Hospital Revenue Cycle Management Health Systems Management Sylvia

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Hospital Revenue Cycle Management 医院营收周期管理 Health Systems Management 医疗系统管理 Sylvia Pan United Family Hospital

Hospital Revenue Cycle Management 医院营收周期管理 Health Systems Management 医疗系统管理 Sylvia Pan United Family Hospital and Clinics Vice President

The Revenue Cycle is the how a medical facility is reimbursed for its services

The Revenue Cycle is the how a medical facility is reimbursed for its services 营收周期是指一个医疗机构从提供服务开始, 到获 得收入补偿的全过程 - usually the first and last encounter a patient has with the institution. 通常患者在医院最先和最后接触的都是从事这项 作的人员 (如: 前台, 收银人员)

Revenue Cycle Overview

Revenue Cycle Overview

Admissions -Registration 患者 – 登记 Note that cashiering is not under admissions.

Admissions -Registration 患者 – 登记 Note that cashiering is not under admissions.

Registration 注册登记 • Registration is the collection of the appropriate demographic information to required

Registration 注册登记 • Registration is the collection of the appropriate demographic information to required to submit a clean claim to a insurance provider. Two types of registration: 注册登记是为了获取适当的信息, 向保险公司提交清晰的资料. 分 为两种: 1. Pre-registration: Where the facility had advance notice for the elective procedure. 预先注册: 医院可以预先通知为某个诊疗进行注册 2. Site Registration: Registration that occurs at the time of service. 定点注册: 在提供服务时进行注册

Demographics 登记注册的内容 • Name, address, phone number, email 姓名, 住址, 电话号码, 电子邮件地址 • Insurance

Demographics 登记注册的内容 • Name, address, phone number, email 姓名, 住址, 电话号码, 电子邮件地址 • Insurance carrier, identification number 是否购买保险, 保险号 • Emergency contact 急沴联系人 • Referring physician 推荐医生 • Employer 雇主 • Guarantor 保证人

Eligibility Determination 患者支付能力的确认 Insurance Verification – 保险审核 - Is their insurance coverage valid, 是否在有效的保险期内

Eligibility Determination 患者支付能力的确认 Insurance Verification – 保险审核 - Is their insurance coverage valid, 是否在有效的保险期内 is it credible 是否可信 does it cover these services 是否属保险公司有效赔付范围内 Pre–Certification – Does the procedure have to be pre-certified by the insurance company. 预先通知 - 确认该诊疗是否需要预先通知 保险公司 Do they have a co-insurance or deductible 确认患者是否有自付部分或绝对免赔额

Registration Collections 注册信息 • Does patient have co-pays, deductible or coinsurance ? 确认患者是否有自付部分或绝对免赔额 –

Registration Collections 注册信息 • Does patient have co-pays, deductible or coinsurance ? 确认患者是否有自付部分或绝对免赔额 – Must know payer contracts 务必了解付款者的合同 – Review insurance cards 核查保险卡 – Build into pre-certification process 设定预先通知系统 • Does patient have balances due on other service? 确认患者是否有其它到期未付的诊疗费 • Delay or deny service if they can’t pay? 如患者不能支付费用,是否需要延期或拒绝提供服务

Charge Capture 收费信息的获取 • Charging accurately for the services and supplies used to treat

Charge Capture 收费信息的获取 • Charging accurately for the services and supplies used to treat the patient. 确保对所提供的服务和治疗用品准确收费 – Super Bills 帐单 – Bar Coding 条码 – Manual entry to I/S system 人 录入I/S系统

Late Charges 延期的收费 • Charges entered after bill has been created 开出帐单后, 录入费用 •

Late Charges 延期的收费 • Charges entered after bill has been created 开出帐单后, 录入费用 • Require rebilling 与保险公司再次核对赔付额 – Some insurers will not accept • Late Charge Reports – Tracking 建立延迟支付保费报告, 并对支付进行跟踪 • System based electronic charging eliminates most late charges 系统应尽量杜绝延迟支付的费用

Late Charges 延期的收费 Days of charge entry lag date of service - date of

Late Charges 延期的收费 Days of charge entry lag date of service - date of charge entry = days of lag 医疗费用录入天数 = 提供服务日 – 费用录入日 should be 0 or 1 (with some exceptions) 应为 0 至 1 天 ( 否则需要解释原因)

Charge Capture Metrics收费信 息获取指标 Number of Missing Charges number of missing charges/ total number

Charge Capture Metrics收费信 息获取指标 Number of Missing Charges number of missing charges/ total number of appointments = % 丢失收费数量/预约人数的比值 in outpatient setting should be close to 0% 门诊情况应该接近 0

Hospital Charge Master医院收费总目录 A hospital-specific computer file that includes all hospital procedures, services, supplies

