Hospital admission and Billing workflow

This article describes the whole process of admission, Discharge, Billing and Claiming workflow in Hospital admissions.

Step 1. Perform OEC (Online Eligibility Check)

CareRight has the ability to complete an Online Eligibility Check (OEC) for a patient/client. This can assist hospitals and day surgeries in determining the patient’s eligibility for a service/s and any out of pocket expenses for care.  It also provides an overview of the information required to ensure the most accurate assessment (forms) is provided and that the assessment (forms) data is clearly interpreted. Before a Patient Eligibility Check can be performed, consent must be obtained from the patient or a legally authorised representative.

The OEC will determine whether the patient is eligible for a selected presenting illness/condition as of the admission date. It will detail the out of pocket expenses a patient has for excess and co-payments associated with the hospital product.

The OEC process utilises the Medicare online claiming process. The results presented are in accordance with the Medicare specifications. It does not produce an Informed Financial Consent (IFC) form. The OEC can be performed as part of the Pre-admission process.

Performing an Online Eligibility Check 

1. Access the Patient record.
2. Select Admissions from the menu.
3. Select the Pre-Admit button.
   1. The pre-admission screen will display the following fields (use the table below for reference).
4. Select Pre-Admit.
   1. A message advising that the Patient was successfully pre-admitted with the display.
   2. The OEC button will now be present at the top of the screen.
5. Select the OEC button.
   1. The OEC screen will display.
6. Fill in any relevant information as requested (these are medicare related fields and not related to CareRight).
7. Update additional services button.
   1. A message advising that CareRight is communicating with the health fund will display.
8. Once the check is completed the standard Medicare eligibility report will display.

Please Note: The OEC functionality is only available to users who have the access granted in Administration → Users and Groups → Groups.

Using Presenting Illness for the OEC

During the OEC process, the CareRight system automatically associates the latest presenting illness with its associated code. The coding system was last updated in Q1 of 2019 and the CareRight platform reflects this revised information.

Flow-through Data

Once an OEC is complete there is some information which will flow through. This information is:

• Excess amounts
• Co-Payment amounts
• Additional Services information such as:
  • Service Type
  • Session Type
  • Provider Type

Step 2. Process Deposit

How to Add a Deposit

Last Modified on 29/06/2019 5:08 pm ACST

How to Add a Deposit

You can process a deposit taken from a patient without raising an invoice. This can be taken as credit amount either  specifically associated with an Account or as an standalone amount.

Standalone Deposit amount (not associated with an Account)

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Invoices & Credits.
   1. The Invoices and Credits screen will display and will default to 'Today'.
4. Select the New Deposit button and the add new deposit screen will open.
5. Complete fields using the table below as reference.
6. Subsequent options include:
   1. Select the Create Receipt button - This will receipt the payment.
   2. Select the Receipt & Print button - this will receipt the payment and open a PDF for printing.

The credit amount will display in the following areas:

• Unallocated Credits on the Unpaid Summary Tab
• Today's Receipts on the Today Tab

Deposit Associated with Patient Account

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Accounts.
4. Select Enquiries button next to the relevant Account.
5. Select the New Deposit button and the add new deposit screen will open.
6. Fill in the appropriate values (as above) however the Medical Provider value auto populate (based on the selected Account.
7. Select either:
   1. Create Receipt button - This will receipt the payment
   2. Create Receipt & Print button - this will receipt the payment and open a PDF for printing

Print Deposit Receipt

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Invoices & Credits.
   1. The Invoices and Credits screen will display and will default to 'Today'.
4. The processed deposit payment will display in Today's Receipts on the Today Tab.
5. Select the check box next to the deposit receipt.
6. Select the Print Select button at the top of the screen.
   1. A PDF will be created for printing

Step3. Admit

1. Select a patient.
2. Click Show.
3. In the Main Menu, click Admissions.
   1. The Admission screen will display, click Admit.
4. Select a Location.
5. Select an Admission Category.
6. Enter a Reason for the admission.
7. Fill in any remaining fields as per your business / statutory reporting requirements.  
8. The Planned Discharge date can be defaulted to today (speak to your system administrator if it isn't).
   1. Adding a Planned Discharge date will not automatically discharge the patient on that date.
9. Click Admit.

 The Patient is now admitted to the chosen location.  

