• Implement the process: The first step in the revenue cycle process is implementing the RCM software or outsourcing the process to RCM services providers who are adept at handling the process with exceptional efficiency. For healthcare practices that have limited staff expertise or large organizations that have branches, outsourcing is the best approach so that they can focus more on their core job of providing quality patient care rather than worrying about financial matters.
• Patient access: This forms the basis for the entire RCM process where the effective functioning of the front office staff can minimize the claim denials and rework at a later stage. In this process, it is essential to check on the eligibility and benefits for patients.
• Pre-authorization: Prior authorization or pre-authorization is the next step in the revenue cycle process where the RCM services professionals have to obtain approval from the health insurer for the healthcare service, treatment plan, medications, or equipment to be used or performed that they are medically necessary for the patient. Pre-authorization is a pre-requisite for certain services with some exceptions in case of an emergency. However, one point to be noted is that pre-authorization doesn’t guarantee reimbursement of the cost.
• Claims submission: Payments for services performed will not be received until accurate claims are not submitted by the office. Practice management software comes in handy for the process of automatic claims submission. Where the RCM process is outsourced, the RCM services professionals need to submit the claims and ensure that they are flawless. In the case of any denials, the cause of denial has to be resubmitted post rectifying the errors.
• Reimbursement for services: Once the claims are submitted, it is time when the insurance payers have to reimburse for the services provided. The payers would verify the procedures with their charges and check the insurance coverage limit. They would check if the bills are accurate and reimburse for their services.
• Collections from patients: When the reimbursements do not cover the services provided fully, then for the outstanding amount the RCM professionals have to send the bill and follow up with the patient to collect the amount from the patients. Medical billers who are an important part of the revenue cycle process have to rigorously follow-up and ensure that the patients pay the total amount.

Performing all the steps properly and in a timely manner will help streamline the revenue cycle effectively. Every healthcare facility whether small or big will need proper revenue cycle management which can be provided by the RCM services providers.

Why RCM Process?

RCM process involving various aspects such as medical coding, medical billing, collections, and data analytics aids in the efficient running of a healthcare facility leading to better financial outcomes and improved patient care. Poor billing practices in a healthcare facility can lead to monetary losses resulting in a potential decline in the quality of care being provided; thus, it becomes critical for every healthcare facility to have a robust RCM process in place.

An effective RCM process ensures that right from the moment a patient comes to a facility for initial inquiry to the time when the final payment is received, the patient interaction is managed competently. The various aspects of the RCM process ensure that all the essential and appropriate information is collected and documented accurately aiding in billing only those services that are provided. Further, the RCM process enables contacting the payers or patients timely and collecting the due payments promptly avoiding denials and bad debts. After all, nobody likes bad debts and losses.

However, revenue cycle management involves multiple and complex patient interactions and mismanagement of any of these interactions can adversely affect the patient and clinical satisfaction scores damaging the reputation of a facility, halting its growth, and creating uncertainty for its financial performance. This is the reason every healthcare facility, irrespective of its size or health system, must prioritize revenue cycle management and revenue collection.

Steps of the RCM Process

• Preregistration: This is the first and most crucial step of the RCM process that allows a healthcare facility to collect important patient information including demographic data, insurance information, and eligibility for insurance. This step helps the facility check the patient’s insurance coverage, deductibles, co-insurance, and co-payments.
• Registration: This step further strengthens the aspect of collecting accurate information from the patient. The patient’s details such as phone number, address, date of birth, and insurance details are verified every time a patient is provided treatment regardless of whether the patient is new or established. This step, if performed diligently, can help avoid many issues at later stages.
• Charge capture: This is the step where medical services provided are transformed into billable charges. Accurate documentation of every service plays a critical role since these need to be submitted for payment from patients or insurance providers.
• Claim submission: In this step, information is sent to the insurance payer after entering the charges where it will be verified if the diagnosis and procedure performed are aligned.
• Remittance processing: This step involves applying or rejecting payments where allowable and write-offs are determined.
• Insurance follow-up: This is the step where the healthcare facility analyses the paid and unpaid amounts through the accounts receivables report.
• Patient collections: This is one of the toughest parts of the whole revenue cycle process where patient balances are determined and the amounts are collected from the patients.

A healthcare facility gets paid for the services delivered only when all these steps are performed diligently and accurately. Thus, the RCM process aligns the clinical care aspects with the business aspects and helps the healthcare facility function efficiently and successfully.

