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Patient Billing

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Although not really part of the back office systems, the patient billing was placed in this section along with the other financial modules.

The module shall provide facilities necessary to invoice patients, perform all necessary amendments to patient’s account and provides comprehensive automatic follow-up of outstanding debts. The system should calculate resource usage for patient treatment where a free healthcare scheme is in operation. The module should include doctor’s fee management that takes care of all aspects of doctor’s involvement. The Billing Module should accommodate centralized and decentralized billing , and assist with every aspect of billing and collection.

The following has been extracted from a recent RFP. I've included it here for your reference. It may prove useful for anyone preparing such a document.
Please feel free to comment on this list, and propose any items that you think should have been included in this list. 

Patient Billing

The module shall provide facilities necessary to invoice patients, perform all necessary amendments to patient’s account and provides comprehensive automatic follow-up of outstanding debts. The system should calculate resource usage for patient treatment where a free healthcare scheme is in operation. The module should include doctor’s fee management that takes care of all aspects of doctor’s involvement. The Billing Module should accommodate centralized and decentralized billing , and assist with every aspect of billing and collection.

>>> General
1   Provide facility to manage Patient Accounts on perpetual basis
2   Ability to Capture, store , and retrieve patient charge information
3   Ability to produce deposits, bills, statements, claim forms and logs
4   Ability to accept receipt, adjustment, and refund
5   Support posting of electronic remittances
6   Ability to deliver auto-proration capabilities
7   Ability to daily transfer of Billing data to General Ledger
8   Ability to transfer Patient refund data to Accounts Payable
9   Ability to pass procedure volumes to Cost Accounting for analyzing
10   Ability to Transfer Patient data to/from the Registration module ( inpatient , outpatient )
11   Ability to support electronic third party billing, with multiple pricing and discounts
12   Allow grouping of financial classes for summary reporting
13   Accommodate Third Party contractual conditions and special negotiated pricing

>>> Billing Process
14   Provide online access to insurance data in admissions and other areas , to view pre-certification and entitlement requirements
15   Allow the Hospital to specify required registration and billing data by patient type and guarantor
16   Ability to edit and validate insurance verification data against insurance limitations and conditions
17   Provide ability to list non-covered services by insurance for different insurance companies and guarantors
18   Ability to include contract payment terms by service ( ex: emergency department, maternity ) in insurance portfolio
19   Provide charge master file that can be viewed online by patient account
20   Allow multiple prices for each line item in charge master ( by class and by insurance )
21   Allow charging different rates for multiple insurance contracts, patient type of financial class ( first, second, ward, etc.. )
22   Allow for automatic calculation of room and service charges on daily basis
23   Support percentage discounts and allowances for third party contracts
24   Allow overriding of charge master prices during charge entry
25   Support a variety of insurance contract billing requirements , such as sending separate bills to Social Security, MOH , various insurance companies
26   Provide coding and billing functions to support the Hospital ambulatory care system
27   Allow users to view previous outpatient visit discharge dates, site of service, and all ICD-10-CM diagnosis and CPT procedure codes
28   Ability to maintain and provide access to current and previous year’s ICD-10 coding tables and users’ tables to accommodate different third party
29   Support selectively or across the board price increases to charge master with effective dates
30   Provide audit trail of all charge master item additions, deletions, and updates with effective dates.
31   Ability to interface to order communications system for automatic posting of charges to patient accounts
32   Provide key data entry functions for posting charges in batch mode
33   Ability to validate entered charges for valid patient account numbers and charge code numbers
34   Allow individual charges on bill up to 15,000,000 Egyptian Pounds and total amount up to 100,000,000 E.P
35   Prohibit posting of batched charges if batch does not balance
36   Support the entry of price and description for miscellaneous charges
37   Allow posting of charges to patient accounts up to a user-defined cutoff period after discharge
38   Allow different late-charge cutoff periods for inpatient and outpatient bills
39   Allow posting of late charges to accounts ( after cutoff point ) and interface summary to general ledger system
40   Allow automatic transfer of outpatient and ER charges to inpatient account if admitted within user-defined time parameter
41   Produce daily late charge report by ancillary department
42   Produce monthly summary of late charge by department
43   Support billing for non-patient accounts ( ex: guest bed and meals charges )
44   Provide comprehensive user defined front-end coding , revenue codes, bill type, etc..
45   Allow for down payments , payments on account , partial billing , etc…
46   Support online cash posting by discharge cashiers as payments are received from patients
47   Allow assignment of primary and secondary financial class codes to patient accounts
48   Support proration of bill
49   Allow re-proration and rebilling
50   Automatically generate bill for second payor on remaining balance after first payor’s payment and eventually a third payor for same bills
51   Support rebilling for late charges and changes in financial class after final bill
52   Allow estimation of late or lost charges
53   Ability to perform series billing for recurring outpatients
54   Ability to maintain a series ( or recurring ) outpatient’s master record and reflect all changes in individual visit records
55   Support retroactive inpatient transfer from a financial class to another and allow recalculation of charges
56   Ability to report on conflicting situations resulting from transfer of patients and their financial impact
57   Ability to adjust accounting entries to reflect financial class transfers
58   Ability to automatically generate allowance amount when third party bill differs from Hospital price
59   Allow automatic change of patients’ financial class based on user-defined parameters
60   Ability to automatically update revenue statistics upon financial class changes in accounts
61   Provide third party log functions to track all payments, charges and adjustments for inpatients and outpatients
62   Support Retro billing for past event adjustments

