Revenue Cycle Concepts
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60 Terms
Explain the Revenue Cycle in simple terms
Register, Verify, Authorize,, Code, Charge, Submit, Pay, Bill, Collect
What is the first step in the Revenue Cycle?
Appointment/Registration
What does Appointment/Registration do?
Collect demographics and insurance, patient signs: AOB, HIPPAA notice and financial policy, collect copay
What is the second step of the Revenue Cycle?
Insurance Verification
What does insurance verification do?
Check if insurance active, and check benefits, deductible, and coinsurance
What is the third step of the Revenue Cycle?
Utilization Management (Prior Authorization)
What does utilization management do?
referrals/prior authorization, and medical necessity
What is the fourth step of the Revenue Cycle?
Coding and Charge Capture
What does coding and charge capture ?
ICD-10-CM = diagnosis, CPT/HCPCS = procedures/supplies, modifiers added, claims scrubber checks errors
What is the fifth step of the Revenue Cycle?
Claims Submission
What does claims submission ?
CMS-1500/837P Forms = professional
UB-04/837I = facility
What is the sixth step of the Revenue Cycle?
Adjudication
What does adjudication do?
Payer decides payment, sends EOB (electronic of benefits) or ERA (electronic health record)
What is the final step of the Revenue Cycle?
Patient Billing and Collections
What does patient billing/collections?
bill patient balance, unpaid = collections
What is the common front office claim denial causes?
eligibility errors, data entry mistakes
What is the common billing/coding claim denial causes?
code linkage error, no prior authorization
What is common back office claim denial causes?
missing documentation
What happens if the claim form has the wrong date of birth, and policy number?
The patient does not pay
Who are the primary stakeholders of the healthcare organization?
patients, providers, payers and policymakers
What is PHI stand for ?
Protected Health Information
What protects PHI?
electronic, paper, verbal
When can provider share PHI without consent?
TPO = Treatment, Payment, Operations
How many years can a provider retain patient’s CMS claims ?
6 years
How many years can a provider retain patient’s HIPAA documentations?
6 years
How many years can a provider retain patient’s documentation after death ?
2 years
How many years can a provider retain a patient’s Medicare Managed Care ?
10 years
What can be Implied consent ?
patient actions (no signature)
What can be informed consent?
risk explained, patient signs or declines
What can be a written consent?
high-risk procedures explained, patient signs or declines
What is Physician Self-Referral Law (Stark Law)?
no self-referrals for Medicare
What is False Claims Act ?
False federal claims (Medicare, Medicaid, TRICARE)
What is the Federal Claims Collection Act?
recover overpayments from providers
What is considered fraud?
intentional overpayments
What is considered abuse?
excessive/unnecessary payments
What does NCCI (National Correct Coding Initiative) edits?
prevent unbundling, same providers for the same day
What is a clean claim ?
no errors, complete documentation, correct claims
What is denied claims?
payment withheld, reasons on EOB/ERA
What are the common reasons if the claim is denied?
wrong ID#, wrong code, wrong date, coverage issue
What does internal audits do?
Supports the documentation for the right codes
What does external audit do?
reviews and protects the payers and government programs
What is Recovery Audit Contractor (RAC)?
recover Medicare overpayments from providers
What is Zone Program Integrity Contractor (ZPIC)?
combat fraud, abuse and waste
What does Medicare Integrity Contractor (MIC) ?
perform Medicare audits
What does Medicaid Fraud Control Unit (MFCU)?
investigate Medicaid provider fraud
What is Assignments of Benefits (AOB)?
Patient allows insurance to pay the provider directly
What is HIPAA (Health Insurance Portability and Accountability Act) ?
Federal law that protects patient health information (privacy & security)
What is Beneficiary?
Person receives benefits
What is Eligibility ?
Checking if the patient’s information is active and covers the service
What is Coinsurance?
Percentage patient pays after the deductible is met
What is Deductible?
Amount the patient must pay before the insurance starts paying
What is Utilization Management?
Insurance review to control costs and make sure care is necessary
What is Precertification (Prior Authorization) ?
Insurance approved required before certain services
What is Medical Necessity?
Proof the service is needed, diagnosis must justify the procedure
What is Linkage (Coding Linking)?
Matching diagnosis codes to procedures codes
What is the Third-Party Payers ?
Insurance companies helps pay the patient’s bill
What is Electronic Data Interchange (EDI) ?
Electronic sending of claims and data between provider and insurer
What is Fraud?
Intentional billing for services not done or false information
What is Abuse?
Excessive or unnecessary billing (not intentional)
What is Adjudication?
Insurance decides who pays what on a claim