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People in medical coding jobs must know the elements of a medical claim and prepare medical claims accurately because the accuracy of these claims brings the healthcare providers full reimbursements helping them to maintain a healthy revenue cycle. There are two parts to a medical claim – the claim header and the claim detail. If you are working for a healthcare provider or a medical billing company, you must be aware of these parts and what information goes into which part.

Claim Header:

A claim header gives the most critical information in the claim including confidential and personally identifiable information such as:

• Date of birth
• Gender
• Zip code
• National provider identifier (NPI) of the physician or healthcare facility
• Primary diagnosis code
• Inpatient procedure, if any
• Diagnosis-related group
• Insurance company’s name
• The overall charge for the claim

Claim Detail:

This includes all the information related to the secondary diagnoses and procedures performed during a patient’s inpatient hospital stay including:

• Date of service (DOS)
• Procedure code
• Diagnoses code
• National drug code, if any
• Attending physician’s NPI number
• Charge for the service

Once a medical claim is prepared by the revue cycle management (RCM) team, it is sent to a clearinghouse which is an electronic intermediary between the healthcare providers and insurance companies. At the clearinghouse, the claims are scrubbed, standardized and screened before sending them to the payers to mitigate and rectify any medical coding and formatting errors in the claims that can delay the reimbursements from the payers. Clearinghouses are not just beneficial for the healthcare providers but also for the payers. The clearinghouses format the data received from various healthcare providers according to the unique requirements of the insurance companies thereby standardizing their data and speeding up their processes.

If you are a medical biller or a part of an RCM services company, you must ensure that you process clean claims for your client so that the healthcare provider gets full reimbursement for the services rendered without any claim denials or rejections that reduce your revenues and hamper your revenue cycle management process. Further, the medical claims prepared by you can be of great use for the healthcare providers to trace referral patterns, increase sales and accelerate the marketing strategies that help them improve their revenue cycles.

If your patients are not satisfied with your approach, diagnosis, treatment course, and/or your facility’s hygiene or maintenance, your patients may not be positive towards you and consult another doctor/facility the next time. It is hence, critical to keep your existing patients satisfied to retain them for a long time. Here are some tips, given by the RCM services professionals that will help you in existing patients’ retention and thereby your revenue cycle.

• Understand expectations: As a healthcare provider, you must understand the patient expectations and needs to be able to meet them. In case, you are unable to meet their expectations, you must explain to them the reasons for the same and explain to them what they can expect from the medical procedures performed. According to the RCM services experts, this will help you make the patient feel valued and involved in their health aspects. Such a feeling will allow them to get comfortable with you and approach you anytime they need medical assistance, thereby helping you retain your existing patients satisfactorily.
• Maintain transparency: Patients come to you burdened with their health issues, so you must be transparent enough regarding their health condition, treatment course and the financial aspects of the medical procedures. Do not create false hopes regarding their health and drain them physically, emotionally and financially. This helps in building trust and patient retention.
• Give value: Patients come with a lot of physical pain, emotional stress and many times, financial burden as well. When they are experiencing such stress and pain, what they expect from you as a healthcare provider is a genuine care and compassion. Providing exceptional patient care by giving them good ambience and attending to their needs promptly makes them feel valued which is the core to patient retention and improve your revenue cycle.
• Serve at all levels: Providing exceptional service in all the departments of your facility is one of the most important aspects of healthy revenue cycle management. You must ensure that every staff member in your facility, right from the front office team to your billing team, along with the medical staff that includes the doctors, nurses and other allied healthcare staff; is aware of patient handling and facilitates easy appointments, quality treatment, prompt billing, comfortable environment, and easy access to people and services.

As a healthcare provider, be compassionate and make the patients feel comfortable, meet their expectations, make them understand that you value them and they are your priority and ensure a pleasant and safe environment for them. This will go a long way in retaining your existing patients and improving your revenue cycle. For better management of your revenue cycle, outsource your billing process to the best RCM services providers and stay ahead of your competitors.

