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Revenue Cycle Management

REVENUE CYCLE MANAGEMENT

NIRMITI Y SURVERoll No.: LPGD/OC14/0246

SPECIALIZATION : HEALTHCARE MANAGEMENT

PRIN. L N WELINGKAR INSTITUTE OF MANAGEMENTDEVELOPMENT & RESEARCH

Year of Submission : MARCH 2016


ACKNOWLEDGEMENTS

With immense pleasure I would like to present this project on “Revenue

Cycle Management”

I would like to thank “Welingkar Institute of Management” for providing

me this opportunity to present this project.

Acknowledgements are due to my family members, friends & all those

people who have helped me directly or indirectly in the successful

completion of this project.

Nirmiti Y Surve


Table of Contents

Sr. No. Particulars Page No

. Executive Summary 05

1. Introduction- What is Revenue? 06

2. Healthcare Revenue Cycle 07

3. Revenue Cycle Management (RCM) in Healthcare 08

4. Revenue Cycle Terminology 10

5. Three phases of Revenue Cycle Management (RCM) 19

6. Healthcare RCM Process 22

7. Claim Adjudication 32

8. Denial Management 35

9. Revenue Cycle Management -Problems & Solutions 41

10. Revenue Cycle Management System 51

11. Growing importance of RCM 55

12. Conclusion 59

13. Webilograpy 60


EXECUTIVE SUMMARYThe fundamental principle on which every business is based is generation of revenue, not

just some revenue but maximum amount of revenue possible. This applies to Healthcare

Industry also. Inspite of offering best healthcare services, a negative cash flow might run the

healthcare business in short term but cannot survive for a long to meet its current and future

needs. On the other way, positive cash flow can be utilized for its expansion and operational

expenses.

Healthcare payment systems are complex and difficult to administer. The healthcare

environment faces ongoing pressure to sustain financially and to continue providing quality

care. Unfortunately, a growing number of hospitals and physician practices are faced with

negative profit margins, increased risk under accountable care models and declines in

traditional reimbursement methods. The evolution of healthcare insurance has affected more

than just payment for healthcare services; it also changed the way hospitals, insurance

companies, and patients interact.

To deal with decreases in payment and the ever increasing complexity of reimbursement

rules, regulations, standards, and systems, healthcare providers have instituted a process

called Revenue-Cycle Management (RCM) for administering their interactions with payers

operating under various payment systems.

At the core of RCM is the need for providers to file clean, accurate claims. The process of

creating a medical claim involves a whole host of activities. These activities typically include

Patient verification, scheduling, eligibility, registration and up-front collection, provider

encounter, charge entry, coding, claim scrubbing and editing, claim submission, payment

posting, claim rework & finally closing of account.

Revenue Cycle Management System (software) helps hospitals to address the challenges

they face with solutions designed to help maximize your billing and collection performance.

Thus strengthen the financial health and profitability of healthcare provider and all that

without adding more time & cost.


1. INTRODUCTION -WHAT IS REVENUE?

In business, Revenue is the income that a business has from its normal business activities,

during a specific period, usually from the sale of goods and services to customers.

The word ‘Revenue’ originates from Latin (revenire) and French (revenir) words meaning

‘Return’. In short one can say that Revenue Means getting back what is yours. Revenue is

also known as "REVs."

“Revenue is vanity, cash- flow is sanity, but cash is king”. This proverb is profoundly

accepted in all fields of business. It talks about the importance of money in all its forms in a

business environment.

Healthcare is a service Industry which includes Public hospitals, Private Hospitals and

academic medical centers who provide a substantial amount of inpatient and outpatient

healthcare services to insured, uninsured, and other vulnerable patients. Although treating

such patients may be central to these institutions' core mission, doing so may pose problems

for their financial solvency, as much of this care may be uncompensated.

To increase profitability of any business it is important to create the widest gap between the

cost & revenue as the more the cash generated, the more will be utilized for its operational

activities and s and renewal & expansion.

Without a constant cash flow there lies a threat to the very existence of any business, hence

it is very essential for the management to make every effort that efficient people are

employed to keep track of the cash flow and take every necessary required to improve the

cash flow management.

2. REVENUE CYCLE IN HEALTHCARE


The Healthcare Financial Management Association (HFMA) defines revenue cycle as "All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue." In other words, it is a term that includes the entire

life of a Patient’s Account from its creation till payment.

The revenue cycle, in the parlance of clinic administrators, describes the totality of the steps

necessary to collect full payment for patient services performed

Healthcare Revenue Cycle starts right at the time the patient places a phone call to the

medical practice for an appointment and it ends when the payment has been received in the

healthcare provider’s account either from the insurance company or from the patient for the

service rendered. .

Revenue-cycle process generally involves following activities namely, scheduling,

registration, case management, coding, billing, payment posting and denials management.

Revenue cycle processes flow into and affect one another. When processes are executed

correctly, the cycle performs predictably. However, problems early in the cycle can have little

effects. It would be easier to detect any mistake early on primary stage and rectify it on time.

The further an error travels through the revenue cycle, it become more difficult to trace it.

3. REVENUE CYCLE MANAGEMENT (RCM)


Revenue cycle management (RCM) is the process that handles claims processing, payment

and revenue generation. In the simplest terms, it is a health care organization’s financial

circulatory system.

Healthcare claims are the center of the RCM universe and providers are engaged in various

activities closely related to claims. In other words, a healthcare claim is “a request for

payment of services for a single client that consists of one or more line item”. But claims are

really more than that because they also include demographic information about the patient,

information about the Payer and Provider. It also includes diagnosis and the reasons for

treatment and charges entry of services offered by healthcare provider.

Thus, there are FOUR key elements of Revenue cycle Management.

1 PATIENT 2. HEALTHCARE PROVIDER

3. BILLING COMPANY 4. INSURANCE PAYER

Providers provide care to patient (services) documenting their services, and coding. A billing

company gets these charges entered and remits to Insurance Payer t the door. Then, they

basically wait until they get responses from clearinghouses or payers in the form of

rejections and denials. If the claims are paid partly or if it is paid after a long period of time,

then resources from the accounts receivable & collection department need to be utilized in

order to get the claim settled. This delay would generally have a negative effect on the

revenue cycle and in certain cases might raise a question on the future growth of the

medical practice. Therefore it is very much essential that all FOUR players to align their

individual responsibilities work together & contribute to smooth functioning of Revenue Cycle

process.

Health care revenue cycle management involves many strategies, including procedures that

hospitals and clinics use to improve cash collections and meet liquidity goals. These


strategies also include customer receivables valuation, underpayment recovery policies and

transactions involving federal government programs such as Medicare and Medicaid.

As the cost of healthcare has increased, the complexity of delivery and insurance

mechanisms has increased exponentially. Also due to the stringent new rules and

regulations laid down by the healthcare regulatory bodies, the insurance payers are bound to

demand detailed records of services rendered to patients. This coupled with the complex

coding standards which are developed and updated quarterly or annually, bespeaks the

need of a seasoned medical billing specialty.

According to a study of American Medical Association it is observed that Health care

providers have to spend a fair amount of time a to perform quite a cumbersome task of filing

a claim. For many healthcare organizations, achieving and sustaining profitability requires

expertise in billing, coding and accounts receivables management.

One of the important reasons to develop an efficient revenue cycle is working on claim

denials and claim rejections. RCM in healthcare helps a medical practice to increase the

revenue by proper claim management, that is making sure that claims are paid to max

possible limit and within a specified period of time.

A proper revenue cycle management works on each and every stage of the revenue cycle to

increase the payments and collections while decreasing the write-offs.

RCM includes the use of technology to keep track of any claims through their entire lifecycle,

ensuring payments are collected and addressing any denied claims. The ultimate goal

allows health care providers doing the billing to follow the process and address any issues

quickly, allowing for the steady stream of revenue.


4. REVENUE CYCLE PROCESS -TERMINOLOGY Before proceeding towards various stages and steps involved, let us have brief introduction

to RCM process related typical terminologies.

Healthcare ProviderA healthcare provider means any individual, institution, or agency that provides health services to health care consumers. In other words a person or team of persons who

provides any form of health care services.

Health InsuranceInsurance is a contractual agreement between an insurance company and an individual or

entity to provide compensation or reimbursement against any form of loss for which

individual or entity pays a premium to the Insurance Company.

Health Insurance is an insurance against the risk of incurring medical and surgical expenses

to the insured entity. Any individual having Health Insurance can either opt direct

reimbursement from Insurance Company or from Healthcare provider.

It can be individual health insurance plan (where only the individual and sometimes the

immediate family members are covered under the plan) or group health insurance plan

(where a group of individual are covered under a single plan) usually provided by the

Employer. Some plans cover certain medical illness and treatment whereas others might not

cover those medical illness and treatment s, while some are flexible,

On the basis of features, the health plans can be categorized in three types.

1) Fee-for-service (FFS) Health Plans/ Indemnity Health Plan: In this type of plan, each

and every service rendered by the provider is paid separately as and Insured person has a

liberty to choose any provider for the medical service. These types of plans are costlier. If

and Insurer having this type of plan, avails or undergoes any treatment, healthcare providers

are instigated to perform more or unnecessary procedures as the payment is directly

proportional to the amount of services provided.


2) Managed Care Organizations (MCO) Health Plans- This organization is an umbrella

organization covering three main organizations, namely, (1) HMO (Health Maintenance org),

(2) PPO (Preferred Provider Organization, (3) Point of service plan (POS)

(i) Under HMO plans, insurer has to take medical service from healthcare providers

which are within the network of HMOs. Healthcare providers get a fixed amount from

HMO and in turn, it has to cater the assigned individuals irrespective of the number of

visits per month by the patient.

(ii) In PPO plans, the insured person benefits from the discounted rates whereas the

healthcare provider benefits from getting more number of patients.

(iii) Point of Service Plan – In this type of health plan, an insured has the option of

choosing a healthcare provider which is outside the network, but insured has to pay

more fees out of pocket as it non-network provider.

