem and measures that should be put in place to ensure that the CDM is correct and that electronic source systems and paper charge tickets are updated.  

In addition to the above real world case, answer the questions below.

1. Identify the phases of the revenue management life cycle and the activities included in each phase.   

2. Discuss the interrelationships that exist among the revenue cycle activities in the different phases, and the impact they can have for the organization’s financial health.

3. Identify tools and techniques used to improve healthcare finance and discuss the role technology plays in successful revenue cycle management

Answer 1

1. Revenue management life cycle

Goal of healthcare revenue management life cycle is to help the organisations to get paid the full amount for services as soon as possible.

Steps in Revenue management life cycle

1.RCM software or Outsourcing prossessing

Depending on the medical organisation size u can decide on processing method.If the organisation is small and have good IT team members they can go for RCM software on their own servers. IF not they can outsource i t to third party experts.

2.Patient Pre-Authorization

Process of obtaining approval from health insurance plan for approving medication. it helps to minimise the cost for the patient .Incase of emergency this is not applicable.

3.Eligibilty and benefits verfication

Front office staff has a duty to check the patient eleigibilty whether they are entitled to particlar benefit. It can be done through internet over secure channels.

4.Claims submission

Claims will be served only when the office properly submit the work done for the patient.They can make use of PM software inorder to avoid.

5.Payment Posting

Once the claim is submitted and reviewed, payment will be processed.can make use of Electronic Data Interchange (EDI).

6.Denial Management

Too many denial claims end up in revenue loss for the organisation.They must ensure proper denial management inorder to boost the revenue.

7.Reporting

To avoid hidden problems in the medical organisation they shoud have a detailed reports in order to prevent it getting worse.They can make use of RCM system to increase the productivity.

2.Interrelationship exist between various phases in revenue cycle activities

• Each phase in revenue management life cycle in healthcare is interconnected.

• Managing health care revenue cycle is more than collecting bills.
• Efficient revenue life cycle is like pillars for success of the healthcare.
• The  process starts form the moment the patient make an appointment till the outstanding bills are paid.
• Each step should be take care since if one step goes wrong it will affect overall. for example ( Failure to capture insurance information at the time of appointment could lead to time waste when patient payer denied)

3.Tools and techniques used and role of technology in healthcare.

a) RCM software :The technology helps to keep track of any claims, ensure payments, and address any denial claims throughout the lifecycle.The organistionsation can do on their own or hire for third party for the process.They should maintain third party followup.

b)Coding/ICD-10: Physcians needs to ensure that they are coding everything correctly in ICD-10,since single mistake can to lad to overbilling and affect audit.

c)PM Software: Helps to have proper control over claims and ensure it is free from errors.Since payment is possible only when there is proper claim submission.