Every patient who needs surgery as a way to correct his/her health condition has two options for surgery depending on the careful diagnosis by the healthcare provider – urgent or emergency surgery and elective surgery. An urgent or emergency surgery is done where it is an urgent medical condition and sometimes the condition could be life-threatening. Surgeries for acute appendicitis and trauma are examples of emergency surgery. This type of surgery needs to be carried out regardless of the other prevailing conditions. Elective surgery is one that can be scheduled in advance in contrast to the emergency one. An elective surgery could be done to improve the quality of life and in some cases, it could be to treat serious conditions such as cancer and heart diseases. Any surgery right from the one done to remove a wart to one performed to remove kidney stones can be an example of elective surgery. When such elective surgeries are postponed due to the fear of transmission of infectious diseases, it leads to revenue loss and is a matter of concern for both the healthcare providers and RCM services providers.

Some health conditions need expensive treatment and also have a high readmission rate. Heart failure is an example of such conditions and from a patient’s perspective, postponement of elective surgeries for such conditions can be costly due to the additional yearly medical expenditure incurred. And, from the healthcare providers’ viewpoint, reduced revenues affect the revenue cycle management and create operating constraints.

Although there are no procedures that can help the healthcare facilities to totally avoid the losses due to postponement of elective surgeries, some solutions as suggested by the best RCM services experts can reduce the burden significantly. The first thing you must do as a healthcare facility is optimizing returns on the services that you are providing. The key to ensuring this is hiring the best medical coding and RCM services providers who can maintain the highest levels of coding accuracy and submit flawless claims to maximize the reimbursements from the insurance providers by reducing denial and rejections.

If you don’t have the right RCM services partner, it could get difficult for you to sustain in this pandemic situation because without a robust revenue cycle management process, you can’t get appropriate revenues for even the services provided. This will not only reduce your revenues but will lead you to losses eventually. To improve your RCM process and work towards financial recovery in these tough times, it is imperative that you hire the top RCM services providers who have the experience and expertise to work in challenging times and steer you towards greater revenues and profits.

Despite having set processes and procedures for the RCM process, you may find gaps in some of the RCM processes including speciality healthcare processes. If your organization provides speciality healthcare, you need speciality-specific RCM services experts to understand the nuances of speciality care and the frequent updates in government policies and regulations. Further, revenue cycle management of speciality healthcare processes can be daunting due to the complex financial and administrative challenges they bring along. Let us take a look at some of the common RCM challenges you may face as a speciality healthcare provider and ways you can overcome them.

• Poor prior authorization process: Prior authorization is the process wherein you take approval from the insurance payers to provide services to a patient before you actually provide the service. If your prior authorization process is not standardized, you may face problems in the form of denials and rejections when you submit claims for reimbursement. According to the top RCM services providers, this can be avoided by implementing a strong prior authorization process that helps you to provide evidence-based treatment to patients thereby adhering to the different requirements of multiple insurance payers so that reimbursements are effortless and unnecessary costs are controlled.
• Inappropriate coding: Appropriate coding for specialty services is a major and complex contributor to the efficient revenue cycle management process. Inadequate knowledge of specialty services’ coding rules and inaccurate coding can lead to revenue loss. To mitigate such losses, you can outsource your coding and billing processes to RCM services companies that employ the best medical coders and billers with exceptional knowledge of specialty services. Another advantage of outsourcing these processes to such companies is that they ensure that their medical coders and billers are well-versed with frequent updates in the industry.
• Capturing charges inaccurately: Charge entry is critical in the revenue cycle as it determines the reimbursement you are entitled to for the services rendered. Since the costing and profitability of your services and facility depend on the success rate of your reimbursements, it’s essential that your charge entry process is accurate and for this, you need medical billers who are adept at the billing process of the specialty healthcare you provide. Employing the right medical billers or RCM services providers becomes even more critical when you offer multiple specialties and multiple systems are used to generate different information. In such a scenario, you must implement data interoperability to mitigate challenges in the charge entry process.
• Inappropriate management of A/R: Your RCM team must be aware of the account receivable benchmarks for various specialty services and ensure that these benchmarks are adhered to. Non-adherence to such benchmarks will impact your revenues negatively. Hence, it’s necessary to draft appropriate standard operating procedures and guidelines to minimize the account receivables days and prevent and manage denials.
• No credentialing process: By following the credentialing process, your services can be validated by various insurance payers allowing timely payments from the payers. If you are not validated by the insurance payers regarding your licenses and specialty accreditations, they may delay your reimbursements impacting your finances negatively. You must ensure that you are credentialed appropriately for the services you render and get your information updated upon acquiring a new specialty or certification.