Step 4. Edit Admission

You can edit an admission regardless of the state that the admission is in (open, discharged or pending discharge). Most of the pick lists on the Edit admission screen can be defaulted to a value or hidden (see the Change Categories section for more details).

From the Patient Record

1. Search for a patient.
2. Click Show.
3. If this is the Current Admission:
   1. Select Current Admission in the Main Menu or in the banner click Currently Admitted.
4. If this is not the Current Admission, click Admissions in the left hand menu.
   1. From Admission History section, click Edit.
5. Fill in relevant fields, as needed.
6. Click Update.

Step 5. How to discharge a Patient

Discharge refers to patients who have completed their admission. Discharge may also be referred to as “separation”. Discharge are administrative and mainly used for statutory reporting purposes.

1. From a Patient Admission, select the Discharge button.
2. Check details and edit discharge date/time as required.
3. Select a Discharge Diagnosis - Mandatory field.
4. Select a Discharge Status – Mandatory field.
5. Select a Discharged to – Mandatory field.
6. Discharge letter will be ticked if you have created a discharge letter on the Discharge Planning page.
7. Check the Confirm discharge box if the discharge is definite or has already occurred.
8. Select Discharge button.
   1. Note: On discharge, the QHAPDC Standard Unit Code will display the admitting doctor's details.

Upon discharge a Patient Snapshot is taken - see section Patient Snapshot for more information.

Cancel Discharge

1. Click the Cancel Confirmed Discharge button.
   1. The Cancel discharge iBox loads – check details of discharge to be cancelled.
2. Click OK to cancel the discharge or Close to close without cancelling the discharge.

Confirm Pending Discharge

If you did not check the Confirm Discharge check box on the Discharge screen then the Confirm Pending Discharge link will appear.

1. Click the Confirm Pending Discharge link.
2. Check the details.
3. Edit date/time if required.
4. Enter a discharge diagnosis if required.
5. Check the Confirm Discharge box.
6. Click Confirm to save.

Tip: The Confirm Pending Discharge field can be set to TRUE by default. Please contact your system administrator for further information. 

Step 6. Coding and Grouping

n Admissions is considered to been coded when it has been 'grouped' (had the DRG - Diagnosis Related Group code set). Note: Users completing this process require a specific privilege - please contact your System Administrator.

There are two ways to code an Admission in CareRight:

• Manually
• Automatically - utilising the integrated grouping software

Clinical Coding Expertise

CareRight is a sophisticated tool designed to collect admission data and produce the extract files for the federal and state statutory reporting bodies. However, Clintel support staff are not coding experts and are not qualified to advise on what clinical data should be entered for an admission.

You need to engage with a qualified clinical coder to establish which values should be entered against each admission. To code an Admission in CareRight you need the appropriate access - this can be granted by your System Administrator.

Manual Grouping

To manually group a admission you or your coder will need to have access to a third party coding product.

Automatic Grouping

CareRight Integrates with 3M grouping software*. This process utilises the Diagnosis and Procedure codes and determines the relevant DRG. Note: If you have a Diagnosis Related Group (DRG) or Major Diagnostic Category (MDC) already entered, then these will be overwritten when the grouper returns the DRG and MDC.

Grouping a Record

1. Search for a patient.
2. Click Show.
3. Select the relevant Admission.
   1. Note: Before pressing Group, you need to add at least one diagnosis to the admission record.
4. Select the Group button.
   1. You will see a message confirming that the Episode has been submitted for grouping.
5. Within ~2 minutes, if the grouping has been successful:
   1. A message will appear on the Admission > Show screen: This episode has been grouped successfully.
   2. The admission record will be updated with a Diagnosis Related Group (DRG) and Major Diagnostic Category (MDC).

Troubleshooting:

• If you receive an error message back from the Grouper - please contact 3M to remedy.
• If you do not receive a response back from the Grouper within 15 minutes then please contact Clintel Support.

* A licence and subscription is required with Clintel and 3M to use the Grouping integration.

