Introduction

It is safe to postulate the relative importance of the revenue cycle to every medical practice. Hospitalist Medicine is no exception, but there is room to argue that it may, in many hospitalist programs, receive lower prioritization and therefore less attention than warranted.
 

Revenue Cycle Defined

We define “Revenue Cycle” as all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue. In other words, Revenue Cycle is the complete spectrum of a patient account from its initial creation to final payment – plus the added dimension of Provider Credentialing.
 

Revenue Cycle Elements

We believe the revenue cycle of a hospitalist program is comprised of the following elements:

• Provider Credentialing with Insurance Companies
• Hospitalist Clinical Documentation (H&P, Progress Notes, Discharge Summaries, etc.)
• CPT Code Assignment Process
• Daily Charge Reconciliation
• Program Charges for CPT Codes
• Claims Submission to Insurance Companies
• Effective Follow – Up with Delayed/Denied Claims
• Billing and Collection of Self-Pay Balances
   

 Factors Impacting Revenue Cycle Results

Many factors affect tangible results within a given Hospitalist Program’s Revenue Cycle, such as:

• Timeliness of Provider Credentialing
• Variety of Insurance Companies (“Payor Mix”)
• Accuracy and Specificity of Clinical Documentation
• Patient Acuity Levels
• Reliance on Paper Documentation of Charges (vs. Charge Capture Software)
• Failure to Daily Reconcile Patient Encounters with Patient Charges
• Timeliness of Charge Submission
• Accuracy and Timeliness of Claims Submissions
• Timeliness of Insurance Follow Up
• Patient Awareness of the Hospitalist Service as it relates to “Balance Billing”
   

Revenue Cycle Importance 

About 50% of the income necessary to support the typical hospitalist program is derived from patient collections (the balance comes in the form of host facility financial support). The last thing that a hospitalist program needs is to provide patient services and not be paid due to internal inefficiencies. Patient care must remain the number one priority. But a highly effective revenue cycle function contributes to patient care in that program sustainability is enhanced. The Revenue Cycle is of great importance to hospitalist programs, and is impacted by the performance of Providers, Administrative Staff, and the Billing/Collections Team.