Classification & Reimbursement - price transparency

AB202019_Ch09.pptx

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Principles of Healthcare Reimbursement and Revenue Cycle Management Chapter 9: Revenue Cycle Front-End Processes—Patient Engagement

Anne Casto, RHIA, CCS

Susan White, PhD, RHIA, CHDA

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Learning Objectives

Describe the processes included in the front- end of revenue cycle component

Analyze patient financial agreements

Explore the scheduling and registration process

Understand the impact of cost sharing on the patient’s financial position

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Revenue Cycle

Revenue cycle: regular set of tasks and activities that produce reimbursement

Revenue cycle management: the supervision of all the administrative and clinical functions that contribute to the capture, management, and collection of patient service reimbursement

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Front-End Processes

Patient Engagement

Middle Processes

Resource Tracking

Back-End Processes

Claims Production and Revenue Collection

Front-end Processes—Patient Engagement

Begins with the patient schedules services

Ends when the patient registers at the point of care

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Schedule services

Prior authorization (if required)

Registration

Financial counseling

Scheduling Services

Contact the healthcare provider

May schedule via a patient portal

Investigate cost sharing (out-of-pocket costs)

May receive pretreatment cost estimate from provider

Price transparency

Federal and/or state regulations require providers to make their standard or list prices available

Review figures 9.2 and 9.3 from textbook

Review example 9.1 from textbook

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Prior Authorization

P A Tips

Check P A requirements before providing services or sending prescriptions to the pharmacy

Establish a protocol to consistently document data required for P A in the medical record

Select the P A method that will be most efficient, given the particular situation and health plan’s P A options

Regularly follow-up to ensure timely P A approval

When a P A is inappropriately denied, submit an organized, concise, and well-articulated appeal with supporting clinical information

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Prior Authorization (P A)

P A is a process of obtaining approval from a health insurance company before receiving healthcare services

P A is a method of controlling the cost of care

Patient Intake

Patient registration

Collection of data

Patient’s medical history

Insurance coverage

Image of insurance card—stopgap to correct data entry errors

Agreement to fulfill financial obligations

Patient financial responsibility agreement

HIPAA authorization form

Advance beneficiary notification of noncoverage (A B N)

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Patient Financial Counseling

Healthcare payment plans

Healthcare loans

Payment support from manufacturers

Drug copay cards

Not available to patients with government-sponsored health insurance

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Patient Connection

Olivia’s husband, Tony, was prescribed a new drug for his asthma. The drug is not on the Super Payer formulary and therefore the copayment amount is 30 percent of the $3,110 price each month.

Olivia and Tony were able to locate information about a copay card that would reduce the copayment amount to $0 for the drug.

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