The Contemporary Guide to Patient Financial Services

Nadia Duncan, CRCS-I, CPC, CPMA
Donna Ellenburg, FHFMA
Linda M. Huckin, RN BSN, ACM, CPC, CDEO, CIC
Wanda A. James, MSM, CRCR, ACPAR
Abdool Razack, BBA
Cindy H. Spencer, CRCS-I
Keli Taylor, CPC, CRCS-I

With healthcare’s rising costs, selective consumers, and constantly changing regulations, creating a stable and successful patient financial services (PFS) department that withstands industry changes and workplace turnover is integral to ensuring accurate reimbursement.

The Contemporary Guide to Patient Financial Services takes readers through a patient’s financial journey from pre-registration and scheduling through posting payments, managing collections, and tackling the denials and appeals processes. This book also explores staffing, recruitment, and retention to ensure PFS teams are thoroughly equipped for their roles and can meet—and exceed—expectations. Downloadable tools, key performance indicators, and performance benchmark strategies are also included to help keep your PFS department on track.

Benefits:

• Time-saving, one-stop reference: As PFS departments become more inclusive of the entire revenue cycle, they need a contemporary book that reflects these changes. Use this book as an onboarding training guide for new staff or as a go-to reference for managers and directors.
• Up-to-date instruction from seasoned experts: This book is written by veteran healthcare professionals who have successfully increased overall collection rates while reducing days in accounts receivable, optimized staff productivity, and minimized the cost to collect.
• Grow your department—and captured revenue: Master every step of the financial journey of a claim while developing a more stable and successful PFS department.

Published: August 2018

Page count: 182
Dimensions: 8.5x11
ISBN: 978-1-68308-836-3

Table of Contents

• Introduction: Understanding the Healthcare Revenue Cycle Process
• Provider Referral
• Eligibility
• Patient Responsibility
• Precertification, Authorization, Predetermination, and Medical Necessity
• Scheduling, Preregistration, and Financial Counseling
• Point-of-Service Registration and Cash Collection
• Patient Encounter and Checkout
• Coding and Charge Capture
• Claims Submission
• Third-Party Follow-Up
• Remittance Processing
• Appeals
• Agency Referral and Bad Debt
• Chapter 1: Scheduling, Registration, and Charge Capture
• Claim Forms
• Scheduling
• Preregistration and Registration
• Capturing Charges
• Chapter 2: Posting Payments
• Explanation of Benefits and Remittance Advice
• Establishing a Process for Posting and Applying Payments or Denials
• Chapter 3: Remittance Processing and Appeals
• Paid Claims
• Return to Provider
• Rejection
• Suspension
• CMS Claims Review
• Levels of Appeals
• Chapter 4: Essential Elements of a Robust and Effective Appeals Program
• Building the Framework
• Types of Denials
• Coding Denials
• The Technical Side of the Appeals Process
• The Clinical Side of the Appeals Process
• Commercial Medical Policies and Government Coverage Guidelines
• Impact of Data Analytics and Reporting
• Audit and Appeal Analytics, Processes, and Quality
• Chapter 5: Managing Collections
• Patient Interaction Best Practices
• HIPAA Rules and Regulations
• Fair Debt Collections Practices Act
• Payment Review Process
• Payment Plans
• Disputes
• Third-Party Collection Agencies
• Financial Counseling
• Self-Pay Patients
• Credit Balances and Patient Refunds
• Charity Care
• Chapter 6: Final Bill and Beyond: Staffing in Patient Financial Services
• Who, What, When, Where, and Why of Patient Financial Services
• Patient Financial Services Staffing
• Outsourcing
• Staff Roles
• Knowledge, Skills, Ability, and Other Traits Useful for Patient Financial Services Teams
• Job Descriptions
• Putting It All Together to Fit Into Your Organizational Goals
• Onboarding Roadmap
• Recruitment and Retention
• Chapter 7: Collaboration in the Revenue Cycle
• Physician Offices
• Patient Access
• Medical Staff Affairs
• Surgery and Diagnostic Testing
• Nursing Services
• Case Management
• Health Information Management
• Revenue Integrity and Chargemaster
• Managed Care Contracting/Contract Management
• Finance
• Admission
• Marketing
• Information Systems
• Security
• Compliance
• Chapter 8: Monitoring Key Performance Indicators
• Use of Metrics
• Performance Improvement
• Benchmark Patient Access Performance
• Key Performance Indicator Work Points

