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Financing for Healthcare P8-12 (P11 (Claim process (The healthcare…
Financing for Healthcare P8-12
P8
Must haves in charge form
patient information
item description
quantity
service code
acknowledgement of data entry completion
charge capture process
Centralized revenue management approach
Data entry clerks are sited in an area away from where the services are performed
A single staff is responsible for the data entry work e.g. charge analyst
advantage: sense of accountability for appropriate charging from the charge analyst
disadvantage: possibility of higher cost due the resources of a charge analyst
Decentralized revenue management approach
data entry clerks are sited in the wards or where the services are performed
A team of staff is responsible e.g doctors, nurses, PSA/PCA
Advantage: manpower need is lower through multitasking of staff
Disadvantage: daily charge reconciliation is often delayed/not performed at all as clinical staff may not understand the revenue aspect of patient care/secondary responsibility as care giver
Online interface
transactions are processed as and when they are entered
Batch interface
transactions are collected over a period of time and then process all of the transaction at once
Benefits
can shift the time of job processing to when the computing resources are less busy
avoids idling the computing resources with minute-by-minute manual intervention and supervision
keeping high overall rate of utilization, it amortizes the IT system
allows the system to use different priorities for batch and interactive work
allows effective use of manpower, key entries only once
charge entry is a service that has been performed and is pending data entry
order entry is a service that has not been performed but "ordered"
closing the bill
closure of bill refers to instruction issued to the billing system to stop accepting service entries/charge code entries for an account
service entered after a bill has been closed is termed a late charge
Late charge
for hospital billing, the bill has to be opened or cancelled if it has already been closed or billed, before any late charge can be entered
debit or credit note are not raised to manage late charges with regard to hospital billing
subvention and CCPS submission of claims will be compromised by the issuance of debit or credit notes
Packages
Item based package
a package defined by a list of items and quantity
dollar based package
a package defined by a price tag to treat a specific medical condition. it is usually further defined by list of exclusion
P9
Fee cap inpatient
to ensure that subsidized patients would not be put to excessive difficulty in meeting the revised hospital charges due to unnecessary tests/investigations
applicable for surgical operations, laboratory tests and specialized investigations, x-rays, rehabilitative services and standard medications
Subsidy cap for implant
50% subsidy for these items up to a maximum subsidy of $500 as long as the consultant-in-charge certifies that there is no other cheaper alternative suitable for the patient, irrespective of whether the implant/prosthesis is "standard" or "non-standard", except for cardiac devices for all ClassB2/C patients
help subsidized patients as previously they would need to pay full cost for non-standard implants for prostheses
GST impact for subsidized cases
subsidized patients are not required to pay the GST for their bill which include inpatients staying in Class B2+/B2/C, day surgery, outpatients (SOC and polyclinic)
funding of GST absorbed by the government healthcare institutions for these subsidized patients is provided by MOH
types of bill
unbilled stage or interim bill
the period when the bill or invoice is open to addition of new charges
Provisional bill
the period when the bill or invoice is closed to addition of new charges but it is not yet ready for generation
submitted via CCPS for claiming against, Medisave, Medishield Life and Private medical insurance
final bill
when all services rendered has been keyed in the system
when the bill returns from CPF board and is ready for generation
bill stamped with "certified true copy" and acknowledge by the staff will be treated as original copy
cancelled bill
the period when the bill or invoice is re-opened for addition of new charges
re-bill
considered as a new bill to the patient as there are changes to the charges in the bill. an original invoice will be given for rebilling
billing category
categorization code used to group service code in a pricing catalogue
bill summary code
code that is used for the purpose of presentation on a summary bill
summary bill does not display the individual items consumed for a particular episode
A&E/emergency dept bill
a single flat fee system applying to both emergency and non-emergency patients
since the amount to pay is much higher, a patient with a minor ailment should be deterred from clogging up A&E departments. this is applicable only to cash paying customers
Non-patient billing
customer referred by an external doctor to consume medical service offered by the healthcare institution
all services must be billed at full rate since no subsidy is granted
P10
shortages
important as it ensures every cent collected is banked in to the hospital account
fraud of negligence could be detected with counter collection mode
a shortage happens when the actual collection in terms of cash and other modes is less than the amount stated in the system
where a shortage is recorded, the shortage is to be topped up on the same day and banked in together with the current day's collection
cash top-up must be handed over to business office staff for bank-in
excess
any excess cash collection should be banked-in together with the current day's collection
