Revenue Cycle Basics
What are the three main segments of the revenue cycle?
Pre-Service, Time-of-Service, Post-Service
What is the first step in the pre-service process for scheduled patients?
The requested service is screened for medical necessity.
What occurs when a pre-registered patient arrives for service?
Their identity is confirmed, and co-payments or other agreed amounts are collected.
What is the first activity in the post-service segment after a patient is discharged?
The discharge information, including disposition code, is entered into the system.
What does HIPAA primarily regulate in healthcare?
The protection and confidentiality of patient health information
In what segment of the revenue cycle is financial responsibility communicated to the patient?
Pre-Service
What information is typically verified during the pre-registration process?
Patient demographic and insurance information
How is patient liability handled during Time-of-Service for scheduled patients?
Financial responsibility is collected at the time of service, and any changes in patient liability are communicated and resolved
How are medical codes handled in post-service processing?
Medical records are reviewed, and required procedure and diagnosis codes are entered into the system for billing.
What is the significance of the No Surprises Act (NSA) in the revenue cycle?
It ensures that patients are protected from unexpected out-of-network charges.
What is the main purpose of financial communication during the Pre-Service segment?
To inform the patient of their financial responsibility, including copayments and health plan deductibles
What role does the pre-authorization step play in the pre-service segment?
It ensures that the service is covered by the patient's health plan before proceeding.
For unscheduled patients, what is the key difference in processing compared to scheduled patients?
Comprehensive registration and financial processing are completed at the time of service.
What happens when all edits are resolved in the billing process?
The bill is submitted to the patient’s health plan for payment.
How does the Medicare Payment model shift impact healthcare providers?
It moves from a volume-based payment model to a value-based model, focusing on quality of care.
What is a key performance indicator (KPI) used in the revenue cycle?
Days in A/R (Accounts Receivable)
How are financial responsibilities communicated to patients before the service?
Through patient financial communication, which explains co-pays, deductibles, and financial assistance eligibility.
What happens when a patient's status changes during their Time-of-Service, such as transitioning to observation status?
The patient type is updated, and notifications are sent to Case Management for monitoring.
How is a zero-balance achieved in post-service processing?
Payments from the health plan are electronically received and posted to the patient’s account
What is the purpose of the IRS Section 501(r) regulations?
To ensure that non-profit hospitals provide financial assistance to patients and comply with the community benefit standard.
What major transition is happening in payment models within the revenue cycle?
Shifting from volume-based to value-based payment models
What is one major issue that can impact patient accounts later in the revenue cycle?
Process failures during the pre-service segment, such as incomplete financial communication or missed verification.
What is the process for ensuring all charges are identified and patient liabilities are correctly calculated?
Health plan benefits are applied, and the patient’s share is calculated based on the identified charges.
What role does the Patient Accounting department play after claim submission?
They monitor the account for payment and ensure that any discrepancies are resolved.
How does the Affordable Care Act influence patient financial responsibility?