>>> Instant Access and Update of pertinent information
63   Ability to grant Authorization to users, based on access restrictions, for data entry, edit, or view-only privileges
64   Support maintenance of complete guarantor, insurance and DRG data
65   Ability to maintain the pricing tables as legislated by the Ministry of Health ( MOH)
66   Ability to abide by the classification and coding of medical procedures issued by MOH
67   Provide capability to adopt to pricing of medications and medical classification pricing as established by MOH

>>> Contract Management ( and Guarantors )
Multiple contract management routines make it easy for the Hospital to govern managed care agreements and assist with negotiating and monitoring contracts with third party payors
68   Provide a contract dictionary that stores vital administrative information such as crucial dates , contract evaluation ( concurrent, retroactive ), contract terms, and notes taken during contract negotiation
69   Provide insurance identification routines for managing various insurance plans
70   Provide proration rules to calculate expected reimbursement to monitor managed care agreements
71   Produce various reports that help management determine if both parties are meeting predetermined managed care arrangements
72   Allow priorities in setting guarantors and self
73   Support group billing for multiple patients to an employer ( or other contract group ) account
74   Support family ( guarantor ) billing
75   Provide ability to edit guarantor data and reflect the changes in all related accounts

>>> Interim Billing
Interim billing routines make it easier to track recurring and long-term accounts for billing and collection purposes
76   Capability of generating an unlimited number of bills based on how billing cycles are established
77   Provide facility to establish rules bringing groups of accounts through the billing cycle prior to a discharge date, allowing the Hospital to bill for charges incurred while the patient account is still active
78   Facility to assign a unique bill number for each billing cycle that is completed on a patient account
79   Ability to support resolution and tracking of claims
80   Ability to support secondary payors billing
81   Ability to support different interim billing methods by patient type and financial class
82   Ability to produce a single bill for patients transferring between divisions, without affecting divisional revenue reporting

>>> Late Charge Bills
83   Provide for facility to establish proration rules for late charge bills in the event a payor requires different reimbursement
84   Provide for facility to report on charges posted after the final bill has been cutoff
85   Support estimation of late / lost charges in final billing process
86   Ability to automatically bill late charges any number of days after the final bill

