Revenue Cycle Management in the US Healthcare

1

• Revenue Cycle Management in the US Healthcare

2
Revenue Cycle Management in the US Healthcare
Revenue Cycle Management in the US healthcare is
the financial process which utilizes medical
billing software to track patient care
information from appointment schedule to the
insurance payment or patient payment of a
balance. Current transition from fee-for-service
to value-based care reimbursement will bring
changes to the traditional revenue cycle
management (RCM) in healthcare. What is another
name for revenue cycle management (RCM)? Medical
billing is the process of submitting and getting
physicians paid for their services from insurance
companies. This process is done by the medical
billing company or healthcare provider themselves
(interaction between billing team and the
insurance company). This process is carried out
by all insurance companies, whether they are
private payor or government sponsored programs.
This entire process of interaction between the
billing team and insurance company is known as
the medical billing cycle sometimes referred as
Revenue Cycle Management. Small practices,
hospitals and groups of physician organizations
are working to save lives and treat patients. All
healthcare organizations need to develop their
successful billing cycle and policies to stay
financially healthy. Here healthcare revenue
cycle management comes in.
Medical Billing Services in Oregon
3
Revenue Cycle Management in the US Healthcare
Why revenue cycle management is important in the
healthcare industry? Revenue cycle management is
a process, this process enables the healthcare
industry to work efficiently without worry of
financials. The overall goal of this process is
to increase revenue throughout the various
steps. RCM prevents fraud, waste, and abuse such
as needless tests and procedures. For you as a
physician, revenue and finance are not the
primary concern. You are more focused on patient
care, here we as a medical billing company can
help you to maintain your cash flow. RCM is an
interaction between healthcare providers and
insurance companies, so it includes patients
medical records and its also important how these
records are accessed and stored for billing
purposes. Nowadays, since technology has evolved
from basic to advanced, there has been an
increase in attacks on medical organizations to
acquire access to medical records. These medical
records and other patients personal health
information (PHI) are protected by federal law
such as the HIPAA (Health Insurance Portability
and Accountability Act) privacy and security
rules. RCM is the important process in
healthcare. Automated RCM processes can give more
room to physicians to focus on patient care.
Contact our healthcare management consultants
today to know why you should outsource your
revenue cycle management.
Medical Billing Services in Oregon
4
Revenue Cycle Management in the US Healthcare
Steps in revenue cycle management Outsource
medical billing or RCM Software You first need to
analyze how to manage your RCM process. What is
the size of your organization? If you are a small
organization and limited with a good IT team in
place as well as in-house medical billing team
members who are well versed in using dedicated
medical billing software, you may need to partner
with us to increase your cash flow and keep your
organization up to date with all billing
compliance. However, if you are running a larger
organization, such as one with multiple offices
in multiple locations. Also, you have a good IT
team and you have the best medical billing staff.
Then you have a choice to manage the RCM process
with your in-house team. But to manage this
staff, their training, perks, and other benefits
your admin team has to invest more time on it.
You need to find an expert in RCM. This will be
beneficial to rely on this outsider for the RCM
process, so your organization can focus on your
core capabilities in patient treatment. Patient
Scheduling and patient Demographic Entry Patient
demographics is the core of the data for any
medical practice or specialty. Demographic
information examples include age, ethnicity,
gender, race, marital status, income, education,
and employment. Gathering all patient demographic
information is required at the time of patient
scheduling is important. It can help to improve
the quality of care for all patients.
Medical Billing Services in Oregon
5
Revenue Cycle Management in the US Healthcare
Patient Pre-Authorization Patient
pre-authorization of each patient is important in
RCM. Pre-authorization is defined by the US
government as a decision by a health insurer or
plan that a prescription medication, procedure,
services or equipment is medically necessary. In
case of a medical emergency, you can make an
exception in pre-authorization. Pre-authorization
does not mean that the insurer will cover
patient treatment costs. Patients and providers
have to confirm if there is any doubt in
coverage. Prior authorization is intended to help
avoid you from being prescribed medications you
may not need. Eligibility Verification Insurance
Eligibility and benefits verification is one of
the top most important steps in revenue cycle
management. As per the industry research, most of
the claim denials or delays in processing the
claim occurred due to missed or wrong coverage
information. Updated medical billing software
includes automatic checking of patient
eligibility online over a secure channel.
Dedicated medical billing software can speed up
your work involved in verifying a patient is
entitled to a particular benefit or not.
Medical Billing Services in Oregon
6
Revenue Cycle Management in the US Healthcare
Claim Submission Claim submission is a process in
revenue cycle management. Insurance claim
submission is a key step in the medical billing
process. It identifies the amount of collection
that the healthcare provider will receive after
the insurance company processes the
payment. Properly claim submission is important
to avoid claim denial in future. Medical billing
software is invaluable in this situation. Medical
billing team can submit claims automatically with
the help of software, including the option to do
this in batches. There can be human errors while
submitting claims to insurance companies. Your
medical billing software should have an option to
detect mistakes and then explain them to you so
you can fix the issue. Payment Posting All the
players either send an Explanation of benefits
(EOB) or Electronic remittance of advice (ERA)
towards the payment of the claim submitted by the
provider. Medical billing companies or staff post
these payments into the respective patient
account, against that particular claim to
reconcile them. Once your outsourced medical
billing team or in-house team completes the
payment posting, you can analyze patient
responsibility. Your RCM software can help in
this respect not only in the convenience it
offers for generating patient billing statements,
also to send automated messages to patients with
a pay online option to encourage them to
reimburse you more prominently.
Medical Billing Services in Oregon
7
Revenue Cycle Management in the US Healthcare
Denial Management and Reporting This is a
critical element of your RCM for a healthy cash
flow. Leverage Medisys Data Solutions team to
create reports for your billing and easily find
the causes of denial of claims. With the help of
our Denial Management process you can mitigate
the risk of future denials and get paid
faster. How often your claims are getting denied
for services rendered out of your facility? If
your monthly reports are showing a downturn in
revenue because too many claims are getting
denied, its time to find the exact cause.
Properly executed denial management processes can
boost earnings. Medical billing reporting can
uncover claim denial patterns. This way you can
work around it to make sure you achieve 99
successful claim submission. Revenue could be
lost if providers cannot identify issues in
revenue cycle management and are unable to
resolve them quickly. We can help you to alert
that address why payers are routinely denying
claims for a specific procedure or code. Contact
the Medisys Data Solutions team today for more
information about how our services can make you
more productive and profitable.
Medical Billing Services in Oregon