As a speciality services provider, you must be aware of these common challenges and be ready with appropriate tools and strategies to overcome them. To eliminate such challenges and improve your financial health, it is better you outsource your revenue cycle process to a reliable RCM services provider with speciality-specific expertise.

• Front-desk work: Whether you believe it or not, your claim work starts at the front desk; you must ensure you get accurate information regarding insurance cards and identity cards. For an efficient revenue cycle management process, it is imperative that your front desk staff verifies insurance and coverage at the time of the registration process and ensures the registration form is filled completely.

According to RCM services experts, it is also beneficial for you if you could get a good financial agreement signed by the patient at the time of registration after duly explaining the patient’s liability in case of no-show, inability to pay timely copay charges, etc. With the backing of a good financial agreement, you can collect patient balances without hassles.

• Charge posting work: Getting the charge posting done by medical billers in a quiet location far from distractions will help you file accurate claims and get timely reimbursements. This is necessary to avoid a hold-up of your payment for minor inaccuracies in data.
• Claim submission: Ensure your medical billers submit correct claims with accurate and relevant data as required by the insurance companies and clearinghouses. Else, your claim may get held for you to rectify the information and resubmit. Some clearinghouses carry out their processes online and you may get information soon, however, if the clearinghouses work in the conventional style, your claims may get stuck for want of accurate information which you would be able to submit only when you get a report from the clearinghouses regarding the errors in the claim submission. To avoid such errors at the time of submission, you must hire the best RCM services providers.
• Claim follow-up: When your medical billers are filling up the post of your front desk executives, there is a huge scope for missing out on follow-up of claims due to the irrelevant pressing duties of the medical billers. To counter this situation, you should partner with the top RCM services providers who lay the focus only on claim submission, follow-up and timely reimbursements. Having dedicated staff for medical billing is crucial because regular and timely follow-up is pivotal for a profitable practice. Running reports on due claims over 120 days and taking rigorous follow-up action is the most imperative task that no healthcare provider should ignore.

A lot of work goes into getting your claims paid as quickly as possible. Starting from the front desk, your claim submission and reimbursement processes should be managed efficiently to ensure you get full reimbursements without any difficulty. To get such timely reimbursements and have a profitable revenue cycle, you must hire the best RCM services providers.

Revenue cycle management (RCM) is the management of finances, a crucial process that keeps an organization going on a daily basis. Medical billing plays a major role in the efficient functioning of the RCM process and thus the healthcare facility. If facilities do not focus on their financials they would be floundering no matter how excellent their patient care would be. Without an effective revenue cycle management process, healthcare facilities cannot sustain their functions and treat patients.

What is healthcare RCM?

Healthcare RCM is the financial process of healthcare facilities that is used to manage various administrative and clinical functions related to medical billing viz. claims processing, payments, and revenue collection. The process begins from the moment a patient seeks medical services with an appointment and ends when all payments associated with the services provided to a patient are collected either in the form of insurance claims or patient payments. The process can be performed with in-house employees or can be outsourced to RCM services providers.

A key aspect of the RCM process is that RCM services professionals unify the commercial and clinical aspects of a healthcare facility by collating the administrative data along with the personal information of a patient with that of the details of the treatment the patient receives. Another key aspect of revenue cycle management is communication with insurance companies that is carried out by RCM services providers or the in-house medical billing employees. Every time a patient visits a healthcare facility and asks for an appointment, the hospital staff or the RCM services professionals communicate with the insurance providers and cross-check the insurance coverage of the patient before providing the services. Thereafter, upon providing the services, they categorize the services according to the ICD – 10 and CPT code sets and sends them to the insurance companies as insurance claims for reimbursement of the costs incurred on the services provided to the patient. In cases, where the insurance coverage is not sufficient, the patient is billed for the remaining amount.

There are numerous factors that affect a healthcare organization’s revenue cycle management. These include –

• Accurate patient information – all the relevant patient information needs to be collected at the time of registration and before providing services.
• Utilization review – the necessity of medical services has to be reviewed and determined.
• Applying codes – accurate codes have to be applied to all the services provided including diagnoses and procedures performed.
• Charge capture – all medical services need to be rendered into billable charges.
• Claim submission – appropriate and timely claims for the services rendered have to be submitted to the insurance providers.
• Insurance collections –amount receivable from the insurance providers has to be collected.
• Patient collections –balance amount has to be determined and collected from the patients.

