Revenue Cycle Management Billing Requirement 1) Provide a flexible schedule for the generation of patient bills based on patient type and payer/payer healthplan or medical service. 2) Provide for several customer-defined bill hold criteria by patient type and insurance type including number of days after discharge, missing data, diagnosis. 3) Continually validate that all necessary information has been entered based on payer/ payer healthplan billing requirements. Provide worklists to alerts for missing information. 4) Generate interim billing for inhouse and recurring outpatient accounts based on length of stay, account balance, or payer/ payer healthplan specifications. 5) Provide for the display of detail on the account and the patient statement including: a. Source of payment (i.e.: Insurance payment, or Blue Cross payment) b. Date of service to which the payment was applied c. Contractual allowances or not-allowed amount d. Co-payment amount e. Co-insurance amount 6) Provide for UB-04 and 1500 CMS billing forms. 7) Support electronic billing of third-party payers with automatic verification of transmittals, retransmission of corrected transmittals, and cancellation of prior transmittals. Charging
1) Provide an enterprise charge definition and pricing master file for use by all facilities and locations with on-line access for query and updating. 2) Allow the entry of multiple prices for individual Charge Master File entries with an effective date for the specific price, maintaining an accessible history of price changes and dates. 3) Automatically generate room and bed charges based on Room and Bed Master. Support room and bed charges by bed type, time increments, half days/ hourly and full day. 4) Ability to explode bundled charges into individual components for revenue and statistical reporting while maintaining a single line item for billing or detailed line items. 5) Logically group charges for the Medicare 72 hour rule, mother/baby billing, and serial billing with no manual intervention. Reimbursement 1) A contract engine embedded in the system that calculates reimbursement, adjustments, and identified underpayments in real-time without need for an interface to another system.
2) Contracting Functions a. Provide a contract file, which includes payer information including addresses, contacts, expiration dates etc. b. Sophisticated criteria for grouping together like services for a reimbursement calculation c. Contract terms are grouped into contract packages that apply to specific encounters e.g. inpatient, maternity, outpatient surgery, emergency, transplants, etc. d. Provide comprehensive reimbursement calculations in addition to DRG/APC that include other prospective payment calculations, case rate, stop loss, percentage of charges, fee schedules, volume based reimbursement, capitation, etc. e. Provide comprehensive reimbursement calculations in addition to DRG/APC that include other prospective payment calculations, case rate, stop loss, percentage of charges, fee schedules, volume based reimbursement, capitation, etc. f. Provide payment variance reporting that compares the expected payment amount to the actual payment. Account Management 1) Provide an encounter numbering system that allows the identification of admissions, visits, and/or medical episodes independently of medical record numbering. 2) Allow the identification of receivables based on various criteria including: patient or guarantor name or number, phonetic name search, address, phone number, driver s license, medical record number, social security number, date of birth, etc
3) Provide online access to the patient s complete financial history, including charges, billing dates and payers in an easy look-up format available both on a system screen and printed. Provide sorts and look-ups including: a. Patient b. Guarantor c. Patient Type d. Receivable Group e. Account Type f. Account age g. Balance range (e.g.: greater than $1000) h. Include or exclude zero balance accounts i. Include or exclude bad debt accounts 4) Allow the definition of institutional accounts against which charges for multiple patients can be posted. 5) Provide for the automatic discharge of recurring O/P accounts and the reestablishment of a new account on demand or at selected intervals. Collections 1) Support the operation of a Central Billing Office serving multiple facilities and office locations with the ability to consolidate functions while maintaining separate accounting buckets. 2) Support the operation of internal and external secondary business offices for collection of receivables. This could include external collection agencies. 3) Ability to define and monitor special payment arrangements by individual account. 4) Produce consolidated patient statements by guarantor showing all related patient or family accounts.
5) Support automatic and on-demand generation of customer-defined collection letters based on account type and aging criteria to pull in patient and account information such as: a. Patient name (separate the name into first, last, middle initial, title) b. Encounter number c. Admission Date d. Discharge Date e. Insurance payer f. Total billed 6) Electronically accept claim denials and perform tracking and appeal processing. Payments 1) Support electronic remittance for Medicare and selected insurance carrier. 2) Enable both online and batch posting of payment and adjustment transactions with adequate audit trail to ensure cash controls. 3) Support multiple point-of-service cashiering sites with separate cash draws, receipts, and balancing functions. 4) Apply payments to an account or line item level. Reporting 1) Generate enterprise reports for the health system while maintaining ability to drill down to facility and departmental information. 2) Provide the ability to store all reports, bills and statements in an integrated document imaging repository.
3) Provide AR reports by a. Service/Location b. Providers c. Patient Type d. Insurance Payer/Healthplan e. Insurance Type f. Type of Account g. Date of Service h. Age of Account i. Balance Range 4) Provide for generation of an A/R aging report sorted by delinquency period by specific information. 5) Provide friendly report writer tool and embedded analytics. Transaction Handling 1) Compliant with HIPAA 1510 requirements for transactional security 2) Handle HL7 batch, realtime communication 3) Handle EDI transaction via modem, ftp transfer 4) Maintains audit logs of user access, data transfered Billing 1. What types of claims scrubbing and transport tools are available with your system? 2. Describe how patient statements can be viewed by the consumer through the internet. 3. Describe the process for handling Primary, Straddle, Interim, Zero Balance, Rebills, Serial Bills or Demand Bills? 4. Describe how the user maintains claim edits. 5. How does the system produce a point of service bill? Charging 1. What type of online editing is available when charges are entered? 2. Describe options for time-based charging.
3. Describe how the system supports online and batch charge entry. Reimbursement 1. Describe your contract management capabilities. 2. What types of reimbursement calculations does your system provide? 3. How does your system support denial management and the appeal process?
Account Management 1. What type of aging criteria is available for accounts? 2. Describe how accounts are transferred to bad debt. 3. How are collectors and supervisors assigned to work on specific accounts? 4. Describe how revenue is reclassified. Collections 1. Describe the overall collection process for patients, guarantors and insurers. 2. Is there a Bad Debt module that is part of your system? How is it integrated into the system? 3. How do collection agencies interact with your system? Payments 1. Describe how co-payments are collected at point of service. 2. How does your system use the internet for patient payments. How are the payments posted to the revenue management system? 3. Describe how the system provides electronic remittance processing. Is it through a clearinghouse? 4. Describe the Lockbox features that are available with your system. Reporting 1. What type of analytical reporting tools are available with your system? 2. Describe the standard and user-defined reports provided with the system? 3. How does your system meet reporting requirements to external agencies? 4. Describe what types of financial reporting is available. EDI 1. What type of EDI transactions will this system handle(inbound versus outbound)? 2. Describe user access tracking 3. Describe how it meets HIPAA 1510 compliance