COMPLIANCE AND THE REVENUE CYCLE合规性和收入循环.ppt

COMPLIANCE AND THE REVENUE CYCLE – What Does the Compliance Officer Need to Understand About the Risks? PRESENTED BY: TAUNA SHELTON MHSM,MS,CHC REGIONAL DIRECTOR COMPLIANCE AND PRIVACY THR REVENUE CYCLE PROCESS Who is involved in the Revenue Cycle? Scheduling Pre-Registration Registration Verification Financial Counseling Charge Capture Documentation Coding Bed Control Billing Payment Posting Account Follow-Up A/R Management Contracting Medical Records/ HIM Case Management Utilization Review IT Clinical Areas EACH DEPARTMENT PROVIDES OPPORTUNITY FOR ERROR AND RISK Scheduling Pre-Registration: patient screening for demographic information, verification of orders, insurance, insurance approval for OP procedures – will ABN be needed for Medicare patient because diagnostic test does not meet medical necessity? Registration Verification: verifying patient identity, insurance card (Is patient the person presented, or is this a fraudulent use of identification to obtain services by using someone else’s insurance card?) (Medicaid / Medicare), fraud perpetuated via follow up services? or case of identity theft by patient or even entity staff ? ERROR OR RISK (cont) Financial Counseling: financial screening for self pays or charity care supported by organizational Charity Care Policy and state laws Charge Capture: are the correct charges for services provided, including number of charges actually being placed onto the patient’s account (medications, procedures) including overcharging, undercharging, lost charges or charging for services not provided? ERROR AND RISK (cont) Documentation Coding: Physician notes, Nurses notes, ancillary staff notes supporting the ordered services detailed enough to provide substantiation to an auditor ? Bed Control: placement of patient in correct bed based upon order timed by physician, patient transfers? Billing: billing the correct patient on the correct account, correct number of services? CHARGEMASTER updates for each service, b