Revenue Cycle Basics
What does revenue cycle management track in healthcare?
payment for healthcare from the first appointment to final payment
What is the difference between facility billing and professional billing?
Facility bills for hospital resources; professional bills for provider services.
Insurance approval required before certain services are provided.
preauthorization
What is coordination of benefits?
Determining the order insurance plans pay when a patient has more than one policy.
A patient has met their deductible and owes 20% coinsurance on a $200 allowed amount. How much do they owe?
$40
Which side (end) of the revenue cycle includes appointment scheduling, registration, and insurance verification?
Front-end
Which claim form is used by physician offices and other non-institutional providers?
CMS-1500
What does "Medicaid considered the payor of last resort" mean?
It pays only after all other insurance plans have paid.
A child has two insurance plans: Mom’s (DOB September 12) employer-sponsored private insurance and Dad’s (DOB September 15) employer-sponsored private insurance. Which is primary?
Mom's (follow the birthday rule)
A patient has not met their deductible. The allowed amount is $500 and their coinsurance is 80/20. How much does the patient owe?
$500
What document must patients receive that explains how their health information may be used?
Notice of Privacy Practices
Which claim form is used by hospitals and skilled nursing facilities?
UB-04
A claim with no errors and all required information.
clean claim
Parents are divorced with 50/50 custody. A court order states the mother must provide insurance. Dad’s birthday is earlier. Which plan is primary and why?
Mother’s plan; court orders override other COB rules.
A patient owes 20% coinsurance on a $1,000 allowed amount. How much does insurance pay?
$800
What is charge capture?
Recording services provided so the provider can bill and get paid.
What document explains to the provider how a claim was paid?
Remittance Advice.
The deadline to submit a claim after the date of service.
timely-filing
Parents are divorced with 50/50 custody and no court order. Both parents have the same birthday. What determines the primary plan?
The plan that has been active the longest.
A patient has $300 left on their deductible. The allowed amount is $700. After the deductible, coinsurance is 80/20.
How much does the patient owe total?
$380
A case is discharged but a claim cannot be submitted due to missing insurance information. What status is this?
DNFB; it delays billing and payment.
A claim was submitted missing the patient’s policy number. Is this a rejection or a denial, and would the biller have to appeal or resubmit?
Rejection; it can be corrected and resubmitted.
A claim is denied for lack of medical necessity. What process must be followed to attempt payment? (be specific)
clinical appeal
A child has divorced parents. Dad (DOB August 11) has full custody and is remarried (stepmom DOB June 20). Both have employer-sponsored private insurance. Mom (DOB February 17) also has employer sponsored healthcare. If the child is covered by all three plans, which is primary, secondary, and tertiary?
Primary: Dad
Second: Stepmom
Tertiary: Mom
A patient has:
Copay: $25, Deductible: $1,500 ($1,400 already met), Coinsurance: 80/20, Allowed amount: $600
How much does the patient owe?
$225
A patient is seen at an in-network emergency room for a foreign body stuck in an unmentionable body orifice. The hospital charges $2,000 and the insurance company determine the allowed amount to be $1,400. Based on their insurance information, determine the patient's responsibility for this visit.
Copay: $20 office visit, $50 ER visit, Deductible: $1,200 ($500 already met), Coinsurance: 80/20
$880