Revenue Cycle Operations Consist of Several Areas

My work site and current employer is The University of Texas Medical Branch in Galveston, TX. UTMB has a rich history that first started in 1891 as the nation’s first medical school and hospital under a unified leadership. 125 years later, UTMB is a 5-star academic health science center with four schools of advanced study, three campuses with a large network of clinics, and a world-renowned research enterprise. UTMB has about 100 primary and specialty clinics throughout 50 locations and has a Level 1 Trauma Center which is one of only three in Southeast Texas.

  At UTMB I work in Revenue Cycle Operations on the Physician Billing and Denials Team. The Revenue Cycle Operations consists of several areas that all specialize and contribute to the flow of the department.

According to UTMB (2018) The RCO Registration Team is the first point of contact for the patient and the first step in the revenue cycle process. This team provides face to face contact or by telephone for arrival registration, bedside registration, resource identification, Point of Service Collections, eligibility verification, transplant registration, off site and special account registration, notification of admissions, pre-authorization for day surgery and most ancillary procedures. The Coding Team captures all the healthcare encounters by data interpretation and encounter documentation. The Systems Reporting Team provides data trends to ensure clean claims and prevent denials. “The Revenue Cycle Claims & Solutions team is responsible for timely billing and processing for all of our hospital and professional claims, as well as the fiscal mitigation of our special contract relationships and the financial management of our UTMB research accounts.”

The Billing department also assists patients with inquiry requests, assisting with payment options, and financial assistance. The Hospital and Physician Denials Management Team is responsible for managing claim denials, determining the root cause to increase revenue. “The Single Billing office is the last stop in healthcare billing, as they are responsible for finalizing patient payments among many other things such as payment plans, bad debt, liens, refunds and customer service. This team is also the most post-care patient facing area of our department.” It is the Revenue Cycle Department that is the primary collecting source of revenue for the university. 

The team I am on is responsible for is all Medicare payors for all services that have been rendered at our three campuses and 100 primary and specialty clinics. Our goal is to collect on any outstanding balances with the insurance companies by determining the root cause for denials and making the necessary corrections to ensure there is no loss of revenue. The most common denials include invalid insurance loaded at the time of registration, no authorization or referral received for service rendered, coding issues, or providers not being credentialed. Once the problem is identified, we take the necessary steps per our policies and procedures to fix the claim, adjust the charges, or bill the patient. We may also enlist the help of other departments such as coding or provider enrollment if necessary.

There are also workques that our team is responsible for where claims have not denied, but we have had no response from the payor in 45 days or more. There could be several reasons for these accounts such as being rejected by the payor, the claim was never received electronically or by mail, or there is a missing payment and explanation of benefits. We resolve these by calling the payor to check status and depending on the outcome will determine the next step. If the payor does not have a claim on file, then we will either resubmit it electronically or drop the claim to paper and mail it. If the payor rejected the claim, then we will correct it or send it to the biller for assistance. If a payment is missing, then we need to gather information regarding the payment and then it gets sent to our payment posting to investigate.

At my externship site, I work closely with my direct supervisor and can get assistance from the other two team managers in addition to the director. I also can network with the training department if I need assistance or clarification on any policies. A Health Services Administration degree relates to my externship in revenue cycle operations as it is a fundamental piece in the healthcare industry. Health Services addresses the business components such as budgets, finance, patient rights, ethics, and policy and regulations. In addition to the business component, patients, faculty, and staff also contribute to Health Services and are necessary to run an organization effectively. 

Today, Healthcare systems are large and complex, and it is important to ensure an efficient and effective delivery of services. To achieve this, it is imperative that there is strong and knowledgeable leadership at each level. Executive management would oversee policy, while mid-level supervisors and managers would focus on operations management the delivery of healthcare.  A key component of healthcare leadership having an effective system not only is knowledge, but keeping workers motivated. By providing employee with incentives it will help keep retention and lower costs by not having to recruit. Additionally, providing ongoing training to management, staff, physicians, and other employees makes sure that everyone stays safe, up to date on polices and procedures, skills are strengthened, and an overall good attitude.

The task of ensuring ongoing training can be a challenge due to time restraints, access, or technology. With collaborative effort and developing a plan with options, it will surely be beneficial with good outcomes throughout the delivery of the healthcare system. Technology increasingly gets better each year and has many advantages for employers. It is had to find time for training without interrupting and providing quality service. However, there are ways to get training information out to employees by email, pod casts, webinars, conferences, online learning, etc. If management collaborates with each other, a wealth of information can be distributed and learned. With feedback and communication, new ideas can be created, and old ones refined.

At my job, all these tools are used university wide, so we can stay up to date and utilize the tools when it is convenient.  By utilizing the online learning approach, Suggests that this offers more convenience by ways of mobile device-delivered educational resources as it allows real time, asynchronous and self-paced learning, with some educational programs available offline. This can allow you to customize and organize data to the needs of the audience and really engage with them. The online learning and other tools mentioned are a good commodity with any organization, not just healthcare systems.

In general, health services administration covers business, policy, ethics, finance, marketing, patient care and any area that contributes to running a healthcare system. The Health Services Administration degree relates to my externship because it not only is a healthcare system, but it is also the financial piece of hospital revenue. Once my degree has been completed, then I can continue to work within revenue cycle operations or move to the clinic as a practice manager or to human resources. There are different subject areas that I have gained knowledge on in the program and will be able to expand on in the workforce. Although I am not sure what route I would like to take yet, I am confident I will find the perfect fit for me.

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