3) Consumer-driven Health Plans- Here certain sum of the untaxed wages of the insured

is deposited regularly into the savings accounts and this amount is utilized to pay for any out

of pocket medical expenses that may arise. These types of plan usually have high

deductibles and low premiums

Co-pay – It is the fixed amount and it needs to be paid by the insured during each visit. The

amount is specified in the opted health plan & insurance card.

Co-insurance- This is cost sharing percentage between insured and his insurance

company. Generally cost sharing is 80% /20% wherein company will pay 80% of the medical

cost and balance to be borne by the patient.

Deductible amount – This is mandatory amount a patient has to pay at the start of the

calendar year else he will not be eligible for his health insurance coverage plan.


Out of pocket – This is the maximum amount a patient may have to pay during a calendar

year. This amount may or may not include deductible amount.

Insurance Payer

Health Insurance Payers are the insurance companies/Payers which provide insurance

coverage to the individual who buy the Insurance Plans. These plans can be divided into

three categories.

1) Government –Funded Payers- these payers are financially are supported by Federal

Government. Some examples of such payers are

Medicare – This is totally a federal government funded program & included healthcare

coverage to individuals who are of the age 65 yrs & above. Government s later expanded

the program to include persons receiving disability benefits from Social Security and those

patients with certain kind of partial or total disability e.g. end-stage renal disease

Medicaid- This is a joint federal-state program, administered by each state—for low-

income people and families and each state has its own set of rules and regulations.

TRICARE—for active duty and retires U.S. armed-forces personnel & their

dependents.

CHAMPVA -The Civilian Health and Medical Program: Veterans Administration

(CHAMPVA)—for spouses, children, and survivors of veterans

Child health Insurance Programs (CHIP)Provides coverage to uninsured children

of families who are low income groups

2) Private funded Payers- These are group of insurance payers which are funded by

private organisations, these may be for profit or non-profit or hybrid type of Payers.

Coordination of Benefits (COB) is a procedure used to determine which plan will make


what payments when a patient is covered by more than one insurance plan. When COB is

an issue, it usually arises under one of two main scenarios: (a) more than one private

insurance plan covers a particular patient, or (b) a private plan and a public plan cover a

particular patient.

a) The first COB task is to determine which payer is the “primary payer” and which payer is

the “Secondary payer.” A survey identified COB as the main reason for claim denials, so an

efficient COB process is very important to revenue-cycle management. When a COB issue

arises between two private plans, the plan terms and state law generally govern which plan

is primary.

b). Private Coverage and Medicare Coverage - In its original form, Medicare automatically assumed as the primary-payer role in any COB

The National Association of Insurance Commissioners (NAIC) maintains a set of Model

Rules for COB. Most states have adopted the NAIC rules or very similar rules. Another

important NAIC Model Rule provision states that the primary insurer must pay a claim as

though the secondary insurer did not exist. But the secondary plan may take into account

payments the primary plan makes.

Medical Transcription

Medical transcription involves receiving dictation by tape, digital system or voice file, the use

of ear/head phones, a foot pedal for start-stop control, a variety of word processing

programs and sometimes the use of a printer and a modem.

Medical transcription is the process whereby one accurately and swiftly transcribes medical

records dictated by doctors and others, including history and physical reports, clinic notes,

office notes, operative reports, consultation notes, discharge summaries, letters, psychiatric

evaluations, laboratory reports, x-ray reports and pathology reports.

Super bill- This is form which contains commonly used billable codes (ICD) for diagnosis

and (CPT/HCPCS) for procedures based on the speciality and based on pre-printed billable


codes on the custom superbill, medical coder or medical coding company can select the

required codes. The rendering provider completes a superbill (a form which lists possible

services which can be quickly selected) describing the service provided.

Claim Adjudication

This is the process of paying the submitted claims or rejecting or denying them after

examining the clams as per coverage of insured person’s health plan. This process can be

manual or it can be auto-adjudication

Explanation of Benefits (EOB)

This is document sent by insurance payer to the patient giving brief explanation covered

amount, patient’s responsibility on his processed claim. The format for EOB varies from one

company to another.

Electronic Remittance Advice (ERA)This is the electronic version of Explanation of Benefits sent by insurance company to

healthcare provider mentioning what all medical services are covered under insured

persons’ plan. There is standard format for ERA.

Medical Coding

Medical Coding is the transformation of healthcare diagnosis, procedures, medical services,

and equipment into universal medical alphanumeric codes. The diagnoses and procedure

codes are taken from medical record documentation, such as transcription of physician's

notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the

codes are applied correctly during the medical billing process, which includes abstracting the

information from documentation, assigning the appropriate codes, and creating a claim to be

paid by insurance carriers.


A brief description of these Medical Code Sets.

Medical code set defines a standardised medical condition, treatment or service. It consists

of unique numeric or alphanumeric code for the specified diagnosis and service performed

by the physician. As per HIPAA (Health Insurance Portability and Accountability Act), the

healthcare providers have to use these medical codes for any electronic transactions. These

are ICD, CPT, HCPCS, CDT and NDC. A Medical coder in case of confusion a Medical

coder has to take help of Coding Manuals.

Healthcare Common

Procedure Coding System (HCPCS)

National Drug

Codes (NDC)

Codes on Dental Procedural &

Nomenclature(CDT)

Current Procedural

Terminology (CPT)

International Classification of Diseases

(ICD)

Medical Codes Sets

Different Types of Medical Codes Sets


Current Procedural Terminology (CPT) codes: These are used to describe medical,

surgical and diagnostic services provided by Healthcare Provider. These are divided into

three categories.

Category 1- covers different sections of services such as Medicine, Surgery, Anesthesia and

these codes are of 5 digits.

Category- 2 covers clinical services or patient management services and denoted by four

digits followed by the character for e.g. 4000F.

Category 3 .These codes are used to show new medical technology procedures & services.

These are temporary codes, which are once approved by AMA (American Medical

Association) becomes Category 1 code. Codes are four digits followed by letter for e.g.

0025T.

CPT Modifiers-These are two digit codes and helpful in case main CPT code is unable to

represent information about the procedures done. These are placed at the end of the main

CPT code.

Healthcare Common Procedures Coding System (HCPCS) codes:

This system was developed by CMS – Centers for Medicare and Medicaid and in most

cases these codes are similar to CPS codes, the reason being HCPCS codes are based on

CPT codes but also contains additional codes for services/procedures which are not covered

under CPT.

HCPCS codes are further divided into three categories, namely levels.

Level 1 These codes are identical to the CPT codes and are numeric. Therefore Medical

coding dept faces difficulty in choosing the correct code to apply. In such case Health Plan

can be referred. If the codes are used in Medicare or Medicaid then these are considered as

HCPCS codes and if these are used in private health plants, they are referred as CPT

codes.

Level2 – These codes include non-physician services like ambulance services. They consist

of a single alphabetical letter followed by four numeric digits for. E.g. P2028 for Pathology

and Laboratory. Level ii HPCPS codes are further divided into 17 sections.


International Classification of Diseases (ICD) codes

The main objective of developing the ICD cods was to create a universal code for describing

the cause of injury, illness and death.

After the publication of ICD 9th edition, a need was felt to include some additional morbidity

details and also to increase the specificity of the code. HENCE the current version which is

being used is ICD-9-cm, where in CM stands for clinical modification. In short CPT and

HCPCS procedures Codes represents “WHAT” was the procedure and ICD codes

represents the “WHY” physician/surgeon has performed that certain procedure.

ICD 9-CM is further divided into three volumes.

Volume 1 contains tabular list of diseases and Volume 2 contains alphabetic list of diseases.

Altogether there are approximately 14000 codes and has numeric codes are represented by

3-5 digits. for e.g. Disease of the digestive system (520 to 579). Volume 1 and are divided

into 19 chapters, out of which 17 chapters which covers certain group of diseases and two

chapters called as E codes and V Codes, wherein E-codes are supplementary classification

of ICD-0-CM and V-codes are supplementary classification of factors influencing health

status and contact with health services.

Volume 3 contains tabular and alphabetical list of procedure codes which are 3-4 digits.

ICD-10

As the ICD-9-CM coding has reached the maximum level and further addition is not possible,

hence the tenth edition of ICD has been developed with additional codes for increased

specificity (wef 1stOct 15)

Similar to ICD-9, ICD-10 is also divided into two parts ICD-10-CM and ICD-10-PCS wherein

ICD-10-CM, Clinical Modification is similar to ICD-9-CM, volume 1 and 2 having all the

diagnosis codes and ICD-10-PCS IS SIMILAR TO icd9-cm volume 3 for inpatient procedural

codes.

The department of Health and Human Services 9HHS) has mandated that all entities

covered by the Health Insurance Portability and Accountability Act 9HIPPA0 must use the

new ICD-10 codes set for electronic transactions


NATIONAL DRGUS CODES (NDC). These codes are used to identify the specific drug or

product administered to patient, if this code is not submitted in the proper format, the claim

will be denied.

CODES ON DENTAL PROCEDURE AND NOMENCLATURE(CDT)-These are codes

maintained and distributed by American and Dental Association for Dental Procedures and

its supplies, it was developed in order to achieve uniformity and consistency in reporting

difference types of dental procedures.

Undercoding- It means providing a service to a patient and deliberately coding it less than

the parameters requires for that service.

Overcoding- is when reporting a more complex/ or higher cost procedure than what was the

actually performed by the physician

Unbundling- is defined as submitting the codes in a piecemeal fashion for a single

procedure or services provided.

Medical Billing CompanyThese are the companies processing claims and follow up with insurance companies in

order to receive payment for services rendered by a healthcare provider.

Billing Company Pricing It means charges payable to billing company for the coding/billing services rendered by them

There are number of customized pricing options available for small and large sized

healthcare providers. Depending advantages and drawbacks of each of these, a provider

has to carefully choose the best out of them.

