Admin Inspecting the Basics of the Healthcare Revenue Cycle Health Care Organizations is the industry that delivers treatment to people through different clinical departments like physicians, nurses, pharmacists, lab technicians etc. Their fundamental purpose is to provide better quality treatment at affordable price. There are different types of healthcare organizations, but here I wish to discuss about the ideal healthcare system to generate right revenue for hospitals or clinics or, in fact explain how to “Inspect the basics of the healthcare Revenue cycle” in an organization through a case study. As we know the world is at fast pace at the blink of eye so does the healthcare system, “Healthcare is constantly changing, and maintaining stable finances is at great challenge.” We always ensure and look for the timely reimbursement for the services provided by provider and also improve our communication with our payers on claims submitted. Revenue Cycle Management - “From a revenue cycle perspective, getting the most accurate information up front starts with patient scheduling and patient registration,” says Gary Marlow, Vice President of Finance at Beverly Hospital and Addison Gilbert Hospital. Revenue cycle management is a cyclic process, utilizing medical billing software that hospitals and other clinics use to track patient encounter from registration, appointments, patient documentation by providers which goes to in house staff for coding. From there, the claims are submitted, posted and adjudicated by payer for the final payment. If in case the claim is denied this goes to the denial management team and the team will look for the retrospective and prospective review of the submitted claim and then again resubmitted before the deadline. This is a normal RCM process flow. Let us now see how to Inspect the basics of Healthcare Revenue Cycle through a simple case - For example, the physician documents a case as follows: A 36-year-old G2P1 woman is second trimester pregnant and being seen for gestational hypertension. At this time, she is not having any other problems. The coder coded it as O13.2 Hypertension, complicating, pregnancy, gestational (pregnancy induced) (transient) (without proteinuria), second trimester, 09.522 Supervision elderly multigravida, second trimester. Z3A.27 Pregnancy (single) (uterine), weeks of gestation, 27 weeks. This coding is as per clinical documentation and claim submitted. Unfortunately, the claim is denied for 2 reasons- Wrong gender on claim form Weeks of gestation is incorrect Denial Reason 1 - When this claim sent to denial management team for further investigation, it was found that the gender of the patient was incorrectly selected or documented as male in the demographic form by administrative staff. Many software today, have drop down list from which staffs select, instead of manual typing. By mistake the staff has selected the wrong gender and the claim had been submitted without a quality audit in place. Claims audit and error resolution is a very important step in any RCM process which would save time and money. Errors which are resolved before submission contribute to a major percentage of preventing rejections. Denial reason 2 - The coder assumed and coded weeks of gestation as 27 weeks, even though the other 2 codes indicate second trimester. This again is lack of quality check before submission. This denial shows lack of Clinical documentation by the physician on number of weeks and also coder’s carelessness in choosing 27 weeks which is not 2nd trimester. Take away on Inspection- Need for Audit team - While Inspecting this case, both these errors could have been resolved before claim submission if an audit team was in place or if both admin staff and coder would have done a self-audit before passing it to the next team. Training - There should always be continuous training for all the staffs of RCM at least as refresher models on their daily roles. Query Management – A coder should be aware when to query the physician and not assume. Clinical Documentation – This case also shows the importance of clinical documentation training for physicians to understand the impact of revenue loss. Successful healthcare revenue cycle management strategies focus on front-end tasks to help claims move along. Many errors occur in the first stages of a patient’s account and these issues can carry through the revenue cycle to disrupt claims reimbursement.