9 Steps You Didn’t Know About Revenue Cycle Management

The healthcare industry’s backbone is revenue cycle management (RCM). It manages the providers’ finances and keeps them running on a daily basis, involving several organizations in the process. The importance of medical billing services and front-desk personnel in the United States cannot be overstated. We’ll look at how each of those departments can improve physician and other clinician payments.
What is Revenue Cycle Management, and how does it work?
RCM, or Revenue Cycle Management, is a process that manages the financial cycle. Whether it’s a small medical practice or a large hospital, RCM is at the functional heart of the industry. To stay profitable, each institution is required by law to follow certain procedures, so the care delivery process moves forward steadily. In light of the current debate, it’s important to recognize the key players in this process: physicians, patients, and payers.
Physicians and patients are directly involved in the care delivery process, but payers play an important role as an engine. Both doctors and patients are motivated by the money. The healthcare industry’s skyscraper is made up of several basic building blocks that work together to complete an end-to-end revenue cycle management process.
Outstanding accounts receivables have a direct impact on a practitioner’s income. The consequences of a sluggish revenue cycle can result in significant backlogs in pending claims for physicians.
In the United States, medical billing services play an important role.
Most medical practices strive for an efficient revenue cycle management process in medical billing. Third-party medical billing and coding companies are mostly to blame, assuming they have the necessary experience and skill set. The comparison of medical billing services in the United States to an anchor is fascinating. As an anchor connects a ship to the shore, they connect providers and payers.
It is critical to contact billing service to run a successful healthcare RCM process. Whether you prefer to outsource medical billing or hire an in-house specialist, even a minor deviation from a certain level of attention can result in the entire process failing. Filing claims on time results in faster reimbursements. Certain skills are required, as well as a mix of new and experienced billers.
9 Steps for Revenue Cycle Management
While there is no substitute for high-quality care, the importance of following the 9 steps of revenue cycle management cannot be overstated.
According to recent publications, AI, or Artificial Intelligence, will improve the efficiency of a revenue cycle management system by acting as a digital employee for doctors.
1. A Medical Billing Outsourcing Company or RCM Software
The decision to install RCM software in-house is the first step in claims management. Do you delegate the job to a revenue cycle management firm? Don’t worry; outsourcing medical billing services with skilled IT personnel to file claims, work on denials, and appeal on your behalf makes things easier.
Physicians typically Google the phrase “medical billing companies near me” to find a billing company that fits their practice. It displays a list of nearby businesses.
When your medical practice lacks expert IT staff, it makes sense to look for revenue cycle consulting companies in your area. It’s ideal for running RCM software on local servers when you run a small practice with a capable IT crew. Medical billing services in the United States, on the other hand, are preferred by larger organizations or those lacking skilled personnel.
2. Pre-authorization or pre-certification of the patient
What exactly is it? Pre-authorization is completed when a patient arrives. This process allows the physician’s office to pre-approve the patient for certain treatments and prescription drugs.
Payers or insurance companies determine whether or not prescription drugs, procedures, services, or equipment are medically necessary at this stage. They will reimburse for the services provided based on the decision. In the event of a medical emergency, the pre-authorization phase is subject to exceptions.
Pre-authorization does not always imply that the health insurer will cover the cost, which is why the procedure is tedious and requires constant verification. Any doubts about coverage should always be double-checked with the insurance company. This holds true for both providers and patients.
3. Verification of Insurance Eligibility
Over the phone, the process is demotivating because it requires a lot of patience. As a result, the RCM software must include a set function to accommodate it. Artificial Intelligence (AI) could be a game-changer in this phase of recognition because it automates the process.
After patients have completed their care, the Explanation of Benefits (EOB) statement contains all of the details of the services or treatments that the insurance company has paid on their behalf.
4. Code and Charge
The visit becomes a set of codes when the patient checks in at the office. Because there is a high risk of human error in these codes, competent medical coders are essential to the process. The codes must adhere to a set of rules and be compliant with CPT guidelines and the ICD-10 coding system.
5. Deductibles and co-payments
A deductible and a co-payment are part of every health plan. Deductibles vary from high to low. Patients pay their copies at the doctor’s office before going home, regardless of how much they owe. The deductible is the amount you must pay out of pocket before your health insurance company begins to pay for those services.
6. Make a claim
The submission of claims is a critical step in the process because reimbursement is contingent on it. If it’s flawed, you’re more likely to get lower payments or even be denied. The claims are filed with the insurance companies via a clearinghouse as soon as the biller prepares them. The clearinghouse verifies that they are clean and error-free.
Internally, when practice management software connects with medical billing software, the revenue cycle management operational process is initiated. In light of those claims, the billing company contacts the insurance company. It ensures that the payer pays on time.
7. Reimbursement for Provided Services
It’s past time for the insurance company to make good on their promises. Under the coverage limit, the payers match the procedures with their charges. If the bills are correct, the acceptance process goes more smoothly and you get the most money back.
Denials are unavoidable when there are incorrect claims, incomplete patient information, or other issues. Unless the RCM is used to its full potential, most low-dollar claims tend to pile up.
8. Control Denials
Claims that are rejected are resubmitted soon after they have been scrubbed for coding errors. Critical screening with a finger on the pulse of the most recent coding guidelines is required during the resubmissions or appeals process. Furthermore, minute details are compared to the patient profile, allowing billers to work directly with payers.
9. Collections
The health plan does not cover all services when payer reimbursement is reduced. Billers are then responsible for sending any outstanding payments to the patient(s) and following up. Medical billing services keep track of their clients until they pay up.