Some of these are options are :-

Percentage based Pricing – Here company charges certain percentage of the total

collection received. Under this type of pricing medical company, put their best efforts

to generate cleans claims which in turn give increase in revenue and ultimately that

both the billing company and providers are benefitted.


Full time equivalent (FTE0 pricing- under this a medical biller is hired and the FTE

rate is fixed at the beginning of the month , however this is not much advangeous

option as the irrespective of volume of work, provider has to pay to billing company

the contracted amount

Per claim pricing option- Pricing is based on number of claims submitted and a rate

for each claim processed in negotiated at the beginning of contract.

Claim Form

This is the bill prepared by Medical biller to be submitted to the Insurance Company on

behalf of Healthcare Provider. Claims forms are either paper claim forms or electronic claim

forms. There are basically two main types of claims. These are

1) UB-04 – Used for institutional providers (hospitals) contains 81 data fields known as form

locators (FL). 2) CMS-1500- Used for non-institutional providers (primary care provider,

physicians) contains 33 data files referred as blocks. These forms are easy to generate

compared to UB-04 forms.

5. THREE STAGES OF REVENUE CYCLE PROCESS

A Healthcare Revenue cycle has three main phases or stages. These are as under.

1. Pre-claim submission Phase

2. Service Phase

3) Post-claim submission Phase

Each of this stage involves various activities which contribute to further movement of

Revenue Cycle Process.

Managing the revenue cycle efficiently is no easy task and requires your constant attention.

Each phase of the Revenue Cycle - from the moment a patient is scheduled for an

appointment until the time payment is received from the insurance company - is equally

important to maximizing insurance reimbursements. It is vital for the financial stability of the

hospital or physician office to have a process in place for each phase of the revenue cycle.


1 Pre-Service Stage

2 Service Stage

3 Service Stage

Insurance Verification Patient Provider Meet/Encounter Claim Submission

Scheduling Medical

Transcription Payment Posting

Registration Coding of Claims

Charge Capture/ Billing Charges

A/C Receivable

Counselling on co-pay, co-insurance Write-offs/Collection

Agency

ABN Closing of Account

REVENUE CYCLE PROCESS FLOW CHART

1. Patient Insurance Eligibility, Verification, Scheduling

9. Write Offs/Collections Agency

2 .Patient & Provider Meet/ Encounter

3 Medical Transcription

6 Claim Submission

8. Accounts Receivables

4. Coding of Claims

7. Payment Posting

10. Closing of Account

5.Documenting/Billing ofCharges


(1) Pre-service Stage The revenue cycle actually starts with at this stage with a process that involves tasks such

as verifying eligibility, scheduling and registration, getting authorization for services,

collecting copayments or coinsurance, taking signed consents.

As soon as the appointment is made, the patient’s insurance information needs to be

verified. Because insurance information can change at anytime, even for regular patients.

Some medical procedures or services may require the provider to obtain authorization prior

to services being performed denied claims due to unauthorized patient procedures or

services can be a major loss in revenue that should not be taken lightly.

Post eligibility comes the part of patient counseling that is explaining patient about his

responsibility towards uncovered payment, collection of co-pay, taking his signature on

relevant consent forms.

(2)Service Stage –This is the stage wherein patient actually meets the healthcare provider

and his begins the medical treatment begins. This stage covers all the core activities of RCM

process such as documentation of diagnosis, Medical reporting, Change entry & Medical

coding. After thorough screening of patient’s medical history, providers (physicians) charts

out diagnosis and proceeds with treatment plan. All this is documented and sent to Medical

Transcription dept who then prepares medical reports and sends to Medical Billing dept for

charge entry and respective patient’s claim is generated. The job of the medical biller is a

little easier than of Medical coder but relies heavily on the performance of the latter

because the Medical coder reads through the medical report , gleans out the diagnoses

and procedures in the report and utilizing the coding skills provides appropriate medical

codes to those diagnosis and procedures.

(3) Post Service Stage

This is the last of Revenue cycle Management. It includes claim submission, follow-up with

Payer, Payment posting, generating Accounts Receivables reports, working of denied

claims, Patient’s invoice, write offs, contacting collection agency, closing of account.


To summarize the three stages of RCM is comprised of all the administrative, clinical and

financial functions of a medical practice.

Managing the revenue cycle efficiently is no easy task and requires your constant attention.

Each phase of the Revenue Cycle - from the moment a patient is scheduled for an

appointment until the time payment is received from the insurance company - is equally

important to maximizing insurance reimbursements. It is vital for the financial stability of the

hospital or physician office to have a process in place for each phase of the revenue cycle.

6. HEALTHCARE REVENUE CYCLE PROCESSHealth Insurance Portability and Accountability Act (HIPAA) now has stricter requirements

for claims data submission. Government’s emphasis on eliminating health care frauds and

abuses has apparently put the focus back on accurate medical billing. Real-time processing,

consumer-centric healthcare & regulations and reimbursement structure reforms, in turn,

have put increased pressure on healthcare providers to improve their revenue cycle

management process. It is crucial to have a well structured RCM process

Basically a Revenue cycle process involves following 10 steps

1. Patient Insurance Eligibility Verification, Scheduling and Registration

2. Patient –Provider Meet/ Encounter

3. Medical Transcription

4. Coding of Claims

5. Charge Capture /Charge Entry

6. Claim Submission

7. Payment posting

8. Accounts Receivables

9. Write off/Collection Agency


Each step is described as under:-


1. Patient Insurance Eligibility Verification, Scheduling and RegistrationThis is the first step in Revenue cycle Process which starts when a patient via phone call,

schedules a visit with the provider or presents himself for treatment. Scheduling is a critical

RCM function for at least two reasons: It is the first opportunity to capture data—such as

patient demographic data, the source of payment, medical history, and information about the

patient’s financial condition, payment due in the past.

Some Medical Practitioners has facilities of online patient pre-registration portals so that

patient can log on to the web portal as per their convenience & do the registration on their

own. In India Apollo Hospitals and All India Institutes of Medical Sciences (AIIMS) have

online booking facility for physician’s appointment.

“Eligibility verification defines who can render what care and under what circumstances.” In

the past, providers usually called a patient’s insurer to capture eligibility information. Getting

accurate eligibility information as early as possible in the revenue cycle, and doing it through

web-based electronic-data interchange (EDI) transactions, prevents rework and allows the

patient to get better information about financial responsibility in a far more convenient way

than making a phone call. Eligibility responses usually inform the provider about what

amounts are due from the patient, so providers may attempt to collect those amounts up

front.

When the patient arrives on scheduled day the registration staff will ask for insurance card,

state/federal government issued photo identification and reference note from patient’s

primary physician. At this the office will counsel the patient regarding their financial obligation

called the Patient’s responsibility. Properly educating a patient about the patient’s financial

responsibilities at this stage of the revenue is an essential part of managing the revenue

cycle. The counseling process includes following activities

To inform patient about co-pay, co-insurance and deductible amount and to collect

the co-pay.

To obtain a signed consent form for treatment and PHI privacy.

To obtain ABN (Advance Beneficiary Notice of Noncoverage- If a particular

medical service is not covered under the insurance plant of the patient , an ABN

needs to be signed by patient to pay for such out-of pocket expenses or to refuse the


altogether. In case ABN form is not signed and the service is not covered b the

insurance payer the provider will then have to write off the total fees because the

patient cannot be billed for the same hence it is of the essence that medical biller

invariably verifies the particulars of the patients ins before the patient encounters with

the provider.

To obtain Advance Directive Form- (if applicable)-This is usually obtained for

inpatient services. This may be a form, a living will , or power-of attorney written in

advance mentioning the patients choices for medical services or mentioning the

name of a person who can make those choice for patient in case patient in unable to

take decision ( for e.g. if patient suffering from Alzheimer disease or lapses into

coma etc.)

Emergency Medical Treatment& Labour Act, 1986 (EMTALA). Under this act hospital

requires to treat patients coming to the emergency department for medical services like

motor accident, cardiac arrest. The triage nurse will begin the treatment without waiting for

patient registration and insurance verification, which will be done by the hospital staff

simultaneously. The hospital is obligated to either provide with treatment until stable or to

transfer to another hospital in conformance with eh EMTALA directives.

EMTALA also stipulates that in an emergency situation ABN (Advance Beneficiary Notice of

Non-coverage) not to be given to the patient until the patient stable medical screened and

clinically stabilized.

2. Patient –Provider Meet/ Encounter

This is first step of Service Stage. Post financial counseling activity, the patient meets the

healthcare provider. The provider will verify the chief complaints, past medical and surgical

history of patient and would start physical examination and chart out recommendation and

formulates a working diagnosis and proposes a treatment plan. Accordingly provider will

make a note of all the observations, assessment record it to Medical Transcription Dept to

create Medical Report.

3. Medical Transcription


Although there are different type of softwares are available e.g. voice recognition, template

creation but since the creation of the medical document even with these applications and

softwares is time consuming, majority of healthcare providers still follow traditional approach

of dictating the recording the audio file which is then accessed by the Medical

Transcriptionists and Medical report is then prepared for the respective patient. The medical

report containing all the billable services which are provided to the patient in the medical

facility is then forwarded to medical billing /coding team.

4. Coding of Claims

To get paid for healthcare services, a provider must communicate the reasons for, and exact

nature of services to a payer. That communication takes the form of coded information

(termed as medical coding). “In its simplest form, coding is the transformation of verbal

descriptions into numbers.”

The coded information appearing on a claim form or within an electronic claim is still the

most important component of reimbursement communication with a payer. The most critical

codes that appear on inpatient, outpatient, and physician claims are diagnosis codes and

procedure codes—generally referred to as code sets. Other less important, but still

necessary codes appear on claims describing the claim’s purpose, circumstances

surrounding the need for treatment, the outcome of treatment etc.

Each and every service for which the healthcare provider needs to get reimbursement

should be assigned a diagnosis or procedure code.

ICD-9 Coding Manual (ICD 10 codes wef 1st October 2015) for assigning diagnosis code

and CPT or HCPCS codes are used for coding procedures, ancillary services.

Medical coder has to ensure that diagnoses code and procedure codes should match up in

order to get reimbursed else claim will be denied. The rendering provider completes a super

bill (a form which lists possible services which can be quickly selected) describing the

service provided... In small size medical provides the coding and billing activities are handled

by one dept and one person only.


5. Charge Capture /Bill Charge Entry

This is the point in the revenue cycle where the claim bill is actually generated. Unique

account for the patient is created and unique account number is generated which can be

helpful to reply post claim submission queries in future. At this step documented services

are manually or electronically translated into billable fees. The Medical biller also enters the

demographics of patient, insurance details into the Medical billing software.

Documenting the charges in a health-delivery setting is vital to RCM because properly

documented charges form the basis of medical claims. A ‘charge’ is an amount a patient, or

the patient’s insurer, owes to a provider for a service delivered. ‘Charge Capture’ is the

process of determining and reporting charges for services a provider performs. Inaccurate

charge capture can result in nonsensible claims, such as a hip replacement seemingly

performed without anesthesia or a procedure to implant a pacemaker without actually using

a pacemaker.

For providers, failing to capture charges accurately can result in claim denial or rejection.

And even though a provider may be able to remedy these issues by reworking and

resubmitting claims, that solution has its own significant costs. Inaccurate charge capture

may be the result of undertrained staff, use of disparate electronic systems, or manual

systems.

CLAIM SCRUBBINGA key to effective RCM is to submit clean claims to payers and prevent errors. Most

providers perform a series of quality checks just before submitting claims for payment and

make necessary changes, or edits. Typically, a provider checks a claim to ensure that its

coding staff has coded supplies and services correctly, there are no missing codes, staff

appropriately documented medical necessity, and the data on the claim complies with local,

national, or payer-specific rules.

In addition, providers should verify demographic and insurance information such as current

eligibility for coverage, membership number, policy number, provider number, referring

physician name, subscriber name, dependent name, admission date, discharge date, and

the like. The claims editing process can be daunting, expensive. To help manage this


complexity, fifty to sixty percent of providers have implemented automated claims editing

software solutions called scrubbers or code editors.

When a provider’s automated scrubber finds a problem with a claim, the scrubber repairs the

claim or puts its submission on hold until coding or clinical staff reviews it and makes

necessary corrections. This process can dramatically reduce claim denial and it can have

Significant side benefits as well—providing feedback to coding staff so they can eliminate

errors before they reach the claim scrubber. Employing a claim scrubber not only increases

the number of claims a payer accepts upon first submission, it can improve cash flow by

reducing overall time to payment Once a provider has properly scrubbed and edited a

claim, the pre-claim submission process is complete and the claim is ready to submit to a

payer.

6. Claim Submission

Claim submission is the first step of the post service stage of Revenue Cycle process. While

providers move most claims electronically, rather than on paper, most computerized

healthcare tools still presents claim information to users using the classic claim forms. For

that reason, a strong familiarity with those forms and the elements they contain is a must to

understand. The claim form should be able to accurately and completely convey the

information to payer about ailment of patient, treatment delivered.

The Standard Claim Form to be used is CMS-1500 for Physician/Professionals (non-

institutional)/ and UB-04 for institutions.)

Before submitting claim the Medical Billing department must ensure that the claim that is to

be submitted is as per the guidelines & policy of the respective payer.

In the past, providers typically printed and mailed paper claims to payers on these form, but

over the last 25 years that process has given way to electronic-data interchange (EDI) as a

means to submit claims to payers. “EDI is the electronic exchange of standardized business

document.

With adoption of electronic claims, the error rate can be significantly reduced as the

reduction in manual interference. Electronic claims are faster to process which in turn lead


to reduction in payment period or reimbursement cycle brings the collection period down

from an average 60 days to 15 days.

Many payers offer mechanisms to providers for submitting claims directly. Those

mechanisms may include the ability to send multiple electronic claims in one file or stream

(in “batches”) by various methods; or the ability to use direct data entry screens hosted on a

payer’s website to rekey claims one at a time. While payers may offer these services at no

charge, some industry players recommend using a clearinghouse.

Clearinghouses are intermediaries between the healthcare practices and insurance payer

that help to transmit electronic claims to insurance payers.

Sending batches containing multiple claims directly from a practice-management or hospital-

information system to a clearinghouse is far more efficient than reentering claims one at a

time. Clearinghouses also typically offer additional claim scrubbing, formatting, and

conversion services to providers. One drawback is that clearinghouses charge a monthly,

yearly, or per-transaction fee for what many payers provide at no cost. And some payers

have, in the past, made exclusive arrangements with a particular clearinghouse that could

limit a provider’s clearinghouse choices or force it to use more than one clearinghouse

vendor. But after the advent of PPACA (Patient Protection & Affordable Care Act)

transaction standards, “smaller size clearinghouses began to gain momentum by luring away

the small providers with better service

Claim Adjudication Process-is the process of paying the submitted claims OR rejecting

OR denying after examination of the claim as per the coverage terms and conditions. This

process has following any of these THREE outcomes.

1) Clean Claim - paying the submitted claim.

2) Denying the claim partly or fully – for reasons like incomplete or inaccurate information,

to ask further clarification such as medical history etc.

3) Rejecting the claim- Payers sends EOB (Explanation of benefits to provider justifying the

reasons for rejection such as patient’s sum insured limit exhausted, wrong payer etc


7. Payment posting

Payment Posting occurs when payment on a claim is received. When the claim is approved

or denied in part or fully, the insurance company sends EOB (Explanation of benefits)/ERA

(Electronic Remittance Advice) to Healthcare provider. The EOB/ERA contains the details

about amount paid, amount denied, patient’s responsibility etc.

The Medical Biller enters all these details into Patient’s Account in the Medical Billing

software. If the patient has a secondary insurance, the cycle continues with claim

submission to the secondary payer.

The process of payment posting is usually manually as different insurance companies have

different format of EOBs, due to this nature of operation, it becomes laborious, time

consuming and affect the productivity. It becomes more difficult if there are huge

Explanation of Benefits involved in a processed claim and therefore care must be taken in

order to make sure that the entered amounts are accurate so as to avoid complications later

on.

Many providers have the ability to calculate an expected reimbursement (also called the

expected amount) for a claim. This allows a provider to more accurately estimate accounts

receivable before it receives RAs from payers, which gives the provider an important tool for

RCM. Combined with good eligibility and preauthorization processes, the ability to calculate

an expected amount allows the provider to know with greater accuracy what the patient and

the payer owe. Even with this capability, the provider still needs to calculate adjustments to

its accounts and additional write offs when it receives ERAs from Payer.

Even with this capability, the provider still needs to calculate adjustments to its accounts and

additional write offs when it receives RAs from payers. To minimize the need to make these

adjustments and to improve account management, providers need good systems for

calculating expected amounts. These systems not only help revenue-cycle managers

maintain more accurate financials; they can also help with denials, appeals, and

underpayment recovery. But a comprehensive process for revenue management still

includes a strong patient-collection process.


After making all the required adjustments towards co-pay, coinsurance, deductible amounts,

amount approved by Payer, then Medical Biller prepares a Patient’s Invoice – a statement

which shows the amount patient owes to Healthcare provider which is sent to Patient.

8. Accounts ReceivablesGenerally every healthcare provider assumes that all claims submitted by their Medical

Billing dept will be clean claims but no matter how efficient the medical biller is there are

always certain instances where claims are partly approved or fully denied or rejected.

Data published by Researchers from the California Nurses Association gathered from

Insurance payers that about 22% of all the claims submitted are rejected for some or other

trivial reasons. Researchers feel that the guidelines for submitting the claims are getting

tougher day by day to root out any frauds in payment- collection. Due to stricter and complex

regulations the rejection rate of claims is rising. A well structured & streamlined Accounts

Receivable Dept is essential part of healthcare provider to generate different kinds of reports

which helps to analyze the financial health of provider and steps can be taken for corrective

actions thereafter.

The important activities of this dept are to identify, monitor and follow up the pending

payments either from Payer or from the patient. The Accounts Receivable department also

analyzes the reason for the delay in submission or settlement of claims utilizing various

kinds of reports that are generated for this purpose.

Some of the important reports generated by this department are

Agewise collection Report

Denial Management Report

Procedure Payment Analysis Report

MIS report

The Agewise collection reports (30, 60, & 120 days) provide details of amounts owed to the

provider either by patient or payer. A very important benchmark for revenue-cycle.

Performance is the accounts-receivable days—an aggregate average of amounts and

lengths of time accounts stay in the receivable state—so it is very important for revenue-

cycle managers to know with as much precision as possible what their receivables actually

are from moment to moment.


During this step, a statement is sent to the patient immediately following payment posting. If unpaid, statements are sent at 30, 60, and 90 day increments. Any balances unpaid at 120 days will be significantly reviewed by the provider and sent to a collections agency agency.

Once the required details are identified, the dept proceeds for collection process. The claims

which are denied or rejected due to incomplete or wrong information, relevant information is

collected and claims are re-submitted or appealed .In case of outstanding amount is from the

patient, reminder/ follow upcalls are made. If the patient is reluctant to pay the due amount,

such cases are handed over to Collection Agency

9. Write off/Collection Agency

Even though Accounts receivable dept puts rigorous efforts & follow up for pending amount,

there are some kinds of patients who are reluctant to make payment. In such cases

providers are left with two options i.e. to write off the amount OR handover the case to

Collection Agency. But it is very difficult for the provider to choose the option.

If the amount is nominal, Healthcare provider deducts that amount from the billed amount in

other words “writing off” the amount owned by payer or patients but if the amount is

significant, such cases are handed over to Collections agencies who are experts in

recovering such payments.

Many revenue-cycle managers regard patient collection and bad-debt reduction as top

priorities. Some authorities suggest that providers who make online information and payment

services available to their patients can improve collections. To collect patient payments up

front, a provider must know what the patient will owe after treatment.

Generally, the copayment amount is the easiest amount to determine because it usually

appears on the patient’s insurance card. The deductible amount is a bit more problematic,

requiring the provider to have good (preferably real-time) eligibility and authorization

processes. Several factors may affect the deductible, such as an individual deductible

amount, family deductible amount, a yearly maximum out-of-pocket expense, or a yearly or

lifetime limit on coverage. Good eligibility and authorization processes can also identify any

services the patient’s insurance policy excludes from coverage. But it is generally more

difficult for the provider to determine the patient’s coinsurance amount because it is usually a

percentage of the payer’s allowed amount. Some providers have solved this problem by


adopting point-of-service systems that calculate the allowed, or expected, amount (or at

least a reasonable estimate) during the scheduling phase or when the patient presents for

treatment.


This is the last step of the post service stage as well as of the revenue cycle as a whole.

Once the final payment is received and posted by medical billing department, the revenue

cycle for that particular claim is over and at this stage the balance of accounts becomes

zero. All the documentation are then filed and are updated in the patients account for future

reference and records.

7. CLAIM ADJUDICATION

Claims adjudication is a term used in the insurance industry to refer to the process of paying

claims submitted or denying or rejecting them after comparing claims to the benefit or

coverage requirements. The adjudication process consists of receiving a claim from an

insured person and then using software to process the claims and make a decision or doing

so manually. If it’s done automatically using software or a web-based subscription, the claim

process is called auto-adjudication

A claims adjudicator is a professional who determines the amount of money insurance policy

holders are entitled to receive from claims. Adjudicators are also known as claims adjusters

and medical bill advocates.


A claim adjudicator is more specifically referred to as a medical bill advocate in the health

care industry. There, the adjudicator ascertains the insurer's payment after the patient's

insurance benefits are applied to the medical claim. Medical bill advocates are essential in

the health care industry because of the high probability of billing errors.

The claims adjudication process has improved recently because of the great advances in

software and the edits created. This process collects a large amount of information, verifies

it, and issues payment. Many claims are submitted on paper and are processed manually by

insurance workers. Automating claims often improves efficiency and reduces expenses

required for manual adjudication.

Many insurance companies take advantage of auto-adjudication as a method of managing

the large number of claims that has to be processed on a regular basis. Claims are

submitted electronically in most cases, although paper filing is still an option, and the

information is entered into software that reviews the claims. The software checks for errors,

eligibility requirements, and deductible payments, and some software programs will even

check for fraud. If the claim meets the insurance requirements, then it will be paid. When the

claim fails the auto-adjudication process, then it can be denied or sent to an insurance

examiner to review the claim manually.

The most common billing error is duplicate billing, which is charging twice for the same

medical facility service or drug prescription. Other billing errors include typos, which involves

the wrong dollar amount, or billing codes assigned; charges for canceled services; and up

coding, which is inflation of health care charges. It is the duty of the medical bill advocate to

negotiate with the insurer to either appeal coverage denials or have charges reduced.

During the investigation, the claims adjudicator should display reasonable knowledge of

insurance policies and practices. The adjudicator should also watch out for insurance fraud,

as there is always a possibility – no matter how big or small – that the claim amount is

inflated or certain statements about the loss are not true. After the investigation is concluded,

the claims adjudicator prepares a report and relays the findings to the policy holder. In cases

when the loss is considerably extensive, the claims adjudicator discusses the claim amount

with the policy holder. The claims adjudicator not only plays the role of investigator, but also

acts as a negotiator between the policy holder and the insurance company in instances of

settlements to make sure that both parties accept fair arrangements.


After the claims adjudication process is complete, the insurance company often sends a

letter to the filer describing the outcome. The letter, which is sometimes referred to as

remittance advice, includes a statement as to whether the claim was denied or approved. If

the company denied the claim, it typically has to provide an explanation for the reason why

under regional laws. The company also often sends an explanation of benefits that includes

detailed information about how each service included in the claim was settled. Insurance

companies will then send out payments to the providers if the claims are approved or to the

provider’s billing service.

The insurance company might only make a partial payment to the provider as a result of

claims adjudication. Insurance companies are often required by law to provide an

explanation (Explanation of Benefits (EOB)/Electronic Remittance Advice) as to the reason

why only partial payment was made. Another possible outcome is a request made by the

insurance company for the person to resubmit the claim. The reason is often to obtain

additional information or to provide information that was missing in the original claim. If the

claim is denied, then the entity or person filing the claim can usually file an appeal.

Many insurance plans require prior authorization or approval before an office visit or

procedure is performed. The insurance company provides a referral number that must be

added to the claim. If this number isn't supplied, the claim will be rejected.

When the claim has made it through the software edits without any errors, the claim will be

paid at the contractual rate. A check in the mail or electronic payment will be made with the

issue of a remittance advice.

The remittance advice explains to the physician with a copy to the patient how the payment

was determined.

There is a difference between a “denied” and a “rejected” claim, although the terms are

commonly interchanged. A denied claim refers to a claim that has been processed and the

insurer has found it to be not payable. A denied claim can usually be corrected and/or

appealed for reconsideration. Insurers have to tell you why they’ve denied your claim and

they have to let you know how you can dispute their decisions. A rejected claim refers to a

claim that has not been processed by the insurer due to a fatal error in the information


provided. Common causes for a claim to reject include when personal information is

inaccurate (i.e.: name and identification number do not match) or errors in information

provided (i.e.: truncated procedure code, invalid diagnosis codes, etc.) A rejected claim has

not been processed so it cannot be appealed. Instead, rejected claims need to be

researched, corrected and resubmitted.

Most commonly, denied or rejected claims are returned to providers in the form of

Explanation of Benefits or Electronic Remittance Advice

Claims adjudication can be a quick process when a clean claim is received. "Clean" in this

case means that all the information on the claim is correct and within the bounds of the

patient's healthcare policy

Upon receiving the denial message the provider must decipher the message, reconcile it

with the original claim, make required corrections and resubmit the claim. This exchange of

claims and denials may be repeated multiple times until a claim is paid in full, or the provider

relents and accepts an incomplete reimbursement.

.

8. CLAIM DENIAL MANAGEMENT

We define a denial as

1) Any partial or incomplete payment,

2) Failure to receive payer response to a submitted claim, or

3) Receiving a written denial from the payer.

When a denial occurs, we perform a root cause analysis to determine why it has happened.

We fix the denial cause, and then take the next step with the payer to have the claim paid.

This process continues, as necessary, until the claim is fully resolved.

Denial Management is the process of

1) Identifying that a denial has occurred,


2) Ascertaining the denial cause (using, when appropriate, Total Quality Management “Five Whys” technique to determine the root cause),

3) Correcting, resubmitting, or appealing claims as necessary to ensure that payment in full is ultimately remitted

A payer may deny payment for services for several reasons, including: a patient’s policy

does not cover the service; payment would exceed coverage limits; or, more commonly,

because the claim exhibited a coding error or other problem. A provider’s failure to deal with

denials effectively could result in a loss of more than 20% of revenue. A claim denial means

the provider, the insured, or both could be on the hook for the cost of services to the extent

that the payer has adjusted reimbursement for those services. Before determining what

course of action to take, it is important to a revenue-cycle manager to sort out those denials

that are its responsibility from those that are the insured’s responsibility.

Denials are usually the result of administrative or clinical problems. Typically, these

problems involve“inadequate information technology (IT), changes in billing and coding

regulations,” or inadequate training. Sometimes a payer denies payment for a service simply

because the payer wants a provider to correct or fill in missing information and resubmit the

claim. But providers must take care to ensure that payers do not view the resubmission as

duplicate billing.

Managing Denials

Effective denial management begins when a patient schedules a visit and continues

throughout the entire revenue cycle. First, denial management must focus on prospective

efforts to improve charge capture, coding, scrubbing, and editing. This may involve a multi

departmental effort, perhaps using a dedicated team, to keep abreast of rule changes,

Regulatory Authorities advisory notices, and compliance programs such as the National

Correct Coding Initiative (NCCI). A continuing-education program is essential to preventing

as many denials as possible. And revenue-cycle managers should develop effective

reporting mechanisms that track trends in denials by payer, reasons for denials.

Second, denial management must represent an effective process for dealing with claims that

payers have already denied. Providers should focus appeal efforts on “on denials with the

greatest likelihood of being reversed.”Effective technology can be a help in this area and a

number of companies have offerings in the denial management arena. Technology tools are


essential because payers have and use them and providers who do not equip themselves

appropriately find themselves at a distinct disadvantage.

Understanding the reasons why medical claims deny can help limit the number of denials

your office receives. Following could be the top 10 Reasons Claims Get Denied

1. Incorrect patient identifier information

Name spelled incorrectly Date of birth doesn’t match Insured group number missing or invalid

2. Coverage terminated

Verify insurance benefits prior to services being rendered.

3. Requires prior authorization or precertification 4. Services non-covered

This is another reason why it is important to contact the patient’s insurance prior to services being rendered. It is poor customer service to bill a patient for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure.

5. Request for Medical Records

6. Coordination of Benefits

Other insurance is primary Member has not updated insurer with other insurance information

7. Bill liability carrier

If the claim has been coded as an auto or work-related accident, some carriers will refuse to pay until the auto or worker’s compensation carrier has been billed.

8. Missing or Invalid CPT or HCPCS Codes

9. Timely filing

Be aware of timely filing deadlines for each insurance carrier.

10. No referral on file Some procedures require that the patient obtain a referral from their family physician prior

to services being rendered.


Effective denials management is all about being proactive and diligent. Engaging in eligibility

verification prior to a patient's visit, for instance, is one front-end strategy to reduce denials.

On the back-end, practices must develop a routine system for denials monitoring.

Denials come in many forms: Perhaps a patient is ineligible for a given service, or a claim

has been miscoded. Payers typically don't make it easy to decipher the reason for a denial,

either. It costs practices roughly $25 just to re-work denied claims, according to an estimate

by the Medical Group Management Association (MGMA). It may not seem worth the effort to

appeal a denial if the return is small, but even small amounts can add up to thousands of

dollars of lost revenue.

Using an electronic claims clearinghouse that not only scrubs claims but also monitors them

and delivers tools to help practices more easily manage denials can speed reimbursement.

Some clearinghouses alert practices in minutes about potential claim errors or patient

eligibility problems so that they can be fixed before submission to the payer. By contrast, a

payer may not deny a claim until days or weeks after submission.

Yet a clearinghouse cannot do everything. Denials management is not a "one-and-done"

effort; it must be ingrained in daily, weekly and monthly workflow. The key is to capture,

analyze and act on denial information. If similar mistakes occur frequently, practices must

determine the origin of the errors - whether at the front desk, in the exam room, or with the

payer - and take steps to prevent their recurrence. Denials management requires diligence,

but technology can help provide essential data analysis. The goal is to eliminate the root

cause of denials through improved workflow and technology - resulting in optimized revenue

and minimized re-work.

As with claims denial management, working with the right clearinghouse can help the

medical practice.

Appealing Denied Medical Claims

When done correctly, appealing medical claims can be an effective way to resolve and

receive payment for those claims that are denied due to reasons other than for simple

registration errors. Some claims are easier to resolve than others due to a coding or billing

error. Others may be more complicated.


Before filing an appeal, it is important to evaluate the claim to determine whether it is worth

spending the time and money. Following factors needs to be considered.

1. Review the Denial Reasons

The reason a claim has denied is important when deciding to file an appeal. If you believe

the insurance company wrongfully denied your claim then you should definitely make an

attempt to appeal their decision. One popular denial that can be easily appealed is for no

prior authorization. Many times authorization has been received for the patient's treatment

but many times is left off of the claim form. This should be an easy fix especially since the

insurance company provided the authorization in the first place. You may be able to correct

this denial with a simple phone call, retile the insurance claim or submit an appeal letter.

2. Do not Delay

Try to submit your appeal within 7 days from receiving a denial notice. The longer you take

to resolve a denial, the lower the chance you have of getting your appeal approved.

3. Get the Patient’s Help Patient's can be your best resource when having trouble getting insurance companies to pay

claims. The patient may not think they can be of a benefit but there are two great motivators

to get them on your side. One - patients pay a lot of money in insurance premiums for their

insurance and if the insurance company is not paying their part, patients may see them in a

negative way. Remind patients that the purpose of the insurance company is to help pay

their medical bills. It would be helpful if they called the insurance company on your behalf.

Two - many times if the insurance company does not pay, the patient is ultimately

responsible for paying the bill depending on the denial reason. Again, remind patients that

they are responsible for the bill and if the insurance company doesn't pay, they will have to.

Many patients are willing to contact the insurance company rather than pay the claim

themselves.

4. Know the Your Contract. Some denials your medical office receives may be against the conditions of contract.

Specifically, it is important to know and understand "Covered Services" and "Compensation".

This information can be useful in appealing claims that should never have been denied in the

first place.


5. Use Outside Resources. If necessary, take advantage of outside resources to help get your outstanding denied

claims paid. Use the services of an outsourcing agency o or provide your staff with job

incentives to get the job done.

9. REVENUE CYCLE MANAGEMENT - PROBLEMS & SOULUTIONS

There are many different leakage points in the revenue cycle When providers mismanage

the revenue cycle, the financial impact may seem relatively small on an individual claim, but

when multiplied by hundreds of visits a week, the effect is much drastic. The good news is

that there is a remedy.

Let's begin with some common revenue cycle management mistakes providers make &

remedies for the same

Errors during Pre-Service Stage 1. Patient’s Information Capture describes 1) obtaining and verifying the patient’s

demographic information and 2) obtaining and verifying the patient’s insurance information.

During Eligibility Verification the patient’s insurer is contacted to verify that 1) the patient’s

information has been captured correctly and 2) the patient’s insurance is active and whether

the procedure is covered. Depending on what the payer provides plan-specific coverage

information. Authorization is the process of determining whether a service requires prior

authorization by the patient’s insurer, and obtaining that authorization if required.

Errors ranges from typing in accurate demographics, entering inaccurate insurance

information of patient, not verifying patient’s eligibility or not obtaining pre-authorization.

Solution

To avoid this provider should have properly trained and well educated staff to handle these

primary processes of Revenue cycle. If the real-time eligibility is not possible then at the end

of the day all the patients’ insurance eligibility should be done by performing batch-

processing, failing to verify these details in a timely manner will lead to claim denial.

Errors during Service Stage


2. Missing upfront Collections

Inability to determine patient responsibility at the time of service - co-pays, deductibles,

subsequently causes delay difficulty to recover such amounts post –discharge or after the

payment posting.

Solution - As soon as patient checks in collecting co-pays must be a priority. The collection

staff can be considered for prompt and timely collection by the provider

Also kiosk type of technology can be installed at the service point to improve upfront

collection of patient co-pays and outstanding balances, as well as increase check-in

efficiency. Practices opposed to that idea might instead consider adding a bill payment

module to their online patient portals. Patients could then view their bills and pay with a

credit card, eliminating the need for costly letters or phone calls.

3. Inaccurate Coding

A recent research report it has noticed a significant increase in claims rejections, resulting in

lower reimbursement. ICD-10 is sending massive waves throughout the healthcare provider

industry As a result, they are seeing more billing errors and coding errors that lead to denied

claims and lost revenue.

As per rules and regulations of to HIPAA, healthcare provider organisation are required to

standard codes for electronic claim submission and organizations still are struggling with

translating the claims to the new EDI format.

Solution

The main task of medical coders is to review clinical statements and assign standard codes

using CPT, ICD-9-CM and HCPCS- classification systems. Medical billers, on the other

hand, process and follow up on claims sent to health insurance companies for

reimbursement of services rendered by a healthcare provider. The medical coder and

medical biller may be the same person or may work with each other to ensure invoices are

paid properly. To help promote a smooth coding and billing process, the coder checks the

patient’s medical record (i.e., the transcription of the doctor’s notes, ordered laboratory tests,

requested imaging studies, and other sources) to verify the work that was done. Both works

together to avoid insurance payment denials.


The medical coder and biller process a variety of physician services and claims on a daily

basis. Medical codes must tell the whole story of the patient's encounter with the physician

and must be as specific as possible in regards to capturing reimbursement for rendered

services.

Education and training is key to becoming a skilled and successful medical coder. The first

step coders must take is to have a thorough knowledge of anatomy and medical

terminology. It's also important to become familiar with the codebook resources CPT,

HCPCS Level II, and ICD-9-CM and their coding systems. It's also vital to know the coding

systems' corresponding guidelines and what codes are accepted by which insurance plans,

which government and payer regulations to follow, and how to be compliant while coding.

RCM systems can include coding functions that help vet billing codes and flag the ones with

possible errors. These flags are based on common mistakes that occur generally and within

your organization specifically. Anyone handling the coding or billing process of the claim

before it is officially filed will detect the flag and correct the error, saving themselves time and

preventing a lengthy denial and appeals process.

For the ICD-10 update, practices should ensure their EHR and PM systems are ready. That

process starts with checking with their vendors. Technology vendors should provide

upgrades that will handle the influx of thousands of new codes. Vendors should offer

educational tools to help coding and billing staff prepare for the transition.

4. Down coding services

Some physicians forego higher reimbursements for fears of being audited. To do this, they

key in procedure code for services less expensive than the one actually provided. But note

that some payers are now able to monitor discrepancies in this area. If they notice a pattern

in your claims or if circumstances that demand full documents about your patient’s treatment

arise, then you’ll find yourself in hassle.

Solution


Don’t hesitate to charge full for the services for the services provided, but ensure that

relevant documents are processed accurately on every step of the way.

Post-service Stage Errors

5. Wrong Claim submission

Medical Biller should be instructed on the use of proper Claim Form (UB-04 /CMS-1500)

depending upon respective insurance prayer’s preference. Using wrong form will result in

rejection of claim. HIPAA, the Healthcare Insurance Portability and Accountability Act have

also had an impact, by tightening the requirements for claim data submission.

Solution:

A provider needs to know all the different nuance and rules that carriers have while

processing claims, and a good revenue management system has the ability to have those

rules so that employees do not have memorize them.

6. Not resubmitting rejected claims

When claims are rejected due to coding errors, many providers are reluctant to resubmit to

certain payers because they lack access to data that can support the dispute, thus resulting

in the lost revenue

Solution

Online research tools are available; the most valuable tools stay up-to-date with the latest

information and help to defend claims. These tools can identify not only where the denial

occurred, but also help automate the process of filing corrected claims and appeal letters.

7. Failure to monitor the entire claims process-

If Provider’s staff is not able to manage the claims process at every point in its lifecycle, then

it will be difficult to identify where it went astray and resolve the issue. Without automated

alerts as to why a payer is routinely denying claims for a given procedure or code, staff will

spend countless hours researching the issue.


Solution:

Claims are complicated and ever-evolving regulations ensure mistakes are easy to make,

yet hard to track. To help lighten -- or even eliminate -- this burden, implement a business

process for timely, thorough follow-up. Take the time to research affordable tools (software

systems) that can help to generate proactive alerts. There are plenty of options available, so

make sure to identify the right system for your organization. With the right tools, the ROI will

happen quickly.

8. Flagging Underpayments

Payers may also make mistakes. Similar to the points above, many times an invoice or claim

will only return with partial payment. Those who do not have any formal system may not

catch them

Solution

A formal system in the Integrated RCM helps this level of auditing to help ensure consistent

payment without placing all of the responsibility on accounts receivable.

9. Inaccurate Payment Posting

Payment posting is performed on receipt of Explanation of Benefits (EOB)/Electronic

Remittance advice (ERA); the medical biller needs to enter accurate details of EPB OR ERA

in the respective patient’s account. Inaccurate payment posting also affects the accuracy of

claims submissions to secondary and tertiary payers. If the primary payment is not posted

correctly, it is possible for the secondary and tertiary payers to get billed out incorrectly.