cashier/collection staff should indicate on the counter discrepancies form the excess collection amount and an explanation resulting in the excess collection
credit card collection
cashier/collection staff is required to print the detailed and batch settlement reports from the credit card terminals
supervisor/leader has to ensure that the sales slips are duly signed by cardholder and are collated according to the detailed report
void sales slips must be submitted to business office
nets collections
cashier/collection staff is required to print the batch settlement report from the nets terminals
supervisor/leader has to ensure that the nets slips are collated according to the batch settlement report
the total count and amount of nets slips must tally with the batch settlement report and void nets lips must be submitted to business office
cancellation of receipt
any cancellation of receipt must be properly recorded in the cancellation of receipt form to be attached to the close counter statement
clinic/location manager will then verify before submitting to the business office
refund
front-end refund
where there is over-charging or collection more than bill amount and a refund is due, cashier/collection staff may process an upfront cash refund if the customer requires the refund immediately
back-end refund
for refund arising from over-charging of patient at the counters after the customer has left the vicinity of the healthcare institution, the refund is initiated through the refund request form
supervisor/executive/manager in charge at the respective department must complete and sign the form before submitting to business office
handover confirmation
the supervisor/leaders of the various service centers shall perform the handover function by generating the handover confirmation report from billing system on a daily basis
reconcile the close counter statements/summary reports to the handover confirmation report, ensuring that all discrepancies are clearly explained and adjusted where necessary
complete set of closing reports
close counter statement
vendor trust receipts (white copy)
detailed reports
batch settlement reports
credit card sales and nets slips
any other supporting documentation
cash float
is the cash given to cashier at the beginning of the day or session to provide change to be given to customers
cash float is kept in the cashier till or drawer throughout the transaction or cashier work session
P11
Common types of claims
First party claim
from patient directly
Third party claim
Patients may pay their medical bills through other agencies other than by themselves common third party payors
Civil Service
payment for employee medical benefits
Medical Claims Proration System (MCPS) - Government restructured hospitals, SOCs and Polyclinics
Medical Billing System - GPs and Dialysis Centres
Private organizations/employers/insurance companies of the patients (Letter Of Guarantee Manual claim)
CPF Board Central Claim Processing System (CCPS Mediclaim System
Medisave
Medishield Life
Intergrated Shield Plan
Claim processing
Patients bills are sent to the respective agencies for payment
Usually such claims are sent electronically via respective healthcare institution’s IT systems
Not all claims can be process successfully due to various reasons
Healthcare institutions will rectify and resubmit if error due to data entry If due to patient’s error payer), the healthcare institution will charge to patient for payment
Claim process
The healthcare institution transmits the medical claims through the electronical claims system directly to the 3rd party
Depending on the various schemes the patients is entitled to, payment will be made accordingly
Approved payments are send back to the healthcare institution
Business office staff confirmed that all claims are processed
Once full payment is received, the patient’s bill status will change from provisional bill to final bill
Billing Stages
Unbilled Interim Bill
The stage when the bill of the patients is not finalized
Charges are not confirmed or keyed in
Changes to bill is possible
Provisional Bill
When charges are confirmed and sent for claims
Changes to bill not allowed
Final Bill
Claims processed
Any changes to bill will have to raise bill amendment
Bill amendment
In the event when the bill needs to be amended, the staff will raise a bill amendment form to the business office
Amendment form needs to be approved by the relevant parties
Supervisor in charge
Business office in charge
Higher authority if amount exceeds a certain limit
Re generate the bill and submit the claim
Once approved by the relevant authorities, staff may proceed to make the necessary adjustments
Claim messages
send via the internet to the respective claim parties using HL7 messages
Health level seven (HL7), is a standard for exchanging information between medical applications
a HL7 message is generated with the necessary information once the patients is being billed
depending on the institution's requirement, these message are process real-time or by batches
Types of unsuccessful claims
Denied claims
refers to a claim that has been processed and the insurer has found it to be not payable
denied claims can usually be corrected and/or appealed for consideration
Rejected claims
refers to a claim that has not been processed by the insurer due to a fatal error in the information provided
Common causes for a claim to reject include when personal information is inaccurate (i e name and identification number do not match) or errors in information provided (i e truncated procedure code, invalid diagnosis codes, etc
A rejected claim has not been processed so it cannot be appealed Instead, rejected claims need to be researched, corrected and resubmitted
