Unit 1 Lesson 1: Revenue Cycle & Regulatory Compliance

Vocabulary flashcards covering key terms from Unit 1 Lesson 1: Revenue Cycle & Regulatory Compliance.

Revenue Cycle

The process by which a healthcare office gets paid for services, from scheduling to final payment; involves office staff and clinicians; requires ongoing checks to prevent payment delays.

Accounts Receivable (AR)

Money owed to the healthcare office by patients or insurance companies.

Revenue Cycle Management (RCM)

The coordinated set of activities—charge capture, claims submission, payer adjudication, payment posting, and collections—that ensures timely reimbursement.

Phases of the Revenue Cycle

1. patient registration

2. charge capture

3. claims submission

4. payer adjudication

5. payment posting

6. collections

step 1 - patient registration

takes place before the patient is seen by the provider:

1. basic demographic and health information

2. check patients insurance and what is covered

3. copays

4. sign required forms

5. insurance verification

patient consent for treatment form

legal permission to evaluate and treat

Notice of Privacy Practices (NPP) form

explains how a healthcare provider or health plan can use and share you protected health information (PHI)

Financial policy form

explains how payment and billing will work for both patient with insurance and those without

Assignment of Benefits (AOB)

gives permission for a healthcare provider to bill the patients insurance company directly

Medical record release forms

gives written permission for healthcare facility to share patients medical records with someone else

Patient Information Form

Photocopy id card/drivers license and insurance card

Insurance Verification

Verify eligibility from beneficiary and policyholder

• Name

• date of birth

• insurance member id number

Out-of-Pocket costs

includes:

• copay

• deductibles

• coinsurance

Step 2 - Charge Capture

1. Documenting (coding) the medical services or treatments

given to the patient.

2. Sending those charges to the patient’s health insurance

company for payment.

3. Asking the provider questions when there are any questions

about the provider's notes.

Encounter form

codes usually comes from a preset form or found through a code search in the EHR

Electronic Health Record EHR

(Electronic Health Record) is a digital version of a patient's paper chart, providing real-time, patient-centered records that make information available instantly and securely to authorized users.

modifiers

additional codes added to procedures that provide more detail about the services performed.

Chargemaster

A list of all services, tests, procedures, and supplies a patient might receive

Step 3 - Claims Submission

Clearinghouses generally get involved to assist with claim scrubbing and identifying any errors in the claims. Types of errors they look for include:

• Diagnosis code errors

• Insurance ID issues

• patient spelling errors

Electronic Claim Submission (preferred)

Use the electronic health record (EHR) to create and send the claim

to the insurance company using the 837P format.

• Use the Electronic Data Interchange (EDI) system to submit claims electronically.

Paper Claim Submission

Use the information from the encounter form, check and add it to

the patient’s account.

• Then, use the CMS-1500 form and mail it to the insurance payer.

Step 4 - Payer Adjudication

After claim is sent:

• 1. Approved

• 2. Deny

• 3. Adjust

Most payments are made within 10 to 30 days,

but allow 30-45 days to receive payment.

Explanation of Benefits (EOB)

to the patient

• What medical services were billed

• What the insurance paid

• What the patient still owes (copays or deductibles)

EOB is NOT a bill, but they help patients understand what they might be billed for

Electronic Remittance Advice (ERA)

to the provider’s office

• Patient name

• Date of service

• Amount charged

• What was paid

• What was denied and denial codes

• Any adjustments to the claim

• Patient responsibility

Step 6 - Collections

unpaid bills - bad debt