The Function Of The Revenue Cycle

The basis of the revenue cycle in Epic is the Hospital Account Record, often abbreviated as the HAR.

The revenue cycle represent the flow of cash from the beginning to end and source. For any business large or small, public or private the revenue cycle is critical. In a hospital setting the revenue cycle begins at the time the patient first presents for treatment and is registered as a patient. This is “depicted within the text in Figure 2-1 as six stages- provide services, document services, establish charge, prepare claim/bill, submit claim and receive payment” (Cleverley, Cleverley, & Song, 2012, p. 14). Accuracy of information entered is paramount because the record created starts is the foundation for all future billing. If the wrong insurance information is documented time is lost on the back end of the cycle contacting the patient to update their

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

Accelerating cash collections at the point of service has never been more critical than it is today. Sophisticated accounting tools that enable providers to analyze patient utilization and outcomes help practice managers monitor payer performance and evaluate external contracts effectively. Growing financial pressure to strive toward more efficient claims flow through the revenue cycle means every provider must search for innovative tools to overcome the challenges.

Reimbursements are a source of revenue for hospitals; payers do not pay a full price for services.

Many health care organizations have issues keeping track of contracts and as a result lose control of monetary outflow. Compliance 360 mitigates this loss of control through the maintenance of contracts through a central portal (SAI Global, 2018). For money managers, this feature is incredibly valuable and allows the organization to control spending through reductions in redundant services.

Over the past fifty years, the method in which healthcare services are funded has gone through significant changes. The country has seen the expansion of insurance from paying medical bills for hospital stays, to the creation of managed care, and the passing of the Affordable Care Act (ACA). While the process has not been without challenges, healthcare administrators must continue to analyze past funding systems to understand the oversights and misinterpretations to prevent complications in the future. This paper will investigate fee-for-service practices and how these practices have progressed to uncontrolled utilization.

The CMS reimbursement rules for never events cause serious revenue loss for the hospitals, hence a shift in the patient care delivery model in inpatient facilities is required. The goal of this rule is to motivate hospitals to accelerate improvement

Although the ACA will make revenue cycles more complex for hospitals, possibly lengthen the revenue cycle, and have complicated payment responsibilities I do think it will give providers the opportunity to improve and excel by adapting the new revenue cycle management (RCM) and acquiring new capabilities that can give them the opportunities to thrive.

Revenue determination is an important tool for health care organizations because it allows for efficient management of payment systems. This paper will look at the different components that form the payment-determination bases of revenue determination. Moreover, the difference between specific and bundled service payments will be discussed. Lastly, the three ways health care providers control their revenue function will be highlighted.

Revenue cycle management (RCM) has become increasingly complex thanks in large part to the almost-constant health care reforms and initiatives. As ICD-10 is about to become the new coding standard, hospitals and private practices have begun arming themselves with as many tools and techniques as they can that will help them better manage their revenue cycles.

In the medical billing revenue cycle, there are ten steps. The first step is patient preregistration where a patient schedules a visit and their insurance is either verified or on file. The second step is to determine the patient’s payment when visiting the provider and the reason for their visit. Next is to check the patient in upon arrival at their visit. This is to verify the insurance and the identity of the patient. The patient is checked out after seeing the provider and charges for services will show on the superbill. After this, the medical biller takes the patient’s superbill and creates a claim. From here, the biller must ensure that the claim is compliant with coding and arrangement. From here, the claim is prepared and finally

Within this organization, revenue is generated from the services given to patients and the medication given to them. Services such as, Social services, dietary, physical therapy, occupational therapy, speech therapy and nursing services. Medication distributions and ancillary services impact revenue and reimbursements.

There is a lack of ownership between Utilization Management and Revenue Cycle to ensure these short inpatient stays are billed correctly.

The major difference between healthcare finance terminology and business finance terminology is that these terms focus on factors unique to the health services industry. For example, the provision of health services is dominated by not-for-profit or¬ganizations (such as ours), which are inherently different from investor-owned businesses. Also, the majority of payments made to health¬care providers for services are not made by patients—the consumers of the services—but rather by some third-party payer (e.g., a commercial insurance company or a government program). Even the purchase of health insurance is dominated by employers rather than by the individuals who receive the services. These terms emphasize ways in which the unique features of the health services industry affect financial decisions. The healthcare industry is a service industry. It is not in the business of manufacturing, say, widgets. Instead its essential business is the delivery of healthcare services. It may have inventories of medical supplies and drugs, but those inventories are necessary to service delivery, not to manufacturing functions. Because the business of healthcare is a service, this overview of key healthcare terminology will focus on the practice of financial management in the services industry.