Brief Overview of the Revenue Cycle Process for Hospitals/Physician Offices

1. a Beverly Brouse Creation
Revenue Cycle
Hospital and Physician Based

2. Key Billing Acronyms a Beverly Brouse Creation
UB92 - Uniformed Billing Form (hospital)
•
HCFA 1500 - Physician Billing Form
•
CDM - Charge Description Master
•
CSA - Contractual Service Adjustment
•
DRG - Diagnostic Related Group (IP reimbursement method)
•
ATB - Aged Trail Balance (accounts receivable)
•
EOB - Explanation of Benefits (receive from payor)
•
ICD-9 - International Classification of Diseases (diagnosis)
•
HCPCS - Healthcare Common Procedure Coding System (drugs, devices, supplies)
•
CPT -Current Procedural Terminology (Procedures)
•
HIM - Health information Management (Medical Records Department)
•
HIS - Health information system
•
EMTALA - Emergency Medical Treatment and Liability Act
•
See exhibit A

3. Revenue Cycle a Beverly Brouse Creation
• Scheduling of Appointment (Hospital IP surgery & most OP visits
are scheduled. All Physician visits should be scheduled)
• Pre-Registration Process (Best of practice suggests that at least
90% of scheduled visits should be pre-registered)
• Registration Process
• Charge Capture/Coding Process (Unique between hospital
and physician practices)
• Billing/CSA Posting Process
• Follow-Up Process
See flowcharts A and B

4. Scheduling & Pre-Registration
a Beverly Brouse Creation
• Schedules should be updated regularly for cancellations,
no-shows or rescheduled appointments.
(Daily schedules should be used to reconcile to daily charges).
• Pre-registration occurs prior to the patient’s visit.
• At time of pre-registration, the following should occur:
1. Verification of insurance coverage,
2. Verification of patient demographic information,
3. Identification of self-pay balances (including co-pays and
deductibles), and
4. Obtain needed pre-authorizations
• Information gathered during pre-registration should be
documented in the system.

5. Registration
a Beverly Brouse Creation
• At time of registration, the following should occur:
1. Obtain copies of all insurance cards (primary, secondary &
tertiary coverage).
2. Practice the Birthday Rule when the patient is a child.
3. Request a form of photo ID to verify the patient’s identity (this
will ensure confidentiality of the patient’s medical records).
4. Verify patient demographic information and document this
information in the system (verify against the patient’s ID).
5. Collect all monies due from patient (self-pay balances, co-pays
and deductibles). The use of a day sheet is helpful when
reconciling to daily deposits.
• Registration information documented in system is usually
automatically pulled onto the UB04 and/or HCFA1500.
See exhibit D & E

6. a Beverly Brouse Creation
Registration Continued
• Registration in the ER is regulated and restricted
by EMTALA. See flowchart C

7. a Beverly Brouse Creation
Charge Capture/Coding
• Physician, nurse or physician assistant document all
services rendered to the patient.
• Charges captured in system by clinical departments or on
charge slips/superbills/charge tickets and forwarded for
entry into HIS
• Some CPT codes are hard coded in the CDM along with
the charge
• Medical records/HIM is responsible for the coding of
HCPC and ICD9 codes (soft coded).
• Once captured, codes are usually transferred from coding
system to HIS by means of interfacing.
See flowchart A

8. Claim Edits/CSA
a Beverly Brouse Creation
• Once claim is created, UBs/HCFA1500 are usually sent
through some kind of scrubbing system for editing.
• Errors identified during the editing process are corrected
by billing personnel.
• Prior to claim submission, CSA automatically calculated
by the system and posted to the patient’ s account or
manually posted after receipt of payor remit. (may vary by
payor)
• CSA is based on individual payor and their method of
payment. (based on individual payor contracts)

9. a Beverly Brouse Creation
Methods of Payment Calculations
Payment based on…
• DRG - fees paid based upon diagnosis (pre-defined).
• Per Diem - fees paid based upon the length of the patient’ s stay.
• Percent of Charges - fees paid based on a pre-determined percentage
(outliers are usually also negotiated in the contract)
• Capitation - fees based upon the estimated number of service occurrences
(fixed payment received in advance regardless of number of services
performed).
• Fixed Rate - fees based upon specific procedures performed (pre-defined).
• Fee for Service – fees for charges billed (no discount).

10. a Beverly Brouse Creation
Claim Submission
• Once sent through the scrubbing or editing
process, claims are ready for submission to
insurance carrier (backlogs may occur in clearing edits)
(additional hold time may also occur before submission).
• Most payors require electronic claim submission
• Some secondary payors require hard copies of the
UB04/HCFA1500 along with the primary payor’ s
remit.

11. a Beverly Brouse Creation
Collection Process
• ATBs should run periodically and be used when
following up on outstanding claims (ATBs list claims by
aging category).
• Claims are worked in order of age and dollar
amount (oldest, higher dollar claims are worked first).
• Productivity tracking should exist to monitor the
efficiency of follow-up.
• Follow-up personnel will also use EOBs as a tool
to work outstanding claims.
Per HIPAA regulations, third party payors must pay or deny a claim
within 30 days of receipt.

12. a Beverly Brouse Creation
Common Denials
The following are samples of possible denials
by insurance carriers:
• Patient Not Covered - this is a registration weakness.
• Untimely Filing - claim was received past the filing limit (this is
typically a billing weakness).
• Invalid ID Number - this is a registration weakness.
• No Authorization on File - this is a pre-registration weakness.
• Other Insurance Primary - this is a registration weakness.
• Pre-Existing Condition – could be a registration weakness.
Note: These are just a few of the many denials issued by payors.