>>> Other Billing Features
87   Facility to establish rules for final, interim, or late bill generation based on payor and/or account type
88   Ability to print or reprint Bills, claims, and statements , on demand by authorized users
89   Ability to track Patient charges throughout the Hospital, regardless of at which entity the costs were incurred
90   Provide one bill for all services rendered
91   Provide ability to identify mode of payment
92   Provide ability to calculate and record Tax and VAT
93   Maintain multiple ( up to four) insurance coverages for one account
94   Support proration and coordination of insurance coverage and billings and level of care changes proration in accordance with inlier-outlier status
95   Bill all payers and responsible parties simultaneously
96   Provide authorized members to view comprehensive patient account information online; print bills, statements, claim forms/logs; accept receipts; and provide account follow-up and management reports on demand
97   Ability to define billing procedures with one code and value based standard costs
98   Track Revenue and receivables separately for each facility
99   Track volume ( in dollars or LL ) of month-to-date and year-to-date charges
100   Track volume ( in approximate units of measurement) of month-to-date and year-to-date activity
101   Maintain and utilize service index table ( Fees Schedule ) :- Price
102   Maintain and utilize service index table ( Fees Schedule ) :- Alternative prices, based on patient type
103   Maintain and utilize service index table ( Fees Schedule ) :- Description
104   Maintain and utilize service index table ( Fees Schedule ) :- Statistical measurement ( RVU, CAP units , K Units , labs and operations units, etc..)
105   Maintain and utilize service index table ( Fees Schedule ) :- Date of last price updated
106   Maintain and utilize service index table ( Fees Schedule ) :- Ability to Automatically coordinate service index table with General Ledger codes
107   Maintain and utilize service index table ( Fees Schedule ) :- Cost per unit and date of last cost update
108   number of room charges by : Financial class
109   number of room charges by : Nursing unit
110   number of room charges by :Service unit
111   Ability to automatically determine service code information by accessing service index table for all hospital services:
112   Allow changing of multiple prices by inputting a single transaction ( ex: raise all room rates by 3%)
113   Allow user overrides of both description and price
114   Provide audit trail of manual price override
115   Allow immediate posting to accounts ( online )
116   Provide transaction description on bills
117   Ability to summarize charges by type of service
118   Automatic retroactivity for Late charges
119   Automatic retroactivity for Late admissions
120   Automatic retroactivity for Late transfers
121   Automatic retroactivity for Change in form
122   Automatic retroactivity for Change in financial class
123   Automatic retroactivity for Erroneous discharge

>>> Bills
124   Ability to print bills in sorted order by inpatient, outpatient, and financial class
125   Allow separate bills for one patient visit
126   Ability to suspend bill printing until required data elements are present ( ex: diagnostic codes, insurance )
127   Print suspended bills management report to track outstanding bills
128   Allow bills to be reprinted on demand ( using a unique number , or reprint sequence )
129   Print ‘demand’ bills for inpatients at discharge and at point of service for ER and outpatients
130   Ability to generate summary of the Bill along with the itemized bill , by group of services
131   Print bills in different formats , and MOH billing forms ( and in Arabic )
132   Allow bills to be reviewed and edited online before releasing for print or electronic billing
133   Print free-format text messages on all bills in a financial class
134   Print or display daily bill summary showing number of bills by financial class, amounts totals, for inpatient and outpatients
135   Ability to accept all charge information from patient care and communication system
136   Ability to produce a single bill for patients transferring between divisions, without affecting divisional revenue reporting
137   Print patient bills :- Patient name
138   Print patient bills :- Guarantor name and address
139   Print patient bills :- Date and type of bill ( interim or final)
140   Print patient bills :- Hospital service
141   Print patient bills :- Physician(s)
142   Print patient bills :- Financial class
143   Print patient bills :- Admit and discharge diagnosis
144   Print patient bills :- Visit diagnosis for outpatients including ICD10 code
145   Detail of charges:- Service code
146   Detail of charges:- Date
147   Detail of charges:- Description
148   Detail of charges:- Quantity
149   Detail of charges:- Amount
150   Detail of charges:- Total
151   Summary of charges by comprehensive groups
152   Comments ( at the hospital’s discretion)
153   Allow grouping of Medical Supplies below certain price, under one code and one set price
154   Ability to separate professional component from hospital portion of charges for separate billing; as required
155   Provide a sliding scale computation for outpatient charges
156   Ability to print interim bills for outpatients