About the Authors

Nadia Duncan, CRCS-I, CPC, CPMA, is a senior compliance auditor at Atrium Health (formerly Carolinas Healthcare System) in Charlotte, North Carolina. She has more than 18 years of healthcare and revenue cycle experience in various patient financial services roles and departments, including training and development, denial management, quality assurance, and corporate compliance. Duncan has earned the Six Sigma Green Belt certification. She has experience in auditing related to patient financial services, NCCI edits, research clinical trials, cardiac and pulmonary rehabilitation, ambulatory surgical centers, ambulance, and more. Duncan is passionate about training and education, and conducts presentations on compliance, regulatory, and billing guidance for Atrium Health departments.

Donna Ellenburg, FHFMA, is the revenue cycle director at Grandview Medical Center in Birmingham, Alabama, and has more than 37 years of experience in the revenue cycle. Ellenburg joined Grandview in 2007 and currently is responsible for scheduling, pre-arrival, registration, and the chargemaster. Prior to joining Grandview, she worked at St. Vincent’s Health System in Birmingham, Alabama, as the CBO director. In that capacity, she was responsible for the health system’s four hospitals. Ellenburg obtained a Bachelor’s Degree from Birmingham Southern College. She is an active member of the Alabama Chapter of the Healthcare Financial Management Association (HFMA) and currently serves as an HFMA board member for the Alabama Chapter.

Linda M. Huckin, RN, BSN, ACM, CPC, CDEO, CIC, is a senior compliance auditor with Atrium Health (formerly Carolinas HealthCare System) in Charlotte, North Carolina. With more than 20 years of experience in the healthcare industry, Huckin’s knowledge and expertise include critical care nursing, clinical care management, utilization, hospital billing, and clinical appeals and denial management for both commercial and government payers. She has performed facility coding and billing audits for various outpatient and inpatient hospital services and payment systems. Huckin’s career value statement is, “Break the silos!” and her mission statement is, “Hospital clinical processes must align with financial processes to support coding and billing compliance.” Huckin believes that building dynamic working relationships across departments improves the business health of the organization and keeps the focus on providing patient-centered care.

Wanda A. James, MSM, CRCR, ACPAR, is the director of patient accounts for Huntsville Health System in Huntsville, Alabama. Prior to her current role, she was the director of patient financial services for Jack Hughston Memorial Hospital in Phenix City, Alabama, and the Hughston Surgical Center in Columbus, Georgia. Before joining Hughston in 2014, James was part of the Baptist Health System in Montgomery, Alabama, holding progressive roles in the revenue cycle. James is an active member of the National Association of Healthcare Access Management and the Alabama Chapter of HFMA. She currently serves as President-Elect of the Alabama HFMA Chapter, and she previously held positions as a voting board member, secretary, and chair for the certifications committee. James is the proud mother of Matt and Ashley as well as the proud Mimi of MacKenzie, Lynzie, and Carlie. Her favorite activities include spending time with her family and mentoring the new generation.

Abdool Razack, BBA, is the senior director of revenue cycle at South Nassau Communities Hospital, which he joined in 2000. Previously, Razack worked for New York Presbyterian Hospital, where he held various positions in patient financial services. He earned his BBA degree in accounting at the Bernard Baruch College and his coding certification from the AAPC. Razack previously taught medical billing and coding at Medgar Evers College and the Roxbury Institute for Medical Management. He is a member of the HFMA Metro chapter.

Cindy H. Spencer, CRCS-I, manages the precertification and authorization denials process for one of the oldest and largest neurosurgical practices in the country. In her 22 years in healthcare, she has also worked for two regional healthcare systems and a global insurance company. Although she has held various roles, including data entry, claims processing, and insurance collections, her passion for patient care lead her to the customer service department at each organization where she has worked. Spencer has six years of healthcare customer service experience that has taught her the true value of communication. She believes true innovation comes from listening to your patients and designing your daily practices around their needs.

Keli Taylor, CPC, CRCS-I, is a patient financial services director in the hospital business office for Atrium Health (formerly Carolinas Healthcare System) in Charlotte, North Carolina. She has been part of the healthcare revenue cycle for various hospital systems and private medical practices for the past 25 years, serving in leadership roles in operations, billing, and private practice management as well as in consulting roles in revenue capture and compliance initiatives.