Revenue Cycle Management to help Healthcare Leaders Simplify their Practice

 

Healthcare facilities use medical billing software to track patient care episodes, from enrollment and appointment scheduling to the full settlement of a balance. This process is known as Revenue Cycle Management (RCM). By combining administrative data, such as a patient's name, insurance company, and other personal information, with the treatment a patient receives and their healthcare data, RCM unites the business and clinical aspects of healthcare.  

 RCM's interaction with health insurance providers is crucial. The employees at the provider's office or the hospital often verify the patient's stated insurance coverage before the visit when the patient makes an appointment. A healthcare professional or coder classifies the type of treatment offered when an insured patient receives care for a specific disease and pays any necessary copayments using ICD-10 codes. The patient is then charged for any remaining costs after the hospital or care facility gives the insurance company the care summary with ICD and Current Procedural Technology codes to determine what percentage of the patient's care will be covered by insurance.

Revenue Cycle   

According to the Healthcare Financial Management Association, the revenue cycle encompasses all administrative and clinical tasks that support capturing, managing, and collecting patient service revenue.  

The revenue cycle involves the following:

1. Charge Capture: Converting medical services into reimbursable costs.  
2. Claim Submission: Submitting insurance companies with claims for chargeable fees.  
3. Coding: The accurate coding of operations and diagnoses.  
4. Patient Collections: The calculation of patient balances and payment collection.  
5. Preregistration: Preregistration information, such as insurance coverage, is gathered before a patient comes for an inpatient or outpatient surgery.  
6. Registration: Additional patient information is collected during registration to produce a medical record number and meet specific regulatory, financial, and clinical criteria. 
7. Remittance Processing: Utilizing or rejecting remittance processing to apply or reject payments.  
8. Third-party Follow-up: Obtaining payments from outside insurance companies.  
9. Utilization Review: Examining if medical treatments are necessary.  

Factors affecting the Revenue Cycle  

Internal and external factors determine how revenue is collected, just like any other financial concern. Interior characteristics, including physician productivity, patient volume, and service costs, are within some control of a healthcare institution. However, it is more challenging to affect outside variables like patient payments or insurance company claim evaluations.

Revenue Cycle Management Systems  

To store and manage patient billing records, healthcare providers frequently invest in and implement specialized revenue cycle management systems. By collaborating with other health IT systems, such as electronic health records (EHR) and medical billing systems, as patients progress through the treatment process, an efficient RCM system can shorten the time between providing a service and collecting payment.

RCM and value-based Care  

According to some analysts, RCM technologies will ultimately aid in the industry's move from fee-for-service to value-based reimbursement. Many RCM solutions include analytics that enables payers and providers to understand better their patient population, including what proportion of their patient population is affected by which chronic diseases. They can also monitor the claims data and identify any potential problems.