How to Make US Medical Billing More Efficient Tips and Strategies
Introduction to Revenue Cycle Management
1. The Healthcare Financial Management Association
(HFMA) defines revenue cycle as:
"All administrative and clinical functions
that contribute to the capture,
management, and collection of patient
service revenue."
In other words, it is a term that includes the
entire life of a patient account from creation
to payment.
Revenue cycle processes flow into and affect one
another. When processes are executed correctly,
the cycle performs predictably. However, problems
early in the cycle can have significant ripple
effects. The further an error travels through the
revenue cycle, the more costly revenue recovery
becomes
REVENUE CYCLE MANAGEMENT 101
DEFINITION OF REVENUE CYCLE:
2. Scheduling &
Pre-registration
Financial
Clearance
Pricing
Charge
Capture &
Entry
CodingCDM
Standardization
CDM (Charge Description Master): Is a file with comprehensive listing of items that can be billed to a patient or insurer by a healthcare provider.
Contracts
Claim
Processing
Account
Collections
Denial
Resolution
Payment
Posting
Financial
Counseling
Arrival &
Registration
Denial
Prevention
Technology
Customer Service
Performance Management and Monitoring
Change Management, Coaching and Training
Charge Integrity “Middle”
Revenue Cycle
Patient Financial Services “Back
End” Revenue Cycle
Patient Access “Front End”
Revenue Cycle
Revenue Cycle Management
3. Revenue Cycle Management
Daily/month-end balance
Month-end reporting
Open issues tracking
Key metric tracking
Non-collectible adjustments
Ad-hoc reporting analysis
Root cause analysis
Pre-Claim Pre-Visit Visit
Claim
Submission
Inbound
Processing
Month-End
Closing
Performance
Management
Account Receivables
Management
Quality
Management
Compliance
Information
Technology
Contract
Negotiations
Eligibility
Verification
EDI/ERA
Enrollment
Fee
Schedule
Scheduling/R
egistration
Banking
Set-up
Patient
Check-in
Mail
Processing
Claim Status
Patient
Statements
Provider
Credentialing
Appointment
Reminders
Co-pay and
deductible
collection
Patient
Payment
Arrangements
Encounter
Documentation
Coding and
Charge
Capture
Scanning/
Indexing
Bank Deposit
EFT,ERA
Processing
Payment
Posting
Revenue
Allocation
Pre-
Adjudication
Claim
Submission
EDI
Management
Request for
Information
Denial
Analysis
Appeals and
Resolution
Inbound and
Outbound
Calls
Collection
Letters
Patient
Refunds
Conveyance,
Small Balance
Write-Off
Transition to
Collections
No-show rate
Charge Entry
Claim
Scrubbing
Analytics
Cash
collected
Revenue Cycle Management Support
Regulation monitoring
Coding and chart audits
Non-collectible adjustments
Coding support for billing process
Practice management system
EMR integration
Other application integration
Interfaces/data exchange
Hosting and support
Process measures and audits
Employee performance audits
External audits
Front End Back EndTransaction Processing
Life of a claim
Total days in
AR
Payers
denial rates
Rejection
analysis
4. Increased reimbursement
through improved, consistent,
and defendable charge
description master (CDM)
efficiencies and identification
of missed billing opportunities.
Reduced outstanding
accounts receivables and
denials through process
improvement and
workflow tools.
Improved accountability
and immediate issue
identification through
design and implementation
of management
performance reporting.
RCM Benefits Include:
Benefit
Accelerated cash flow and
improved annual net revenue
by streamlining every step
in the revenue cycle by
focusing on people, process,
and technology.
Benefit Benefit Benefit
5. Charge Capture:
Documented services are manually or electronically translated into billable
fees.
Claim Submission:
Billable fees are submitted to the insurance company via a universal claim
form for payment.
Coding:
The process of transforming descriptions of medical diagnoses and
procedures into universal medical code numbers.
Patient Collections:
Collecting patient balances, making payment arrangements.
Pre-registration:
Collection of all registration information, including eligibility, benefits and
authorizations, prior to the patient's arrival for inpatient or outpatient
procedures.
Registration:
Collection of a comprehensive set of data elements required in
establishing a Medical Record Number and satisfying regulatory, financial
and clinical requirements.
Remittance Processing:
Posting or applying payments/adjustments to the appropriate accounts,
including rejects.
Third Party Follow-up:
Pursue collections from insurers after the initial claim has been filed.
Utilization Review:
Evaluation of the necessity, appropriateness, and efficiency of the use of
medical services and facilities, which includes regular reviews of
admissions, length of stay, services performed, and referrals.
REVENUE CYCLE TERMS REVIEW
