CHBME cheat sheet
CHBME · Keep the key ideas within reach.
Revenue Cycle Management
Revenue cycle spans front-end (scheduling, registration, eligibility, prior authorization), mid-cycle (coding, charge capture, claim editing), and back-end (billing, follow-up, denial management, collections).
Net revenue = gross charges − contractual adjustments − discounts − bad debt − charity care; it is the actual collectible amount, not billed charges.
Key lag metrics: days in accounts receivable (A/R) = (total A/R ÷ gross charges) × days in period; days in A/R above ~35-40 days signals collection risk.
Clean claim rate = claims accepted on first submission ÷ total claims submitted; each rework adds cost and delays cash.
Denial rate = denied claims ÷ total claims; categorize denials as front-end (registration/eligibility), clinical (medical necessity), or coding (modifier, bundling).
Gross collection ratio = payments ÷ gross charges; net collection ratio = payments ÷ net (allowed) revenue; net ratio near 95-100% indicates effective collection.
Point-of-service collections reduce bad debt: collect copay, coinsurance, and deductible estimates before or at service.
Charge capture integrity: reconcile charges to scheduled procedures and supplies; missed charges are unrecoverable once the claim is filed.
Under Medicare OPPS, status indicators (e.g., J1, N, S, T, Q) and payment indicators determine whether an item is separately payable, packaged, or not paid.