Revenue Cycle Management in the US Healthcare

Revenue Cycle Management in the US healthcare is the financial process which utilizes medical billing software to track patient care information from appointment schedule to the insurance payment or patient payment of a balance. Current transition from fee-for-service to value-based care reimbursement will bring changes to the traditional revenue cycle management (RCM) in healthcare.

What is another name for revenue cycle management (RCM)?

Medical billing is the process of submitting and getting physicians paid for their services from insurance companies. This process is done by the medical billing company or healthcare provider themselves (interaction between billing team and the insurance company). This process is carried out by all insurance companies, whether they are private payor or government sponsored programs. This entire process of interaction between the billing team and insurance company is known as the medical billing cycle sometimes referred as Revenue Cycle Management.

Small practices, hospitals and groups of physician organizations are working to save lives and treat patients. All healthcare organizations need to develop their successful billing cycle and policies to stay financially healthy. Here healthcare revenue cycle management comes in.

Why revenue cycle management is important in the healthcare industry?

Revenue cycle management is a process, this process enables the healthcare industry to work efficiently without worry of financials. The overall goal of this process is to increase revenue throughout the various steps.

RCM prevents fraud, waste, and abuse such as needless tests and procedures. For you as a physician, revenue and finance are not the primary concern. You are more focused on patient care, here we as a medical billing company can help you to maintain your cash flow.

RCM is an interaction between healthcare providers and insurance companies, so it includes patients’ medical records and it’s also important how these records are accessed and stored for billing purposes. Nowadays, since technology has evolved from basic to advanced, there has been an increase in attacks on medical organizations to acquire access to medical records. These medical records and other patient’s personal health information (PHI) are protected by federal law such as the HIPAA (Health Insurance Portability and Accountability Act) privacy and security rules.

RCM is the important process in healthcare. Automated RCM processes can give more room to physicians to focus on patient care. Contact our healthcare management consultants today to know why you should outsource your revenue cycle management.

Steps in revenue cycle management

Outsource medical billing or RCM Software

You first need to analyze how to manage your RCM process. What is the size of your organization? If you are a small organization and limited with a good IT team in place as well as in-house medical billing team members who are well versed in using dedicated medical billing software, you may need to partner with us to increase your cash flow and keep your organization up to date with all billing compliance.

However, if you are running a larger organization, such as one with multiple offices in multiple locations. Also, you have a good IT team and you have the best medical billing staff. Then you have a choice to manage the RCM process with your in-house team. But to manage this staff, their training, perks, and other benefits your admin team has to invest more time on it. You need to find an expert in RCM. This will be beneficial to rely on this outsider for the RCM process, so your organization can focus on your core capabilities in patient treatment.

Patient Scheduling and patient Demographic Entry

Patient demographics is the core of the data for any medical practice or specialty. Demographic information examples include: age, ethnicity, gender, race, marital status, income, education, and employment. Gathering all patient demographic information is required at the time of patient scheduling is important. It can help to improve the quality of care for all patients.

Patient Pre-Authorization

Patient pre-authorization of each patient is important in RCM. Pre-authorization is defined by the US government as a decision by a health insurer or plan that a prescription medication, procedure, services or equipment is medically necessary. In case of a medical emergency, you can make an exception in pre-authorization.

Pre-authorization does not mean that the insurer will cover patient treatment costs. Patients and providers have to confirm if there is any doubt in coverage. Prior authorization is intended to help avoid you from being prescribed medications you may not need.

Eligibility Verification

Insurance Eligibility and benefits verification is one of the top most important steps in revenue cycle management. As per the industry research, most of the claim denials or delays in processing the claim occurred due to missed or wrong coverage information.

Updated medical billing software includes automatic checking of patient eligibility online over a secure channel. Dedicated medical billing software can speed up your work involved in verifying a patient is entitled to a particular benefit or not.

Claim Submission

Claim submission is a process in revenue cycle management. Insurance claim submission is a key step in the medical billing process. It identifies the amount of collection that the healthcare provider will receive after the insurance company processes the payment.

Properly claim submission is important to avoid claim denial in future. Medical billing software is invaluable in this situation. Medical billing team can submit claims automatically with the help of software, including the option to do this in batches. There can be human errors while submitting claims to insurance companies. Your medical billing software should have an option to detect mistakes and then explain them to you so you can fix the issue.

Payment Posting

All the players either send an Explanation of benefits (EOB) or Electronic remittance of advice (ERA) towards the payment of the claim submitted by the provider. Medical billing companies or staff post these payments into the respective patient account, against that particular claim to reconcile them.

Once your outsourced medical billing team or in-house team completes the payment posting, you can analyze patient responsibility. Your RCM software can help in this respect not only in the convenience it offers for generating patient billing statements, also to send automated messages to patients with a pay online option to encourage them to reimburse you more prominently.

Denial Management and Reporting

This is a critical element of your RCM for a healthy cash flow. Leverage Medisys Data Solutions team to create reports for your billing and easily find the causes of denial of claims. With the help of our Denial Management process you can mitigate the risk of future denials and get paid faster.

How often your claims are getting denied for services rendered out of your facility? If your monthly reports are showing a downturn in revenue because too many claims are getting denied, it’s time to find the exact cause. Properly executed denial management processes can boost earnings.

Medical billing reporting can uncover claim denial patterns. This way you can work around it to make sure you achieve 99% successful claim submission.

Revenue could be lost if providers cannot identify issues in revenue cycle management and are unable to resolve them quickly. We can help you to alert that address why payers are routinely denying claims for a specific procedure or code.

Contact the Medisys Data Solutions team today for more information about how our services can make you more productive and profitable.

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