Every healthcare organization has to deal with all these influencing factors and a healthcare facility can have control over the internal influencing factors like providing a good patient experience, the productivity of the employees and fee collected, etc. However, it cannot exert control on external factors like insurance companies’ claim reviews and patient collections. Hence, it is essential that every healthcare facility has a robust revenue cycle management process in place.

A healthcare facility’s health depends on its revenues from reimbursements and out-of-pocket payments from the patients. While payments from patients can be collected with a little ease with a few processes in place, reimbursements from insurance payers are not that easy and they become even more difficult in cases where the claims are denied. A claim denial is one of the most recurring problems encountered by healthcare facilities and it has to be effectively managed to have efficient revenue cycle management. Let us know how problems in denial management can be addressed effectively and facilities’ revenues can be maximized with a few revenue cycle management steps.

• Get familiar: The first thing every healthcare facility and RCM services professionals should learn is that, claim denials are pretty common in the industry for various reasons. Although denials are a part of the healthcare revenue cycle process, appropriate measures should be taken and strategies implemented so as to minimize revenue losses. Facilities should understand where and how they are losing money due to denial, what is the percentage of denials in claims submitted, etc.
• Denial reasons: RCM services providers insist that facilities should identify the reasons that are leading to the claim denials on a regular basis. Mostly denials occur due to false or missing information, delay in filing claims, including services that not covered, filing duplicate claims, etc. Identifying the exact causes of claim denials will help in minimizing the denials.
• Best practices: Denial management should be always done proactively rather than after denials happen. RCM services professionals have to put robust measures in place to avoid denials rather than tackling them later. Healthcare providers or RCM services providers should identify the best practices for claim denial management and ensure that they are being implemented without fail.
• Front-end practices: Claims submission process is not possible without the processes of front-end processes of patient registration, scheduling, healthcare documentation, and medical coding. Denials can happen due to errors at any stage of providing health care and hence, it is always essential to implement strong processes that minimize errors and help in preparing flawless bills for accurate and timely reimbursements.

A healthcare facility’s revenue cycle involves several processes and procedures that need to be performed efficiently so as to improve the facility’s financials and be successful as a healthcare provider. Facilities that are not equipped to tackle medical billing, claims submission, denial management, and other related functions can outsource the process to RCM services providers who have exceptional expertise and experience in dealing with all the processes of a revenue cycle.

A healthcare facility’s growth depends on the healthy patient-provider relationship that is dependent on the quality of services the facility provided to the patients. Healthcare facilities work hard in every department right from the physicians to the support staff to ensure that the patients have a positive experience with the facility and get great patient care. However, all these efforts become futile when the patients receive a medical bill with errors from the revenue cycle management staff. Avoiding these common billing errors can save healthcare facilities from developing negative patient-provider relationship:

• Wrong entry of patient details: One of the most annoying causes of medical claim denials is inaccurate or incomplete patient information in the medical bills. Things that may look trivial like a misspelt patient name or incorrect policy number can play a pivotal role in the claim denial. Persons involved in RCM services should always ensure to input accurate and complete patient information to avoid claim denials, get timely reimbursements, and maintain healthy patient relations.
• Avoid mismatch of codes: Many times, patients suffer a lot of inconveniences and sometimes agony too because of wrong medical bills given by the revenue cycle management staff. Billing errors can happen when wrong codes are entered in the bills for the services provided either due to technological or human error. Entering correct code is essential to arrive at the correct bills otherwise it may result in patients getting angry for the incorrect bills.
• Duplication of codes: As per rules, a medical claim should not have any duplicate ICD-10 CM diagnosis code within item 21 or else; the claim will be unprocessed and returned. To avoid this, RCM services providers should ensure avoiding any duplication of codes.
• Upcoding: Whether accidental or intentional, the addition of unnecessary services or procedures in the bills will spoil the provider-patient relationship. Upcoding in a bill happens when a patient gets a bill more expensive than what it actually should have been for the service provided. A upcoded bill may be sent to an insurance provider or the patient. Whatever the case may be, when the bill is wrong it will affect the healthcare facility because the insurance provider will decline the claim or the patient will refuse to pay more for the wrong bill.

To avoid errors resulting in a poor provider-patient relationship and a negative impact on the financial position of the facility, every healthcare facility should have a robust revenue cycle management process in place. Else, it should ensure flaw-less bills by outsourcing the process to the best RCM services providers.