QBRS cheat sheet

Revenue cycle phases in order: preregistration, registration, charge capture, coding, claim submission, remittance posting, denial management, and collections.

Gross collection rate = total payments divided by gross charges; net collection rate = payments divided by allowed amount after contractual adjustments.

Net collection rate is the preferred performance metric because it excludes contractual write-offs and reflects collectible revenue.

Days in accounts receivable = (total A/R divided by net charges) multiplied by days in the period.

Clean claim rate = claims accepted on first submission divided by total claims submitted, measured before edits or rejections.

First-pass resolution rate measures claims paid on first submission without denial, rework, or appeal.

Cost to collect = total revenue cycle operating expense divided by total cash collected.

Front-end errors (registration, eligibility, prior authorization) drive a large share of downstream denials and rework.

Minimum registration data set: legal name, date of birth, sex, address, insurance identifiers, guarantor, and subscriber relationship.

Eligibility verification confirms active coverage, effective dates, plan type, copay, coinsurance, deductible remaining, and network status.

Coordination of benefits order is typically determined by the birthday rule for dependent children and by Medicare Secondary Payer rules for Medicare beneficiaries.

Medicare Secondary Payer: group health plan pays first when the employer has 20 or more employees and coverage is based on current employment.

Prior authorization requirements should be confirmed at scheduling or preregistration to prevent authorization-related denials.

Real-time eligibility (270/271 transaction) returns coverage and benefit data electronically; batch verification runs on scheduled patient lists.

Insurance card capture should record both front and back, including payer ID, group number, and customer service and precertification phone numbers.

Uninsured or self-pay patients require screening for Medicaid, marketplace plans, and financial assistance before cash collection.

ICD-10-CM codes report diagnoses; ICD-10-PCS reports inpatient procedures; CPT and HCPCS Level II report outpatient services and supplies.

Evaluation and management level selection depends on medical decision making or time, per current code set guidelines.

Modifier 25 indicates a significant, separately identifiable E/M service on the same day as a procedure.

Modifier 59 and the X{EPSU} modifiers identify distinct procedural services not normally reported together.

Charge capture must reconcile documented services to billed charges; missed charges are a leading source of lost revenue.

National Correct Coding Initiative edits identify code pairs that are not separately payable; modifier overrides require documentation support.

Medical necessity links the diagnosis to the service; lack of medical necessity supports denial and refund exposure.

Coding queries to providers must be non-leading and based on clinical documentation already present in the record.

CMS-1500 is used for professional claims; the UB-04 (CMS-1450) is used for institutional claims.

ANSI ASC X12N 837P transmits professional claims and 837I transmits institutional claims electronically.

Clearinghouse edits fall into two tiers: front-end syntax and data edits, and payer-specific edits applied before forwarding.

Claim rejections occur before payer adjudication and can be corrected and resubmitted; denials occur after payer adjudication.

Timely filing limits vary by payer and contract; the clock typically starts at date of service or claim submission.

Common claim edits include invalid subscriber ID, missing NPI, mismatched date of birth, and missing prior authorization number.

Electronic remittance advice (835) delivers payment and adjustment data that should be auto-posted and reconciled.

Claims with errors should be corrected at the source so the same edit does not recur on future submissions.

Denial categories: eligibility, authorization, coding, medical necessity, timely filing, duplicate, and bundling.

Denial rate = denied claims divided by total claims submitted; denial value should be tracked alongside claim count.

Root cause analysis assigns each denial to a front-end, mid-cycle, or back-end owner to prevent recurrence.

Appeal levels typically progress from first-level reconsideration to second-level review and then external or independent review.

Payer appeal deadlines are shorter than timely filing limits and must be tracked per contract.

Medical necessity appeals require clinical documentation and often a letter linking documentation to coverage criteria.

Preventable denials should be measured separately from non-preventable denials to guide process improvement.

Write-offs require documented approval; unappealed denials within the appeal window are recoverable revenue at risk.

A/R aging buckets commonly used: 0-30, 31-60, 61-90, 91-120, and over 120 days.

A/R greater than 90 days is generally considered at risk and should be prioritized for follow-up.

Patient responsibility includes copay, coinsurance, deductible, and non-covered services.

Point-of-service collection improves yield; balances should be explained before or at the visit.

Payment plans and financial assistance policies should be applied consistently and documented.

Collection agency placement and credit reporting are governed by contracts, state law, and fair billing practices.

Bad debt write-offs should be reconciled against allowance for doubtful accounts and reviewed for recoverability.

Charity care eligibility is determined by organizational financial assistance policy and income thresholds, not by collector discretion.

False Claims Act liability attaches to knowingly presenting a false claim, including reckless disregard of truth or falsity.

Anti-Kickback Statute prohibits remuneration intended to induce referrals for items or services payable by federal health programs.

Stark Law prohibits physician self-referral for designated health services when a financial relationship exists, absent an exception.

Civil Monetary Penalties Law covers false claims, improper inducements, and excluded persons providing services.

Exclusion screening against the OIG List of Excluded Individuals and Entities (LEIE) and SAM should occur at hire and monthly.

Compliance program elements include written policies, a compliance officer, training, auditing, hotline, and enforcement and discipline.

Overpayments identified must be reported and returned within 60 days of identification under the 60-day repayment rule.

Fraud is intentional deception; waste is misuse of resources without intent; abuse is practices inconsistent with sound fiscal or medical standards.

Price transparency requires good-faith estimates of expected charges for scheduled services upon patient request.

Financial responsibility discussions should occur before the service whenever possible, not only after claim adjudication.

Plain-language explanation of benefits should distinguish billed charges, allowed amount, payer payment, and patient responsibility.

HIPAA permits discussion of financial information with the patient or a person the patient has authorized.

De-escalation technique: acknowledge the concern, restate the issue, explain the process, and confirm next steps.

Interpreter services must be offered at no cost for limited-English-proficiency patients; family members should not be relied on as interpreters.

Complaint and grievance tracking should capture root cause, resolution, and turnaround time.

Documentation of every patient financial conversation supports dispute resolution and compliance review.