Hospital Charge Master医院收费总目录 A hospital-specific computer file that includes all hospital procedures, services, supplies and drugs that can be billed to payers. 具体医院的收费总表包括操作、服 务消耗品和药品 Each record listed in the charge-master file has five corresponding data items: 每个条目包括五个项目:项目 和说明、部门或成本中心、HCPCS代码、收入代码、价 格

Hospital Charge Master Sample 医院收费样板 Charge Code Description GL Dept HCPCS (cost center) Revenue

Hospital Charge Master Sample 医院收费样板 Charge Code Description GL Dept HCPCS (cost center) Revenue Code Charge 70117 CT Scan; Head; w/out contrast 7011 70450 350 (Radiology) $955 70118 CT Scan; Head; with contrast 7011 70460 350 (Radiology) $1075 60223 OR Level II Operation 1 minute 6022 Transferred from Medical Record 360 (OR) $45 602236580 Orthopedic Total Knees 6022 G 0860 360 (OR) $5950 101045368 CEFAZOLIN 1 GM INJ 1010 J 0690 250 (Pharmacy) $45

Medical Coding 医疗编码 • Converting or capturing the patient encounter in an agreed upon

Medical Coding 医疗编码 • Converting or capturing the patient encounter in an agreed upon numeric representation. 将患者的就 诊经历转化为用数字代码

Codes编码种类 • • • DRG ICD-9, ICD-10 Procedural Revenue CPT Evaluation and Management

Codes编码种类 • • • DRG ICD-9, ICD-10 Procedural Revenue CPT Evaluation and Management

Coding Metrics 编码规范 Dollars of Rejections for Coding 由于编码错误而遭拒付的帐款 dollars of coding rejections/ total

Coding Metrics 编码规范 Dollars of Rejections for Coding 由于编码错误而遭拒付的帐款 dollars of coding rejections/ total dollars rejected claims = % 编码引起的拒付款项/ 所有拒付款项= %

Billing Job Description 帐单核审员的 作 • • • Review accounts to verify insurance 确认帐户保险

Billing Job Description 帐单核审员的 作 • • • Review accounts to verify insurance 确认帐户保险 Review account coding for completeness 进一步确认编码的完整 Obtain missing or incomplete data to complete the bill 补齐帐单中缺失的信息 Submit claims(electronically or hard copy) 电传或邮寄帐单 Document billing activity 记录保存所发送帐单的一切信息 Track trends miscoding of insurance or other fields 查询保险或其他方面的错误编码

Secondary Billing 第二次发帐单 • Primary Insurance Pays • 主要保险理赔后 • Second to primary is

Secondary Billing 第二次发帐单 • Primary Insurance Pays • 主要保险理赔后 • Second to primary is secondary insurance or patient responsible for • 第二保险或病人应付款项包括 – Deductible绝对免赔额 – co insurance 病人自付额 • Must bill with Explanation of Benefits of primary insurance • 要寄送第一家保险公司的赔额细节及受益 说明

Biller Quality-Productivity 帐单核审员的质量及效率 • Accounts billed per day/ week • 每周每天寄送帐单数 – Electronic submission

Biller Quality-Productivity 帐单核审员的质量及效率 • Accounts billed per day/ week • 每周每天寄送帐单数 – Electronic submission 100 -125 day电子寄送: 100 -125/天 – Paper claims 25 -50 day 书面材料寄送25 -50/天 • . 98% of accounts that are billable are billed to the correct payer • 98%的帐单准确寄送到保险公司 • No backlog of unbilled accounts • 无积压帐单

Patient Bills 病人的帐单 • Easy to read • 易读 – – – balance due病人应付余额

Patient Bills 病人的帐单 • Easy to read • 易读 – – – balance due病人应付余额 date of service看病日期 account number帐号 summary of service服务摘要 patient 病人 reflect all prior payments adjustments显示所有以前付款的调 整 • Do not need itemization with detail unless requested • 除非病人要求,否则不必显示具体细节

Payments 付款 • • • Bank transfer, 银行转帐 Checks by mail 邮件支票 Credit cards信用卡

Payments 付款 • • • Bank transfer, 银行转帐 Checks by mail 邮件支票 Credit cards信用卡 Checks to a lockbox投交支票 Cash现金

Cash Application The posting of payments to patient accounts. 冲帐 • Separate function from

Cash Application The posting of payments to patient accounts. 冲帐 • Separate function from billers and collectors to maintain segregation of duties. 分开帐单寄送员和帐款应收员的职 责 • Control underpayments. 控制缴付不足及 少付 • Apply contractual allowances. 按照合约规 定的偿付

Collections收帐 • Facilitation the receipt of money the institution would not receive without the

Collections收帐 • Facilitation the receipt of money the institution would not receive without the collectors effort. • 更有效地追收帐款是离不开帐款追 收员的努力

Collector Job Description 帐款追收员的 作 • Seek payment from insurance and patient (payers) •

Collector Job Description 帐款追收员的 作 • Seek payment from insurance and patient (payers) • 向保险公司和病人收取帐款 • Resolve conflicts or issues of missing data with payers • 协调解决因付款事宜及丢失的数据与病人及保险 公司产生的矛盾冲突 – work effectively with internal departments – 有效协调医院各部门之间的 作 • • Track trends leading to payer denials disputes 追踪处理被付款方拒绝赔偿的款项 Document collection activity 记录收款过程的信息

Collections: Metrics: 收款规范 Key Reports主要报告 • Aged Trial Balance -monthly Charges, Payments (receipts) and

Collections: Metrics: 收款规范 Key Reports主要报告 • Aged Trial Balance -monthly Charges, Payments (receipts) and adjustments aged A/R per Month ( separates the A/R by "aging buckets, " i. e. , 0 -30 days, 30 -60 days, etc. ) • 过期帐款的试算平衡表——每月应收帐款,每月实收 帐款和每月挂帐数额的调整(挂帐数额按0 -30天,3060天依此类推的时间跨度来分期) • Gross and Net Collection Rates (by month) • 每月收帐款总额和净收率 • Total A/R and Days in A/R Trends • 挂帐总额及总天数 • Total A/R and Days in A/R Trends by Major Payer • 每个付款方挂帐总额及天数

Gross Collection Rate 总收款率 How much money is collected on the charge for the

Gross Collection Rate 总收款率 How much money is collected on the charge for the service. 医院在提供服务当天所收帐款 Total Payment / Gross Charges = Gross Collection % 付帐总额/ 收费总额=追收帐款百分比 • Hard to pick target depends on payers and contracts. • 这个比例取决于付款方及合同

Net Collection Rate 净收款率 How much money is collected on what can be collected

Net Collection Rate 净收款率 How much money is collected on what can be collected (is not contractual write off). 实际追收帐款占可以收取的帐款的百分比(其中可 收取的帐款不包括有合约的注销帐目) Total payments / (Gross charges-adjustments) = net collection% 收款总额/ (总收费-调帐总额)=净收帐款百分比 • Should be 100% • 应为 100%

Collection Time Line 收款安排(Sample) • Day 1 - Account Billed • 第一天----寄帐单 • Payment

Collection Time Line 收款安排(Sample) • Day 1 - Account Billed • 第一天----寄帐单 • Payment may take 17 -90 days depending on payer location and edits • 付款时间应在 17 -90天不等取决于付款方不同地区及处理 过程 • Day 17 -90 follow up #1 • 第 1次追帐应在第 17 -90天 • Day 24 -94 follow up #2 • 第 2次追帐应在第 24 -94天 • Day 31 -103 follow up #3 第 3次追帐应在第 31 -103天 • collections/ write off之后应做注销

Self-Pay Collections 自付费的收款 • Uninsured patients无保险患者 • Denied claims保险公司拒付 • Balances after insurance保险公司 支付的差额

Self-Pay Collections 自付费的收款 • Uninsured patients无保险患者 • Denied claims保险公司拒付 • Balances after insurance保险公司 支付的差额

Denials Management 拒付管理 • Responsible for reviewing all denials负责 审核所有拒付 • Filling appeals and

Denials Management 拒付管理 • Responsible for reviewing all denials负责 审核所有拒付 • Filling appeals and recovering funds重新 申请理赔 • Tracking trends追踪升降趋势 • Conducting root cause analysis of trended data 对趋势数据进行根本原因分 析 • Working with departments and payers to prevent future denials与各科室和支付方 合作减少拒付的发生

Write-off 坏账注销 All final denials “written off” should be tracked. 最终所有的注销应被追踪及记录 Standards: Final denials

Write-off 坏账注销 All final denials “written off” should be tracked. 最终所有的注销应被追踪及记录 Standards: Final denials are defined as denials where all appeals have been exhausted (denial management had reviewed). It is strongly suggested at least two appeals be done before write off consideration. Remind: contact the local tax bureau for the business tax refund for the write-off at the year end. 标准: 最终的拒付是经过所有努力得不到偿还的案例(拒付管理已 经评审)。强烈建议只有在两次重新申请失败后才考虑选择 注销。 提示: 年终应就注销坏账部分的营业税退缴问题联系当地税务局 ( 非常重要)

上海和睦家医院 Shanghai United Family Hospital 2004年 11月开业

上海和睦家医院 Shanghai United Family Hospital 2004年 11月开业

上海和睦家医院 Shanghai United Family Hospital

上海和睦家医院 Shanghai United Family Hospital

上海和睦家医院 Shanghai United Family Hospital

上海和睦家医院 Shanghai United Family Hospital

 • 谢谢。请访问我们的网站 • www. unitedfamilyhospitals. com

• 谢谢。请访问我们的网站 • www. unitedfamilyhospitals. com