Rectification for claim rejections
Business office staff will need to amendment claim message and resubmit
Make necessary adjustments to the bill
If patient is no longer covered by the 3 rd party payer, send outstanding bill to patient for payment by other mode
Imagine how the patient will feel when this happens
Manual Submission of Claims
Some Third Party Payers do not have a electronic claims submission, e g employers of patients
In such cases, the claims for the outstanding amount is sent either by mail or by email
Ranking payers
Patients are usually asked by the hospital counter staff to “ their payers in order of preference
1, Medisave-approved intergrated shield plan
Medisave
cash
Some places may even provide a form for patients to indicate the ranking of payers formally
good idea to do this to avoid misunderstandings
The amount not paid by the highest payer will flow to be paid by the next payer rank
P12
Account types
Accounts receivable
money owed by patients (individuals or corporations) to another entity in exchange for goods or services that have been delivered or used, but not yet paid for
Accounts payable
Debts that must be paid off to another entity within a given period of time in order to avoid default. At the corporate level, AP refers to short-term debt payments to suppliers and banks
General ledger
A general ledger is a complete record of financial transactions over the life of a company. the ledger holds account information that is needed to prepare financial statements, and includes accounts for assets, liabilities, owners' equity, revenues and expenses
Profit & loss
A financial statement that summarizes the revenue, costs and expenses incurred during a specific period of time - usually a fiscal quarter or year. these records provide information that shows the ability of a company to generate profit by increasing revenue and reducing costs
Payment issues
Reconciliation issue
Payment amount may not tallied with outstanding amount
Delay in reflecting correct payment status
payment from other payment modes take longer time to clear and the billing system may not reflect the correct payment status
NETS
Cashcard is a stored-value smart card used widely in the motoring market in Sg
Flashpay card which is used for public transport payments and at NETS acceptance points in SG
eNETS online payment through online and mobile merchants
Refund
There must be a credit balance in the Accounts Receivables in order for refund to be made
scenario where a refund is required
Return of medications
service paid but not performed
lapse in service provided
over-charge of service rendered
Deposit balance from surgery
duplicate payments
Partial refund
may not be necessary be the full amount
Refund process
various documents and processes required to prior to processing a refund to a patient
investigation on whether a genuine refund is required
support documents
refund voucher. stating the reason for refund
medication refund note form the pharmacy
approval from supervisors and finance department
issues with refunding patients
limited mode of refund
mostly by cheque for cross day refund
monitoring required
staff need to monitor the different stages of refund
refund approved
cheque issued
system updated
cheque cleared
Potential fraud
cheque being issued to the correct payee
patient may claim that they did not received the refund
bank reconciliation
when the amount in the Handover Confirmation Report tallies to the amount credited to the bank, Business Office Assistant will perform clearing to the Main Bank account on a regular basis
Business Office Assistant will prepare the Bank Reconciliation monthly to be reviewed by the Supervisor and Executive
A copy of the Bank Reconciliation will be forwarded to the Finance Department for their retention
Outsourcing
institutions may choose to outsource some of their business functions to another party. for public healthcare like NHG and Singhealth, certain business functions are consolidated to Finance Shared Services (FSS) which processes for institutions under the same cluster. E.G.
bank reconciliation
refund can be processed directly from the bank
payment posting outsourced to other financing companies
debt recovery
3rd billing
issues relating to outsourcing
external parties may not have proper understandings of the business process of the institution
any rectification required by the institution may take longer time
decision to outsource may come from cluster and not necessary cost effective for all the institutions involved
Account receivable report
is a report that shows services that is rendered and payment not collected
from a management perspective, the AR reports will identify problems with your receivables management process
from a operational perspective, the AR reports identify accounts that required collection action
"working" on AR
the most common use of the AR report is for collecting overdue balances from both 3rd party payers and patients
the report should be stratified by:
the payer
age
balance amount
staff should work on the largest accounts first when making the collection effort to patients
additionally, determine the minimum level for small balance write-offs
finally, whatever system use to work on the AR, ensure that it covers each and every account
avoiding AR
the most effective way of reducing your AR is to collect charges at the time of service. all payment should be collected at the time of registration, before the physician sees the patient
Patient with co-payment (e.g. the 80% of the insurance, 20% out of pocket by patient) could be charged at the time of service
provide staff at the checkout with the insurance payment schedule for those services provided, along with the pre-calculated co-payment amount