>>> Collection
157   Provide collections management functions for hospital collections department
158   Provide online ‘tickler file’ function for scheduling follow-up collection actions
159   Support entry of online collections notes for individual accounts to track follow-up activities
160   Support automatic collection processing that routes account to specific follow-up steps per user-defined criteria ( ex: balance greater than 5,000,000 over 90 days )
161   Print standard collection letters on demand to individual or groups of accounts ( ex: 30,60,90, 120 days )
162   Print pre-list of accounts meeting hospital bad debt criteria before assigning to collections
163   Provide for Patient and guarantor collection
164   Provide for account look-ups by patient name and number, guarantor name and number, and medical record number
165   Ability to process reminders
166   Provide entry of free text and coded comments
167   Provide for unlimited generation of form letters for user-specified accounts ( in English and Arabic )
168   Support reports that can be customized by the user
169   Elaborate security access that show and audit trail of who has posted transactions to an account

>>> Claims
170   Provide for a facility to check on all required information on a patient’s account prior to printing of the claim
171   Ability to online override facility in every field on the electronic claim form , to produce claims that meet payor’s specific requirements
172   Provide for claim establishment based on different insurance and account types such as mother/baby billing, inclusion/exclusion of professional components, ‘clean claim’ data checking, and exclusion of ‘cross over’ claims

>>> Queries
173   Provide online inquiry into billing data for current and past visits
174   Provide for detailed workstation displays and printouts by patient/guarantor demographics and account statuses, patient and insurance balances, transaction details, and follow-up statement histories
175   Maintain charge detail after billing for reference and inquiry for :- Inpatients
176   Maintain charge detail after billing for reference and inquiry for :- Outpatients
177   Maintain charge detail after billing for reference and inquiry for :- Transfer

>>> Reports
178   Print daily receipt log for ER and outpatient registration
179   Ability to generate cycle statements by either account or guarantor
180   Include an unlimited number of hospital-defined dunning messages
181   Operations summary, displaying all billing , A/R activity for a particular date or range of dates
182   Revenue reports: revenue summary, procedure revenue report, procedure period end comparison and patient revenue report
183   Charge exception, late charges, and general ledger reports
184   Collection reports such as biller and collector worklists
185   Collector performance reports
186   Patient and insurance receivable reports and third party logs
187   Late charge transaction report
188   Ability to identify, produce and report patient billing and account receivable ledger by division as well as combined
189   Inpatient in-house account report
190   Provide the flexibility for the user to determine which financial classes are to be broken out on the revenue reports
191   Ability to produce the following revenue and statistical reports
192   Produce patient census report by user defined criteria
193   Patient revenue for accounting period reports by :- Hospital charge
194   Patient revenue for accounting period reports by :- Sub-department totals
195   Patient revenue for accounting period reports by :- Department totals
196   Patient revenue for accounting period reports by :- Hospital service
197   Patient revenue for accounting period reports by :- Financial class
198   Patient revenue for accounting period reports by :- Accommodation
199   Patient revenue and usage statistics summaries with year-to-date figures by: type of service, third party
200   Daily income reports by: patient type, financial class, hospital service
201   Administrative operating summary showing aged Egyptian pounds totals by financial class for all accounts in the accounts receivable and bad debt files

>>> Integration
202   Accounts receivable module
203   Ordering system
204   Payable module

Last Updated ( Tuesday, 28 October 2008 01:10 )  

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