Step 7. Creating a Linked Invoice

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Admissions.
   1. Select the hyperlinked ARN for the relevant Admission and the Admission screen will display.
4. Under the Invoices section, select the New Invoice button (Note: this will only display if the Admission has been discharged).
5. Select the following:
   1. Guarantor - Typically the patient's health fund e.g. BUPA
   2. Service Provider - Typically the hospital e.g. East St Kilda - Day Surgery
   3. Account Provider - Typically the hospital e.g. East St Kilda - Day Surgery
   4. Service Location - The hospital Service location where the admission took place - East St Kilda - Surgery
6. Select the New Invoice button
7. Most of the following screen should not need to be changed:
   1. Medical Provider- preset from last screen
   2. Service Location - preset from last screen but can be changed 
   3. Invoice Date - Preset to today
   4. Compensation Claim - Preset to False/unchecked (select this if it is a Work cover claim etc – see Worker cover) 
   5. Admission - Preset to the admission from step 2 (however, all admissions for this patient appear in the pick list)
8. Select Create Invoice button, the invoice screen will display.
9. Select the relevant item number and fill in the appropriate fields.
10. Select the Add line item to invoice button (if there is more than one item number), else select the Create Invoice button.
11. Repeat the process for additional item numbers for this invoice, these will display in the Line Items section.
12. When complete select the Create Invoice button.
    1. This process will automatically link the created invoice to the Admission record.
13. Access the Admission to review the Invoice.

Note: If an invoice is marked as Held for Claiming then you will see a message like the one below: The admission with this invoice is currently marked as 'Held from claiming' at 05/12/2017 at 10:21 AM. Refer to the Held Claims section for further information.

Step 8. Claim

Eclipse

Claim Generation

Eclipse claim generation is only supported for Day Surgery. If an admission is for more than one day and the guarantor is configured as "Electronic Claiming (Eclipse)" then a message needs to be displayed to the user on the claim screen that a paper-based claim will be created for this claim.

Currently when you "Prepare" a claim that is marked "Electronic Claiming" a Thelma XML file is created. If the guarantor is set to "Electronic Claiming (Eclipse)" instead the system should generate and send a IHC claim via eclipse. In the case when the guarantor is set to "Electronic Claiming (Eclipse)" the 'prepare" button shall be renamed to "Send to Health fund"

Claim Status
 
 Once the claim has been successfully sent to the health fund by eclipse the claim screen will show the status as per the methods outlined by the Medicare communications. The Submissions section is not used or displayed for eclipse claims.

IHC Adjustment Claims

After a successful claim is complete it may be necessary to send an adjustment to the claims. This may be an alteration to the charges of the claim or simply altering other parts of the claim data.

Invoice Adjustments

Claims need to reflect invoice value including adjustments. Currently the claim displays, and uses, the line items values as the per the originally entered invoice value. This needs to be changed to use the value with all adjustments applied.

When building a claim, the adjusted value needs to be used for each segment.

Supplementary Claims

Supplementary claims are extra claims created against an Admission that only contain Miscellaneous or Prosthetic items. (No accommodation or theatre). These are used to claim for extra items after a "normal" claim has been submitted.

When generating a claim and the user selects contiguous claim code of "not in series", the claim has NO accommodation and all items are classified as "Miscellaneous" then the generated claim needs to default to a supplementary claim.

 Important Note:  There are a number of key setup items for In Hospital Claiming (Eclipse) - please refer to your Systems Administration Guide.

Thelma

To process a claim via Thelma:

1. Select Associate that is a service location and click ‘Create Invoice’.
2. Select referral or Invoice Override Code.
3. Select Service Location and if necessary set invoice date (it will be today’s date by default).
4. As Service Location is an Inpatient or Procedure Centre location type  then a ‘Default Hospital Settings’ section appears. These should have the correct values by default (which for most funds are  the values “Agreements’ and ‘Verbal’ but for Medibank Private are ‘Scheme’ and ‘Not Obtained’).
5. Select required completed admission.
6. Click Create Invoice.
7. Entering line items - For each item on the invoice.
   1. Set the ‘Date of Service’ if the item wasn’t given/performed today and you failed to set the invoice date above.
   2. Enter the item number (or select from pop-up list).
   3. Enter the time the item was given/performed.
   4. Set units if required.
   5. If there are other details about the item to enter click on ‘Other Line Item Values’ and enter the details in the appropriate field of either the ‘Medicare Online’ or ‘Administration’ sections.  Patient Co-payment and excess amounts are entered here in the ‘Patient Contribution’ section..
   6. Click Add Line Item to Invoice.
   7. To remove an item click the ‘Remove’ button next to the item in the ‘Line Items’ section.
   8. If there are multiple procedures in the item list an ‘Apply MPR’ button will appear to allow the Multiple Procedure Rule.
8. Once all items have been added and all their details are correct click the Create Invoice button.
   1. The invoice is now ready to be submitted or you could enter/allocate a payment to it before sending.
9. To submit the invoice click the ‘Claim’ button.
10. In the resulting window click the ‘Inhospital Claim’ button top right.
11. In the resulting window, accept the declaration.
12. Classify the items (Accommodation/Theatre/Miscellaneous/Bundled).
13. If it is the first time this item has been used in an IHC for the fund you will need to fill in the number of information segments required (subsequent use of item number will auto populate these fields).
14. Click ‘Next’ button.
    1. The resulting window displays all the data fields required for the IHC  - fill in any that are not marked as ‘Optional’ and then click the ‘Prepare’ button.
15. This will highlight all field that fail to verify.
    1. If there are set values for a field they will appear in a pop-up list as soon as you start typing in the field.
16. Data entered here does not currently auto-copy back into the relevant admission record for statutory reporting (e.g. HCP, VAED, ISCOS).
17. Once all required fields are populated properly click the ‘Save’ button.
    1. The window now gives a link for downloading the file that you then need to submit through eHealthWise.

8. Adding Medical Certificates

Medical Certificates

At times, health fund processing/claiming cannot proceed unless a medical certificate can be quantified. There are some treatments the Health funds wont pay for unless a Medical provider has signed off that the treatment is required.

CareRight enables the recording of certificates, with a start and end date, the certifying provider and the date the certificate was issued. These Medical Certificate details get sent off electronically with the claim (if there is an active certificate during the admission period.)

Examples of the type of certificates available:

• Type B
• Type C
• Nursing Home Type Patient (Acute Care)
• Psychiatric
• Rehabilitation
• Multiple Admission (Chemotherapy and Dialysis)
• Critical Care

To Add a new Medical Certificate

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Admissions.
4. Select Medical Certificates.
5. Click New.
6. Complete fields using the table below as reference.
7. Click Create Medical Certificate.

Step 9. Check Uncoded Admission

1. From the CareRight Dashboard:
2. Select Locations Menu item and choose relevant Location.
3. Select Admission Coding.
4. The Admission Coding Summary screen has a matrix, for given date ranges, showing the number of admissions which are:
   1. Ungrouped - Not yet grouped i.e. the admission does not have a DRG code (or at least one Diagnosis or Procedure code).
   2. Ungrouped and Held for Claiming - Not yet grouped and flagged in admission screen as Hold Claims For This Admission = Yes.
   3. Grouped - Admissions with a DRG code (or at least one Diagnosis or Procedure code) and which are not cancelled.
   4. Total - Total of all Admissions discharged on the date which are not cancelled.
5. Click the hyperlink number to display admissions for a date period.

Note: If you do not require a DRG to be populated for an Admission to be deemed "coded" then check the setting "Enable Manual Coding"  in System Administration>Locations (edit a location)

Example screen:

** this screen contains pagination results that will flow to additional pages after 30 entries

 6. The list of Admissions will display with the following fields:

       7. The values in this list can be sorted by the following fields:

            a. Admission Date

            b. Discharge Date

            c. ARN (admission record number)

            d. Patient First Name & Last Name

      8. From the list, the ARN is a hyperlink to the admission - click this to go to the admission record

      9. This admission can then be edited, coded, invoiced, etc

Alternative way to access this screen:

Step 10. Accessing Invoices and Claims

From the CareRight dashboard:

1. In the Main Menu, click Location.
2. Select the relevant location.
3. Select Invoices & Claims from menu.
4. The Invoices and Claims Screen will display:
   1. The complete view of accounts for your practise/organisation. This will assist with daily debt management.
5. From this screen you can also:
   1. Access all processed claims
   2. Manual ERA payments

How to View a List of Invoice Claims

1. From the Invoices and Claims screen, click a value under a column to display a listing of relevant invoices.
   1. A list of invoices will appear.

Loan Accounts are displayed separately on the Invoices and Credits screen: