Insights

The Accounts Receivable numbers on most hospital balance sheets are inflated. To give your organization’s finance executives accurate revenue expectations, you must ensure that your receivable is as accurate as possible. Here are three areas where revenue cycle professionals can upgrade their procedures to maximize the accuracy of expected reimbursement:

Registration/Admitting
Your patient access team plays a critical role in ensuring successful billing and collections. They should review eligibility and benefits before admission or at the time of service and request that self-pay obligations be paid ahead of time. If not paid, those obligations move to self-pay. The expected amount due by the payor should only include the expected reimbursement from the payor.

Contract Manager System
Is your contract manager software working correctly? Here are a few tips to ensure consistency and efficiency:

• Open balances allocated to a payor should equal the expected reimbursement. If the contract manager software is loaded properly, allowances will post electronically.
• If rebills are required because the patient’s payor changes, review the contract manager process, make allowances changes, and verify they are entered electronically or manually.
• Specifics for carve-out items (implants, 636 revenue code drugs, etc.) and stop/loss thresholds must be loaded correctly into the contract manager system. Verify expected reimbursement and allowances based on the payor contract language.
• If a payor uses a repricer, your contract manager system should offer the ability to select the correct repricer for the patient’s provider. Repricers have varied arrangements depending on the hospital.
• Medicare Advantage plan’s DRG codes must map to the Medicare pricer, rather than the commercial or per diem pricer. Medicare Advantage pays on the MS (medical severity), while Medicare DRG and commercial payors price via the APR (all payer refined) rates.

Complex Claim Expected Reimbursement:
Complex claims have a significant impact on your accounts receivable numbers. Based on decades of experience, our experts have identified the most difficult challenges—and they know how to overcome them. To ensure accuracy, keep these critical points in mind:

• Medicare Benefits: Medicare Part A must pay a DRG rate for the remaining days. Part B pays ancillary charges for exhausted days. The tertiary payor amount due is the contracted rate for the exhausted days less the part B only payment and any part A cost share. This complex expected reimbursement should be calculated at the time of initial billing.
• Split Claims - Two Commercial Payors: If a patient is in the hospital through a coverage change at the end of the month, split the charges and allowance accurately per the covered days.
• Coordination of Benefits: Estimated reimbursement is overstated when a patient has two payors and the primary payor payment exceeded the amount the secondary payer would consider. As soon as you receive the secondary denial, know the contracts and allowance time.
• Credit Balances: Review to determine if there is a true overpayment and adjustment needed, inflated or duplicate allowance, or hidden secondary balances due. If a refund/recap is necessary, allowance to the accurate refund amount due.