ABSTRACT
Introduction ......................................................................................................................................66 Issues Impacting the Revenue Cycle ............................................................................................... 67 Impact of Regulations, Laws, and Healthcare Reform ....................................................................68 Organizational Structure ..................................................................................................................69 Benchmarking ..................................................................................................................................69 Technology ....................................................................................................................................... 70
Patient Access .............................................................................................................................. 71 Health Information Management ................................................................................................ 71 Patient Financial Services ........................................................................................................... 71
Revenue Cycle Operations .............................................................................................................. 72 Front-End Processes ......................................................................................................................... 72
Pre-registration ............................................................................................................................ 72 Scheduling ................................................................................................................................... 73 Patient Access and Registration ................................................................................................. 73 Pre-authorization, Pre-certification, and Insurance Verification ................................................. 73 Point-of-Service Collections and Financial Counseling ............................................................. 74
Middle Processes ............................................................................................................................. 74 Clinical Documentation/Medical Records .................................................................................. 74 Charge Capture and Coding ........................................................................................................ 75 Charge Master and Master Patient Index ................................................................................... 75 Late Charge Reductions .............................................................................................................. 76 Case Management ....................................................................................................................... 76
Back-End Processes .........................................................................................................................77 Billing: Primary and Secondary Insurance .................................................................................77 Reimbursement, Posting, Refunds, and Adjustments .................................................................77 Follow-Up/Tracking .................................................................................................................... 78 Denial Management .................................................................................................................... 78 Bad Debt and Collections............................................................................................................ 79 Customer Service: Front, Middle, and End Processes ................................................................ 79 Management Expectations .......................................................................................................... 79
Performance Measurements .............................................................................................................80 Revenue Cycle Improvement Processes and Quality Measures ......................................................80 Conclusion .......................................................................................................................................80 Acknowledgments ............................................................................................................................ 81 Appendix 1 ....................................................................................................................................... 81
For many years, hospitals and healthcare organizations have struggled to maintain and improve their operating margins. They continue to face a widening gap between their operating costs and the revenues required to cover current costs as well as the costs to finance strategic growth initiatives and investments. Faced with increased operational costs and associated declines in rates of reimbursement, many healthcare hospital executives and leaders are concerned that they will not achieve margin targets. To stabilize the internal financial issue, some hospitals have focused on lowering expenses to save costs-an area they control and an area that will show an immediate impact; that is not, however, the best solution. Executives are concerned with the effect that these reductions may have on patient quality and service. Finding ways to maximize workflow to lower operating costs is vital. Every dollar not collected negatively impacts short-and long-term capital projects, lowers patient satisfaction scores, and possibly affects quality of patient care.