Payment posting involves posting and deposit functions and reconciling posting activities

with deposits. Although it seems simple enough, this is an extremely fundamental feature of

the revenue cycle. The wrong payment posting process effects many other functions of the

medical office and can have a major impact on patient satisfaction, efficiency, and overall

financial performance.

Solution


Most billing systems have the capability of submitting secondary claims and some tertiary

claims electronically. Unless there are edits within your system or billing scrubber to stop

these claims for review it is possible that some of your claims may go out with mistakes if the

primary payment has not posted accurately.

10. Lagging collection times and lack of follow-up

Sluggish approach on the part of A/R department may greatly impede your revenue cycle.

Solution

Agewise reports shows financial health of provider and to take corrective action if needed

A/R department should have pre-determined policies or guidelines for follow-ups for 30, 60,

90 days outstanding payments from payer or from patient. Deadlines needs to be set for

achieving targets

11. Not recognizing trends

Busy practices with heavy administrative workloads tend to process claims one at a time.

When claims are addressed individually, administrators often fail to see high-level, macro

trends and make the same processing error repeatedly. This results in slow payment and

increased administrative time and expense.

Solution:

Workflow tools that flag repeated, routine denial of claims for a certain procedure or code

can greatly improve a provider's short-term and long-term revenue cycle. By understanding

common mistakes, your team is able to proactively adjust their processes for cleaner first

time claims submission.

Best practice is to avoid errors and rejections in the first place. If the provider is making

any of these common revenue cycle management errors, chances are there that it is experiencing both delayed and lost revenue.


To eliminate initial data errors and improve first-time payment rates, consider implementing a

payer-specific claim editing and eligibility verification solution. Research vendors carefully

and choose one with established payer relationships, proactive reporting and audit tools, up-

to-date coding information and online claim correction functionality. By doing so, you'll be

providing your staff with the tools to streamline daily revenue management and improve

overall practice performance.

For smooth & effective functioning of entire revenue cycle management process and for

overall productivity, following factors should also be considered:-

1. Analyze Your Revenue Cycle

Improper insurance coordination, lagging collection times, and lack of follow-up are factors

that greatly impede your revenue cycle. Write-offs may be acceptable when the amount is

insignificant, but these write-offs accumulate and affect the overall income. You can get

teams in the collection department to compete by first, creating periodic goals and then

working to meet financial targets. Monitor their performance regularly and put a rewards

system in place. Use a centralized calendar of activities to help managers determine the

numbers, tasks, and follow-ups with patients and insurance companies.

2. Resolve Recurring Problems

Many problems may exist within the revenue cycle that can be resolved with accurate

payment posting. Payment posting not only consists of posting payments but also involves

posting adjustments and denials.

Certain payers may deny an entire claim or deny by individual line on the claim. For

example, when the payment is posted, it is important that a denied line not be included with

the adjustment or part of the patient responsibility. If this happens, it is almost impossible to

catch. Identifying line denials is important in resolving the reason for the denial to prevent

future claims for denying for this same reason.

Line denials can occur for medical necessity, noncovered service, and service not

authorized or frequency limits. The ability to identify the reasons for line denials can help


prevent them from recurring as well as assist the medical office in identify ways to improve

your current billing and coding processes.

3. Enhance Current Processes The revenue cycle processes directly impact the efficiency of the medical office staff.

Sometimes management can be blind to the fact that their processes may be preventing the

revenue cycle from functioning at maximum performance.

Once problems have been identified, it is necessary to determine whether a process could

be added, improved or removed to current processes in order to enhance the effectiveness

of the revenue cycle. The most accurate way to identify what processes need improvement

is to perform a Medical Office Assessment.

Usually managers and administrators only consider performing an assessment when the

medical office is in financial trouble; however, an assessment can be done any time to

evaluate your overall performance. When performing an assessment, keep in mind the

specific problems that are recurring and analyze ways to prevent them in the future

4. Speedup Denial Resolution Time Of course, the most effective method for resolving denials is preventing them. The number

one prevention tactic is monitoring instructions from insurance payers by keeping up-to-date

on bulletins and other correspondence from the payers that provide information on new

billing or coding rules. Prevention, however, is not the only way to resolve denials because

some claims will slip through with information that may be incorrect or outdated.

The faster you can get those denied claims corrected and back out to the insurance payers

the better. Each day your denials go unresolved contributes to your overall accounts

receivable days. The ability to quickly identify denials, correct and refile them is the

difference between have an excellent AR record of 38 days or less or 60 days or more which

can be problematic to cash flow and possibly timely filing submissions to secondary and

tertiary payers.

To take this point along with payment posting Expectation of benefit statements offered by

insurers are not always easy to interpret. Doing so can take up valuable time of back-office

employees that could be spent more productively.


An RCM can help you automate eligibility for reimbursement programs upon admitting,

letting you avoid having to parse through every EOB. Patients who are unsure or

misinformed about their coverage areas can be notified immediately whether they are

ineligible for certain procedures or services under their current plan.

5. Establish Workflow Consistency

It goes without saying that any successful practice needs to establish consistency in its

workflow processes to improve revenue cycle management. There are a number of workflow

issues a practice should resolve for the sake of revenue cycle efficiency. For one, your

practice can implement processes and tools to better streamline the revenue cycle.

Inefficient A/R follow-up can also be a factor that hinders a practice’s revenue cycle greatly.

The answer here is simple – keep tabs on lagging collection times, improper insurance

coordination and excessive write offs, all of which interfere with practice’s livelihood.

Reduce inefficiency via periodic goal setting, which can be enhanced with healthy

competition. Split departments into teams and have them compete for financial benchmarks,

like time-of-service collections. Reward the winning team(s) and enjoy more efficient

performance monitoring.

6. Streamline Workflow and Revenue Oversight

Paper systems can lead to confusion, which compounds exponentially when a mistake is

made and someone passes the buck. The next thing you know, a file is found crumpled at

the bottom of the drawer and no one knows what to do with it.

Digital RCM systems clearly indicate the next step in workflow, all the way from admitting

and provision of care to the final billing and accounts receivable stages. Every single file and

service ordered is tracked and automatically pushed along to the next stage, helping make


back-office duties simpler and more clear-cut than ever. Files that fall by the wayside for

several days in a row can be flagged, and any human error that does arise does not have to

set anyone back more than a few moments.

7. Educate the Staff

Think about how much money inaccurate coding can cost your practice. No one is ever in

the mood to lose tens of thousands of dollars. Your practice’s staff should be educated on

what their role is within the revenue cycle. In this sense, RCM is similar to an assembly line – every member does his or her job and passes it on to the person in charge of the next

phase. Whether or not you rely on technology, every staff member should understand what

his or her responsibilities entail and how it impacts the practice’s bottom line. To better

educate your staff, communication at your practice should be enhanced.

Better Communication between Physician and Financial Staff

It’s not uncommon for physicians to lose touch with the financial state of the practice. And

seeing as a physician is essentially the chief executive of his or her own practice, what do

you think happens when a CEO loses financial touch of a Fortune 500 Corporation?

Small problems will escalate rapidly if a physician stops keeping tabs on his practice’s

financial status – sometimes resulting in as much as 20% of practice income being lost. It

shouldn’t be difficult to solve this disconnect. Bi-weekly meetings should occur between you

and your financial staff, where billings, collections and office revenue should be reviewed. Along with periodic reports, preferably via email to provide you with remote access, this top-

down approach will ensure enhanced practice-wide communication, which means you’re

also beginning to establish consistent workflow processes

10. REVENUE CYCLE MANGMENT SYSTEM

In the past, RCM activities in provider organizations were fragmented across departments

with each department pursuing different methods and practices for managing claims,


contracts, and revenue. Also softwares from different vendors being used and would be

difficult to integrate all the activities of RCM process.

.

However, over the time, however, many providers have adopted a more integrated, process

centered, or multidisciplinary approach to RCM that is Advanced Revenue Cycle

Management System (software) single software application that handles all the activities of

Revenue cycle Management Process, this is the one way you can set your facility up for long

term success is with the implementation of advanced Revenue Cycle Management System

(software). A system running effectively prevents denials of claims and maintaining a visible,

efficient billing process. It also encompasses everything from determining patient insurance

eligibility and collecting co-pays to properly coding claims using ICD-10.

A medical practitioner/healthcare provider should choose the practice management software

(PMS) wisely and the choice should be largely centered on how the RCM needs to be

implemented A right choice of PMS would lead the medical practice on the path of ascent

whereas wrong choice of Practice Management Software (PMS) would lead the medical

proactive on the part of descent

Choosing the right revenue cycle management (RCM) system can make or break a hospital

or physician practice. The moment a patient makes a doctor's appointment or enters the

hospital, the RCM system kicks in. What happens after that depends a lot on whether there

is an effective and transparent marriage between claims data, clinical data and Information

Technology.

According to the IT Yearbook report of Accountable Healthcare Organizations (ACOs), 95%

of hospital and healthcare system executives polled said they were accelerating their

acquisitions of health information exchange (HIE), electronic health record (EHR), clinical

decision support, care coordination, business intelligence, and complex revenue cycle

management systems

Some features of idle Revenue Cycle Management System

1. Speedy Data generation:


The software is to be used basically by three major categories of people; these are front

desk staff, back desk staff and clinical staff. The detailed reports generated by these staff

are to be utilized for quick and effective decision. Therefore, the Revenue Cycle

Management system should be generating all such reports within a moment. As the front

desk staff generates insurance verification or reports which helps them instantly the status of

patient’s eligibility and they can go ahead with further formalities of co-pay, deductibles,

which ultimately gives idea of claim rejection or denial in future. The reports retrieved by

back office staff are number of financial reports helping them to analyse the financial stability

health of the provider and to quickly take required. corrective actions. Clinical staff also

generates number of reports such that a particular treatment is allowed and covered under

insurance coverage or not and thus helping the Physician to change to modify his course of

treatment or advice the concerned staff to go ahead counseling process with the patient. The

systems should also be able to integrate clinical and care management information along

with the financial information along the patient's journey."

