Revenue Cycle Management

Revenue cycle management (RCM) is the process by which healthcare organizations handle financial operations such as billing and collecting payments for medical services. RCM begins when a patient makes an appointment and concludes when the account balance is reconciled through insurance payments, contractual changes, write-offs, or patient payments.

RCM improves revenue by lowering claim denials, shortening days in accounts receivable, and increasing collections. As a result, healthcare providers receive accurate and timely reimbursements, resulting in improved financial performance. Effective RCM can also assist healthcare firms meet regulatory requirements and increase patient satisfaction.

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RCM bridges the gap between patient accounts and the clinical side of healthcare. For example, RCM associates demographic data (a patient’s name, insurance provider, and other private information) with the therapy they get.
A well-designed and proper RCM system speeds the billing and collection cycles by accurately pre registering, establishing appointments for, and rescheduling patients; collecting existing balances; processing payments; and interrogating insurers when they refuse claims.
Accounting software and electronic health records (EHRs) are used to communicate among the healthcare team, which includes doctors, managers, and billing, coding, and preauthorization specialists. Using EHRs becomes easier with the aid of RCM software or systems. This streamlining shortens the time between giving a service and getting paid for it, while also lowering administrative overhead costs.

RCM solutions enable healthcare personnel to enter all of the information necessary for claims processing, reducing the need to amend or resubmit claims. Reducing refused claims helps providers save time and money.
RCM improves patient care, providing a better experience for patients. For example, through eligibility for insurance verification, patients will be aware of any balances or financial expectations from the start.
Correct billing and coding, in addition to understanding the reasons for denials, improve the patient experience by charging appropriately, resulting in fewer denials. This accuracy reduces stress for both patients and healthcare providers.

RCM systems allow patients to pay their bills online, and healthcare professionals can utilize them to store and manage patients’ billing records.
RCM relies on documentation to demonstrate the medical necessity of the charge. Patient safety improves because proper documentation leads to greater overall patient care quality. Many professionals analyze the patient’s chart to ensure clear documentation, which provides a more complete picture of the patient’s condition.
RCM technologies make it easier to report and analyze data as necessary to ensure that the organization’s revenue cycle is functioning properly.

How to Improve Revenue Cycle Processes

Clinics and medical practices can optimize revenue cycle procedures by reviewing each phase to see what is functioning effectively and where there is space for improvement. Using the data analytics stated above provides RCM managers with organization-specific information to assist them make judgments regarding potential improvements. The following are some key areas to monitor to enhance revenue cycle procedures.

Medical billing begins with appointment scheduling and registration since erroneous patient demographics and facts, such as name, residence, gender, spouse information, and whether the visit is for a work-related injury, will result in a medical claim denial. Insurers will not accept claims that contain missing or erroneous patient information.
Verifying the eligibility of patients prior to each visit will prevent denials. This phase ensures that the patient is covered by the payer and plan that the patient has chosen.
Careful handling of previous authorization (also known as precertification or preauthorization) will aid in revenue management. Practices cannot afford to lose revenue due to the lack of prior authorization, which refers to the health care plan requirement for patients to acquire approval for certain healthcare services before receiving care.

Involving providers as needed may increase the possibility that a payer is going to reimburse a service. For example, an ordering provider may be required to participate in a peer-to-peer evaluation alongside a payer-employed provider. These evaluations focus on why a patient requires a service or prescription, so that the payer understands the provider’s request for prior authorization. The business team must interact with the clinical team to organize this, keeping in mind that a provider’s time is valuable while also communicating that if the peer-to-peer call fails, the authorization is lost.
Communication and collaboration between staff members who maintain healthcare records and those who manage patient accounts can help to avoid errors caused by contradicting information.

Additional steps to improve RCM include the following

Keep up with current rules and modifications, including medical code upgrades. Using improper or erroneous reporting codes causes claim difficulties and payment delays.
Charges and coding adjustments are in place. adjustments will detect improper reporting and missing information such as modifiers, National Correct Coding Initiative (NCCI) adjustments, and more, resulting in faster claims processing and payment.
Have a compliance liaison who analyzes charges to guarantee proper billing.
Work denials should be done not only on time (within the term specified by the payer), but also strategically. Assess for comparable denials and work together to recover revenue as efficiently and promptly as possible.
Allow technology to help streamline operations when it is advantageous to do so.