Revenue Cycle Time Line: Revenue Capture and Claims Control

This article has links to allow easy access time line content from Scheduling to Bad Debt Recovery. Use this information as a starting point for planning, SWAT Analysis, or to review policies and procedures for gaps. Create a time line for your facility to assure all participants share the same expectations.

Goals:

· Accounts are billed on the first day past “Bill Hold” days

· Exceptions are monitored and controlled

· Revenue codes billed are appropriate for services provided based on payer reimbursement requirements

· Late charge issues are reviewed and resolved

Activities and Considerations:

Managing accounts in transition from discharge to bill date is overlooked by some organizations. At minimum, failure to manage these accounts results in unnecessary billing time lags; poorly managed DNFB accounts will result in losses due to original claims filed past the timely filing deadline. Build up of accounts greater than the bill hold is often an indicator of broken processes in charge capture and abstracting/encoding.

DNFB

Daily reports of all accounts not billed should be available and reviewed for reasons, associated dollars and opportunities to improve. Most computer systems provide bill edits that report by type of edit to individuals responsible for updating claim data. Daily review should include both inpatients and outpatients (usually based on some service type to accommodate recurring patient care spanning a month of service).

Late Charges

Most hospitals confuse “late charge claims” with “late charges.” Late charges should be defined as any charge entered in the system after the profiled “bill hold days” for charge entry lags has expired. Reports should be configured to review for late charges and credits posted later than the bill hold days.

Claim Corrections and Controls

Claims editing systems include some host systems with very well-developed core product that handles bill edits, to other systems that provide basis edits and anticipate the use of third party claim editors.

If billing edits occur in a claim scrubbing system, the transfer of claims from host to the sub-system MUST be reconciled on a daily basis. Documentation should be clear. Consider whether the modified claim data should be uploaded to the host system (so the Host can be used as the core decision support system).

Regardless of the whether occurring on the host system or a claim sub-system, the data report systems should be configured to monitor:

· Count and amount of claims billed outside the bill hold threshold (preferably by final hold reason e.g. diagnosis coding, procedure coding, bill edit flag, insurance verification, open order, etc)

· Average Age from LDOS to date claim received in Claims sub-system

· Number of accounts with revenue changes made after the initial bill

· Count and Amount of Claims Requiring Attention due to edit errors

· Count and Amount of errors that were worked today

· By type of error

· Count and Amount of Claims Transmitted to Payers

· Count and Amount of Claims Deleted

· Count and Amount of Claims in Final Inventory

· By Payer

· By Reason Code

· By Biller

· Individual Production Report (user) day, week, month\

· Count of edit errors by type (one claim may have more than one error)