2. Inter-operability

The data generated by one system will be able to be retrieved, exchanged, and analyzed as

and when required by other existing systems within the hospital.

3. Scalability

Scalability is the ability of the system to handle a growing amount of work in a capable

manner or its ability to be enlarged to accommodate the growth. The evolution in healthcare

field is continuous and it stimulates the need to scale the existing System to cope up with

this flexibility.

4. Integration & Mobility

Integration helps practices reduce the risk of data entry error and decrease the time to claim

submittal. The result is a more accurate, quicker reimbursement. Perhaps more importantly,

though, it allows for better quality reporting. By more closely linking clinical and financial


workflows, practices can more easily begin to participate in quality-based reimbursement

models.

Not only is this inefficient, it prevents practices from accelerating the revenue cycle. With an

integrated solution, physicians or medical assistants can capture charges at the point of

service. The information then can flow directly into the PM system, where billing staff can

review the charges and submit the claim.

Mobility should be in terms of being able to access the information from outside hospital

location and this can be achieved by web based solutions which can be accessed though

WAN (wide area network), but data security factor should also be taken into consideration

before implementing such system

5. Affordable

Before choosing the new software, the healthcare provider should also consider cost factor.

The healthcare provider should try to customize or re-develop the existing system to fit its

needs rather than to opt for a readymade solution. This may reduce the cost of acquisiting

the new system.

6. Vendor Selection

The vendor should be established one and should be a long-term player. He should have

knowledge of global healthcare guidelines and data compliance. The vendor should be able

to customize the software according to requirements of the provider. He should be able to

provide 24x7x365 support the staff of provider.

7. Dynamic

The Healthcare industry is developing at a fast rate and due this there are lot of changes &

upgradation occurring in the medical practice and related services, There is need of dynamic

and integrated system which can take care of changing business rules. Therefore RCM

system should be dynamic with ability to upgrade as and when need arises.


8. Hybrid system

The RCM system should be a hybrid system that is it should be able to manage both the

professional side and institutional side of billing. As per the new trend, to earn more profits,

hospitals are taking over private medical practices so as to increase their patient ratio.

9. User Friendly

Various types of softwares are available with different kinds of built-in functions the use

should be able to operate the same without any hassle. Also software should be such that it

can be viewed on standard office PC as well as on smaller screen devices such as Tablets

or Smart phones.

10. Security

This is one of the important characteristic any RCM system should possess. Also care

should be taken to ensure that it is a HIPAA certified system. It should have admistrative,

physical and technical safeguards to prevent the misuse of any protected health information.

A system should be such that data can be accessed only on use of Introduction of Password

system or a bio-metric system or personal identification number and depending on the

employee’s job responsibilities.

11. Patient Centric systemSystem should be based on patient centric approach as now a days patients have become

more aware and willing to participate in the decision making process of their heath care.

Patient’s involvement in his own claim process is considered as valuable factor. It helps in

Provider in joint decision making on various situations, it may be at the time of portal

registration by patient or it may be at the point of financial counseling or it could be balance

outstanding collections or refund


Following are some of the popular Revenue Cycle Management Software available

McKesson’s Revenue Cycle Management

CareCloud Revenue Cycle Management

GE Centricity Revenue Cycle Management

NueMD Practice Management Software

Although lot number of RCM solutions is available with various kinds of innovative features,

the provider should be careful while selecting the system which fits hospital’s financial status

as well as future needs.

11. GROWING IMPORTANCE OF REVENUE CYCLE MANAGEMENTIn today’s healthcare industry, executives and leaders wrestle with the challenge to bring

down operational costs, while keeping high-quality patient care. In order to keep profits on

an upward trend, it’s vital that medical facilities receive payments from patients and

insurance companies in a timely manner. To accomplish this, the revenue cycle – or the life

of a patient account from the time their case is opened until final payment is received – must

be managed effectively.

Managing revenue cycle means improving compliance as much as it means ensuring

complete and accurate billing processes and A/R follow up procedures.

Quality Revenue Cycle Management (RCM) processes are required today more than ever.

It is the responsibility of all staff, especially those with clinical and financial responsibilities. In

today's Medicare environment — and it is not much different if a provider's primary payer is

insurance or the patient — mere automation is insufficient.

RCM processes must build in compliance. Building in compliance requires that

communication and interdisciplinary coordination are part of a plan of care that manages a

patient's medical needs.


In order to achieve compliance in the contemporary regulatory environment, healthcare

providers must employ more than just point-of-care technology and a centralized

billing/coding system.

Lost revenue and poor compliance go hand in hand because coding errors are often the

result of incomplete and incongruent assessments. Billing mistakes typically occur because

visit activities vary from physician orders. Data errors are frequently triggered by hurried

keying into point-of-care and EMR systems.

It is imperative to utilize the RCM processes in order to verify assessments, review clinical

processes and reconcile resulting data as part of compliant revenue generation.

Incorporating RCM processes as part of an overall business strategy often results in

improved reimbursement, bullet-proof billing compliance and stellar clinical outcomes.

A well-developed RCM system as part of operations, implemented in real time, can mitigate

most of these costly mistakes.

Some of the different challenges that stand in the way of an optimized revenue cycle include:

Disparate systems and work types

Each department uses different tools to measure success and productivity

Manual processes and multiple touch points

Lack of transparency to team and individual performance

High, seasonal volumes

Inflexible workforce


These dysfunctions cause troubles for patients and providers alike as out-of-pocket costs

and operating costs have risen for both parties. Collecting payments from patients is a

difficult enough task for providers and these problems only add to the struggle.

Each revenue cycle process – from patient intake to accounts receivable – flows into and

affects one another. When they are executed correctly, the cycle works effectively. However,

if an error occurs and is not caught early in the cycle, revenue recovery becomes very costly.

Systems must be designed into processes that identify errors prior to revenue generation.

Catching up with after-the-fact chart audits is no longer an adequate process in today's

environment. Operations must have built-in processes that catch incongruence in real time

while it is occurring...not after the bill has flown out the door.

How Revenue Cycle Management Helps

Administrators, billing professionals, coders and physicians must work together to ensure

that patients are being charged for the correct treatments and paying on time. As the amount

of money the healthcare industry spends on submitting and processing claims each year

continues to rise, it’s becoming more critical to find ways to keeps revenue flowing.

Experts advice following Tools and Guidelines to an efficient revenue cycle management:

Quicken the timeliness and accuracy of your receivables processing

Lower how many days accounts receivable are outstanding

Minimize the amount of time it takes for a statement to be sent to the recipient

Improve reconciliation of patient self-pays

Store denial and remittance information digitally

Streamline the account information update processes

Improve customer service

Reduce potential fraud.


Making these improvements can increase revenue by eliminating the amount of time spent

in receivables, reduce administrative costs, and allow staff more time to spend on tasks that

increase revenue.

A system running effectively prevents denials of claims and maintaining a visible, efficient

billing process. RCM also encompasses everything from determining patient insurance

eligibility and collecting co-pays to properly coding claims using ICD-10. RCM includes the

use of technology to keep track of any claims through their entire lifecycle, ensuring

payments are collected and addressing any denied claims. The ultimate goal allows health

care providers doing the billing to follow the process and address any issues quickly,

allowing for the steady stream of revenue.

A streamlined and efficient revenue cycle is one of the pillars of a successful health care

organization. However, one that lacks efficiency, proper skills set of staff and effective

denials management can negatively impact the healthcare facility’s bottom line.

Clearly, RCM must begin with management's confidence that assessments are accurate.

Crucial to this phase are clinical tools. It is management's responsibility to assemble the

tools — especially comprehensive and ongoing training programs — that will properly

channel the critical thinking skills required and expected of field staff.


12. Conclusion

There are a number of different processes that go into running a successful healthcare

organization. However, regardless of whether you are a multi-location hospital network

spread across the country or a private practice of one doctor and one nurse, Revenue Cycle

Management (RCM) is one of the most critical processes that organizations need to master

to be successful for, prompt payment from insurers and patients is essential.

Reimbursements on claims filed and the money paid out of pocket by patients are the basis

of revenue cycle.

The extent to which you effectively manage your payment processes and have a handle on

collecting payments that are past due is an indicator of your practice’s financial health. While

this makes sense intuitively, actual execution of Effective Revenue Cycle Management is a

challenge to the average practice owner.


13. Weblilography

www.ehow.com

www.cms.hhs.gov

www.en.wikipedia-the free encyclopedia

www.investopedia.com

www.about.com

www. [email protected]

www. [email protected]

www.selectdata.com/the growing-importance of RCM

www.info.ahrg.gov.

www.mb-guide.org/claims-adjudication-process.html

www.wisegeek.org / what-is-claims-adjudication .htm l

www.ohsu.edu /xd/about/services/patient-business-services/ revenue-cycle

Selected Works of Timothy D Martin,Southern Methogist University

www.capario.com. Article by Jim Riley is the president of Capario, a provider of revenue

cycle management solutions

www.ohsu.edu/xd/about/services/patient-business-services/revenue-cycle

Becker's Healthcare- An article by Monte Sandler is Exe. VP of practice solutions for

NextGen Healthcare Information Systems.

http://www.capario.com/

http://www.ohsu.edu/xd/about/services/patient-business-services/revenue-cycle

http://www.wisegeek.org/what-is-claims-adjudication.htm

http://www.selectdata.com/the

mailto:[email protected]

http://www.selectdata.com/contact

http://www.investopedia.com/

http://www.en.wikipedia-the/

http://www.cms.hhs.gov/

http://www.ehow.com/

s3-ap-southeast-1.amazonaws.com · web viewthe word ‘revenue’ originates from latin (revenire)...

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