CHAM cheat sheet

Scheduling accuracy depends on three data points captured at booking: patient identifiers, payer/plan, and reason for visit; missing any one drives downstream denials.

Real-time eligibility (270/271 transaction) should be run at pre-registration and again on the date of service; coverage changes mid-month are a leading cause of eligibility denials.

Point-of-service collection rate = patient payments collected at or before service / total patient responsibility; benchmark-driven targets typically exceed 30% for hospital outpatient.

Prior authorization must be verified against the specific CPT/HCPCS code and date range; a PA tied to a different code or facility does not transfer.

Medical necessity screening at scheduling (using payer rules or clinical criteria) prevents the majority of medical-necessity denials before service occurs.

Registration quality metrics: clean claim rate, registration error rate, duplicate medical record rate, and insurance verification turnaround time.

Price transparency: hospitals must publish standard charges (CMS machine-readable files); patient estimates should reflect deductible, coinsurance, and out-of-pocket maximum status.

Referral management: a referral is valid only for the payer-specified number of visits and time window; exceeding either requires re-authorization.

Identity verification: two patient identifiers (name plus date of birth or MRN) are required before any registration record is created or merged.

Net patient revenue = gross charges - contractual allowances - discounts - charity care; bad debt is not a contractual allowance.

Clean claim rate = claims accepted on first submission / total claims submitted; first-pass resolution rate measures claims paid without rework.

Days in accounts receivable (A/R) = (total A/R / total charges) x days in period; a common equivalent is A/R divided by average daily charges.

Aging buckets (0-30, 31-60, 61-90, 91-120, 120+) show collectability; A/R over 90 days signals front-end or follow-up breakdown.

Denial rate = denied claims / total claims; root-cause categories are registration, eligibility, authorization, coding, and medical necessity.

Charge capture integrity: charge lag (days from service to charge posting) and late-charge rate are leading indicators of lost revenue.

Underpayment recovery compares contracted rate (per fee schedule or case rate) against remittance; variance beyond contract tolerance is appealable.

Cash acceleration levers: electronic remittance advice (835) auto-posting, claim scrubbing edits, and payer portal follow-up replace manual work.

Cost-to-collect = total collection expenses / total collections; rising cost-to-collect with flat yield indicates process inefficiency.

HIPAA Privacy Rule governs uses and disclosures of PHI; the Security Rule applies specifically to electronic PHI and requires administrative, physical, and technical safeguards.

Minimum necessary standard: access to PHI is limited to the least amount needed for the purpose, except for treatment, payment, and health care operations disclosures to providers/payers.

Breach notification: individual notice without unreasonable delay and no later than 60 days after discovery; HHS notification follows the same 60-day threshold.

False Claims Act liability attaches to knowingly submitting false claims; the reverse false claim provision covers retaining overpayments beyond 60 days after identification.

Anti-Kickback Statute prohibits remuneration to induce referrals for federally reimbursable items; the Stark Law separately bans physician self-referral for designated health services absent an exception.

Two-midnight rule: inpatient admission is generally appropriate when the physician expects the stay to span two midnights; otherwise outpatient or observation status applies.

Conditions of Participation (CMS) set minimum health and safety standards for Medicare participation, including grievance, infection control, and patient rights requirements.

Compliance program elements (seven): written policies, compliance officer, training, communication lines, auditing/monitoring, enforcement/discipline, and response/corrective action.

Charity care and financial assistance policies must be written, widely publicized, and applied consistently; 501(r) rules apply to nonprofit hospital organizations.

Span of control = number of direct reports per manager; wider spans require stronger standard work and self-service tools.

Staffing to volume uses productivity ratios such as registrations per FTE or accounts worked per FTE per day; variance from target signals over- or under-staffing.

PDSA (Plan-Do-Study-Act) cycles test small changes before scaling; each cycle has a measurable prediction and a documented result.

Root cause analysis distinguishes proximate cause from system cause; repeat denials usually trace to a front-end data defect, not the payer.

Key performance indicator dashboards should pair a volume metric (registrations, claims) with a quality metric (error rate, denial rate) to prevent gaming.

Change management: stakeholder mapping, communication plan, training, and go-live support are required for any workflow or system change.

Turnover cost includes recruitment, onboarding, and productivity ramp; registration turnover above industry norms erodes clean claim rates.

Capacity planning: forecast volume by day-of-week and season, then align schedules to peak arrival patterns to reduce wait times and abandonment.

Vendor and payer contract management: track SLA performance, escalation paths, and contract terms for outsourced eligibility, coding, or collections.