Getting Back to the Basics: Know the Fundamentals of Healthcare Revenue Cycle Management (RCM)

As a healthcare provider, you must be considering the Revenue Cycle Management (RCM) process as the backbone of the healthcare industry. From the top view, RCM looks like managing the overall finance of the provider or organization, but in actual RCM works at the functional core of any healthcare facility. Each facility by law has to follow a unique process to stay righteous and commercial in the market to remain profitable.

9 Steps in the process of Revenue Cycle Management (RCM) 

Revenue Cycle Management (RCM) is a process with huge challenges and denials.

RCM Software or An Outsourcing Company:

The first step towards the claims management is to decide whether to install in-house RCM software and manage highly paid experts or outsource it to skilled revenue cycle management professionals.

Outsourcing your medical billing services with expert IT personnel to file claims, work on denials, and appeals, allows you to focus more on patient care rather than you involved in billing services.

When you run a small practice, having the support of the IT crew, it is ideal to run an in house RCM software set up on local servers. However, when it comes to larger organizations or those who lack skilled IT staff should best consider outsourcing Revenue Cycle Management (RCM).

Patient Pre-certification or pre-authorization:

When a patient comes in, they undergo pre-authorization. The provider’s office pre-authorizes the patient for certain treatments and prescription of drugs. This is the step where the patient or the insurance companies have to decide whether the prescription of the drugs, procedures, services, or equipment is medically necessary or not. Based on the decision, insurance companies will reimburse for the services provided. The pre-authorization process is repetitive and needs continuous verification each time. It is always a good idea to double-check any doubts related to coverage with the insurance company. The pre-authorization phase faces exceptions in case of a medical emergency.

Know the Fundamentals of Healthcare Revenue Cycle Management (RCM)

Eligibility and Verification of the insurance:

This process demands a lot of patience. Therefore, when you are handling your billing services in-house, then you must have a set of functions to be a part of the RCM software to cater eligibility and verification process. Once the patient goes through the care delivery, the Explanation of Benefits (EOB) statement incorporates all the details of the services or treatments paid on their behalf by the insurance company.

Charge and Code:

When the patient visits the provider’s facility, the visit gets transformed into a set of codes, and there is a high probability of human error in these chargers and codes. Therefore, it is highly recommended to ask professional medical coders to manage this activity. The codes have to follow a certain set of rules and concur with the CPT guidelines and the latest ICD-10 coding system.

Co-payments and Deductibles:

You must be aware of this right? Each health plan comes with a deductible and a co-payment. Some patients have high and some have low deductibles, according to their insurance. Whatever the amount is, the patients have to pay the copays at the provider’s office before they go back home. The deductible is the amount fixed in a health plan that you have to pay before the insurance company starts paying for those health care services.

Submission of the Claims:

Submission of claims is the most important stage in the overall RCM process because the reimbursement directly depends on it. If this procedure is followed with mistakes then there are the high chances to get reduced for or outright denials. As soon as the biller prepares the claims, they are filed with the insurance companies via a clearinghouse. The clearinghouse makes sure they are clean and free from errors.

Reimbursement for the Services Provided:

It is the most awaited step in the entire process. It is time for the insurance company to pay up for your services. The insurer matches the procedures with their charges under the coverage limit. If the bills are appropriate, the process of reimbursement becomes smoother and returns maximum payments. But, in the case of mistaken claims and incomplete patient information, or any other issues, the denials are inevitable.

Manage Denials:

The claims who are suffering under rejection are resubmitted soon after they are restored with coding mistakes. The resubmissions process demands crucial screening with a pointer on the latest coding guidelines. Also, every minute detail is checked against the patient profile. It makes the billers work directly with the payers.

Collection from patients:

When you get reduced reimbursement from the insurer, it means that patient’s health plan does not cover all the services received. Therefore, it is the duty of the billers to send those outstanding payments to the patient and check for rigorous follow-up until the patient finally pays up.

Following all the above steps will help you maintain constant revenue growth and access numerous medical claims with fewer errors and denials. Handling the complex process of revenue cycle management, you need to manage a well-trained IT team to carry the process towards the finish line. On the contrary, you can just outsource all the hectic process and outsource it to someone who is specialized in bringing back your reimbursement with very few denials.

Know the Fundamentals of Healthcare Revenue Cycle Management (RCM)

If you are considering outsourcing your revenue cycle management process, and are likely wondering where to start? Don’t worry – you are in the right place –

iPatientCare, is a leading provider in transforming RCM services with built-in Cloud-based Meaningful Use Stage-3 certified EHR and PMS technology. It provides efficient, responsive, and accountable billing implementation and back-office services that give more than 98% first-pass claims submission and efficient A/R follow-up/denial management at very competitive rates. To learn more, visit iPatientCare’s Healthcare Revenue Cycle Management.


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