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Basics of Healthcare Revenue Cycle Management


The noble cause of saving lives and treating patients is the prior most aim of the healthcare providers like doctors, physicians, imaging centers, emergency and intensive care centers, pharmacies, etc. Perfect financial management, tools and techniques to meet inevitable crises and expertise are needed to run and flourish the healthcare industry smoothly.

So, the healthcare revenue cycle management is all about this management of administrative and clinical tasks to deal with the processing of claims, payments, generation and collection of revenue. There is no other way for healthcare providers to pay their bills and cater to the needs of patients without this revenue cycle management.

The Process of healthcare revenue cycle management:

  • An appointment for a medical service is made by the patient. Further creating and verifying the patient’s account, scheduling and insurance ability requirements are done by the administrative staff
  • The pre-registration process involves getting the medical history and insurance coverage to create the patient’s account
  • The patient can go through the actual medical service or procedure; sometimes prior authorization approval is needed
  • The claim is eventually created and forwarded. Wherein, using the appropriate ICD-10 codes, the nature of treatments received can be identified by the functional coder
  • As per applicability, the private or government payer receives the claim for reimbursement. Still, the back-end processes of statement processing, handling the collections and claims denials are to be dealt with
  • Evaluation of the claim occurs. Here, the reimbursement based on the patients’ coverage and payer contracts is done to the healthcare organization for their services. But, improper coding, missing items, or/and incomplete patients’ account details may lead to the denial of claims.
  • Apart from the coverage, the patients are liable to pay the charges for the services rendered and the materials used in the procedure that are not included in the coverage

The revenue cycle management should be so excellent so that the complete and hassle-free reimbursement or payment must be achieved by the healthcare management for the services provided.

What happens actually?

Perhaps, sometimes the scenario is exactly the unexpected wherein, the healthcare back-end staff has to work exclusively for claim settlements and payment issues. The shortage of in-between time and the utmost care they provide to the patients leads them to deal with such unexpected situations.

Ways to tackle this…

  • Here comes the assistance of the role of the medical billing service provider. They can be hired at affordable prices for the best-suited service provided to run the revenue cycle management smoothly with the best options and solutions whenever needed. 
  • To achieve an outstanding position, unmatched and clear prices for services, top-level clinical outcomes and effective billing and collection process is a must at this hour.
  • Revenue can be lost if the identification and resolving of issues are not done timely. An automated alert system can be designed to address the reason for unexpected claim denials by the patients.

To empower the revenue cycle management, alloying the technology and utmost human vigilance with the revenue cycle is the topmost priority. 

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