Term
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Definition
- All administrative and clinical functions that contribute to the capture, management and collection of patient revenue.
- Why is this important?
- Many small practices are struggling financially |
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Term
| Practice Management System (PMS) |
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Definition
- Electronic Claims Submission and Accounts Receivable management (AR Days)
- Electronic scheduling, Internal HR (payroll, vacation, credentialing, education), material management (office and clinical supply chain)
- Some practices satisfied with existing PMS (often have spent considerable time and money to find a system that work for them). In this case they need an EHR that will interface with the PMS.
- Other practice choose to acquire EHR that includes integrated PMS |
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Term
| Using Practice Management Systems to Run the Office |
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Definition
- Practice Management Reporting
- Key Metrics
- Benchmarking
- Interim Reporting
- Embezzlement
- Future payment reform will mandate close integration between PMS and EHR. Payment based on ‘quality’ not fee-for-service (ACO’s)
- Bundled payments, capitation (PMPM) |
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Term
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Definition
- Based almost exclusively on encounter note documentation. EHR’s greatly improve accuracy of billing.
- Four levels of E&M codes are used for each type of visit
- Level 1 corresponds to the least complicated exam; Level 4 corresponds to the most complicated
- “Allowed payment” based on exam level |
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Term
| Seven components are used to determine the level of E&M services: |
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Definition
History
Examination
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time |
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Term
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Definition
- Penalties are assessed to offices that over code, or select an E&M level that is too high.
+ This creates a financial and legal risk for providers.
- To compensate, some paper-based offices purposely under code, or code too low.
+ Under coding creates financial losses for providers.
- Over and under coding problems are alleviated by an EHR with a standard nomenclature.
+ Software calculates the E&M based on coded entries.
+ Codes directly transfer to billing modules. |
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Term
| Posting at Point of Service |
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Definition
- Occurs while patient still present
- Allows for collection of copay
- Shortens revenue cycle (charge posting complete at day’s end)
- Often conceptual (varies by setting – as EHRs mature and providers improve skills, this could be a strong asset to improve cash flow |
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Term
| Electronic Data Interchange |
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Definition
- HIPAA standardized healthcare EDI by requiring use of standard formats developed and maintained by ANSI
- HIPAA requires specific transaction standards for eight types of electronic data interchange |
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Term
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Definition
- Use either CMS-1500 form (paper) or ANSI 837-P (electronic) transaction
+ Medicare now requires most providers to submit claims electronically
- CMS-1500 “fields” are numbered boxes called form locators
- Form includes HCPCS/CPT-4 code; associated with one or more diagnoses that justify its medical necessity |
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Term
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Definition
- Posted in both in batches and real time
- Patient payments, especially copays, posted while patient is present to generate receipt
- Insurance plan payments often posted in batches
+ May include lengthy EOB or ERA files
- Payors send one check that may have hundreds of individual claims that need to be posted back to individual accounts. |
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Term
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Definition
- Bill-hold period (Hospital wait period)
- Batch claims – submit weekly, biweekly, etc.
- 14-day delay (electronic claims) and 29-day delay (paper claims) imposed by Medicare intermediaries and other health plans
- Mistakes on claim
- Proof of medical necessity
- Secondary insurance plan billing
- Payment from patient
- Accounts receivable is uncollected money owed |
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Term
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Definition
- 1st level rejection: clearinghouse
- 2nd level rejection: insurance carrier denial |
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Term
| Accounts Receivable Management |
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Definition
- Practice should have time based strategy for working A/R
- Prioritize working largest accounts balances over 45 days old
+ Check on claim status; works towards immediate claim adjudication
- Old or uncollectable A/R should be turned over to collections or written off for reporting integrity. |
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Term
| PMS (Practice Management) Reports |
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Definition
- Practice Summary Report
+ Charges
+ Collections
+ Adjustments
- Patient Statistics
+ # of visits
+ Types of visits
+ Ratios |
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Term
| AR’s (Accounts Receivable) |
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Definition
Why work accounts receivable?
- Accounts typically lose 15% of their value every month after the first three months |
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Term
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Definition
| - The percentage of charge dollars that have been collected. GCR= Total Collections / Total Charges |
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Term
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Definition
| - The percentage of collectable dollars that have been collected. |
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Term
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Definition
| - The number of days it takes, on average for an account to be paid. |
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Term
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Definition
| - Date of service to Date of Charge Entry identifies the amount of time between the service and entry of the charge into the system. Delays in charge entry may create lost charges, increased past filling deadline denials and potential lost revenue |
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Term
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Definition
| - This is a measure of the total number of claims rejected by the payor / clearinghouse or edited for missing/incorrect data compared to the total number of claims submitted during the month |
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Term
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Definition
| - This is a measure of the total number of claims denied compared to the total number of claims submitted during the month |
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Term
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Definition
| - This is a measure of the money transferred from insurance responsibility to patient responsibility within the current month |
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Term
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Definition
| - The percentage of revenues required to meet company operating expenses |
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