Revenue Cycle Management Healthcare

what-is-the-revenue-cycle-management-healthcare-and-its-components

Revenue growth is the second crucial aspect for healthcare providers after patient care, and it lies in flawless revenue cycle management healthcare. This financial operation aims toreduce claim denials and payment collection delays while evaluating faster reimbursement and increased cash flow.

Healthcare businesses that are more conscious about their financial performance stay with us. This guide explores an overview of the revenue cycle process in healthcare, management steps, benefits, and common challenges to avoid.

What is the Revenue Cycle in Healthcare

 The healthcare revenue cycle management is defined as a revenue process starting from patient scheduling appointments and ends at collecting payment and reporting. This process cycle facilitates practitioners to collect each penny for the service they deliver to patients.

There are many major RCM roles, including insurance processing, registration, eligibility, coding, claims management, and revenue collection. Taking all these steps seriously leads to better revenue collection, satisfied patient experience, and, above all, helping your practices stay at the top of the healthcare business.

Benefits of Revenue Cycle Management in Healthcare

A well-targeted RCM system offers plenty of benefits for revenue cycle management. According to Global News, the RCM market is expected to grow to around USD 453.47 billion by 2034.

Better Billing with Smarter Integration

Revenue cycle operations improve communication by integrating EHR with accounting systems for better billing processes and faster reimbursement.

Faster payment with accurate codes

It offers flawless, accurate medical codes and claims for quicker reimbursement and lower financial stress.

Error-free billing

RCM streamlines the error-free billing process, which fills the gap between patients getting service and practitioners getting paid.

Less paperwork, more patient care

The administrative team will now be freed and could be more focused on patient care as RCM systems are designed to handle all revenue cycle components.

Stay on top of billing rules

Revenue cycle healthcare systems assist providers in complying with ever-changing billing regulations and payers’ guidelines. Ultimately, it is beneficial for accurate claim submission.

Get paid faster with less stress

A well-implemented RCM system shortened the revenue collection cycle by quickly registering, scheduling, applying, managing, and processing payments.

Satisfied patient experience

Engage patients throughout the process about costs, billing procedures, and payment to improve their satisfaction so they keep coming back.

Lower cost and reduced administrative burden

An efficient RCM assists providers by replacing the manual billing with an automated process that handles every step, such as claim submission, denial management payment collection, and compliance management. This not only reduces administrative burden but also decreases overhead costs by reducing billing errors and delays. 

Enhance financial transparency

The healthcare revenue cycle system provides real-time access to all financial data, which means 100% transparency in the revenue cycle. It includes clear billing payments, detailed cost breakdowns, and easy-to-understand payment options to boost trust among patients and doctors.

Overview of Revenue Cycle Process in Healthcare

Revenue Cycle Process in Healthcare Overview
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The healthcare revenue cycle process is an entire financial process practices follow. It includes all clinical and administrative functions that contribute to revenue generation and reimbursements. The revenue cycle includes the below general steps:

  • Registering patient information on EHRs.
  • Verifying patient insurance and eligibility for service.
  • Delivering required medical service and documenting it.
  • Record charges associated with the service.
  • Assign codes to diagnosis and treatment.
  • Converting codes into claims.
  • Submitting claims to payers.
  • Tracking denials and creating appeals.
  • Posting payments from payers and patients.
  • Generate reports and update practices.

Effective Revenue Cycle Management Steps

Revenue cycle management in healthcare (RCM) involves active management and optimization steps that enhance the above revenue cycle process. Without wasting time, let’s elaborate on the important steps in revenue cycle management.

Effective revenue cycle management steps

Patient Registration and Eligibility Verification

The revenue cycle management process in healthcare begins by registering the patient, either through front office staff or via a patient portal. This provides the practices with access to necessary patient information, which is later used to verify patient insurance. 

These steps in revenue cycle management in healthcare are essential for providers for two purposes. Firstly, whether patient information is accurate and he/she is allowed to schedule a meeting. Secondly, if the patient has active insurance coverage, what are their terms? Also, how much does a patient have to pay out of pocket besides the insurance?

Medical Coding and Charge Capturing

As soon as the patient receives medical services, convert them into appropriate codes. This healthcare revenue cycle management process step includes translating medical procedures, diagnoses, and services into ICD-10 and CPT-9 codes. Manual coders or automated coding tools integrated within healthcare IT platforms enter these medical codes.

The next step involves entering charges in the billing system based on medical codes and practitioners’ fee schedules. The charge entry needs to be accurate as it directly impacts the claim accuracy and total amount of reimbursement.

Claim Scrubbing and Submitting

Once medical services are properly coded, they are sent for a claim scrubbing process. This involves reviewing medical claims for errors before submitting them to payers. The scrubbing process analyzes various issues, such as invalid codes, incorrect patient information, incomplete documentation, etc.

Nowadays, modern claims are submitted electronically through the EDI (Electronic data interchange) processing or ERA (Electronic remittance advice) platform to ensure accuracy and faster reimbursement. Payers validate that the claims comply with payment policies and agreements to decide whether they should be denied or paid fully or in half.

Denial Management and Appeals

If the claim is denied, revenuecycleclaimsmanagement and appeals take place. This process means the claim does not follow payer guidelines, and they rejected it. Major reasons for denial could be missing patient information, coding errors, eligibility issues, etc. 

At this stage, the denial management service finds denial errors and resubmits the appeal to payers for quick approval. Additionally, every reason for claim rejection is recorded to prevent repetitive future denials.

Payment Posting and Reconciliation

Payment posting and reconciliation are the next steps in revenue cycle management. The payment posting process is responsible for recording and reconciling receivable payments from payers and patients to healthcare providers for the services they offer.

The reconciliation process balances the record payments with the expected payment to ensure accurate recovery and avoid discrepancies. Perfectly completing these processes is essential for ensuring accurate payments are collected for the practice revenue cycle.

Reporting and Analysis for Optimization

The last steps of revenue cycle management are actively analyzing and reporting key monitor indicators and industry trends. When providers use these insights, they are able to flag potential areas of improvement in overall RCM and implement innovative strategies to optimize financial performance.

Components of Revenue Cycle Management

6 key components of revenue cycle management

The key components of revenue cycle management are strategy making, process optimization, data analysis, compliance, and staff training. Each one is elaborated on below.

  1. Strategic planning: Create and implement RCM strategy to optimize revenue and financial performance.
  2. Optimization of Process: Automate tasks, navigate workflow, and improve communication to maximize approvals.
  3. Data Analysis: Monitoring industry data to identify trends and identify areas for improvement.
  4. Adhere to Compliance: Adhering to HIPPA-compliance and federal regulation standards to ensure the protection of patient data, including insurance details, medical history, and payment info.
  5. Implementing Technology: Using technology to automate tasks, improve process accuracy, and boost patient-practitioner communication.
  6. Training Staff: validating staff members are highly trained to take out precise RCM processes.

Challenges to Avoid in Healthcare Revenue Cycle Management

A recent study revealed that $262 billion in healthcare claims are initially denied, a big loss of revenue caused by major challenges in RCM. Get to know these challenges in revenue cycle management healthcare to maximize financial return.

Note.

Staying updated with billing and coding changes

Monitoring frequent updates and changes in billing and coding regulations is challenging for effective revenue cycle operations.

Tackling Cybersecurity Risks in RCM

Healthcare providers relying on digital systems for effective medical billing revenue cycle could be more prone to vulnerable cybersecurity breaches, resulting in lost revenue and reputational damage to the organization.

Lack of tracking key RCM matrices

Inability to track and analyze key medical revenue cycle management metrics, including net collection rate, denial rate, days in accounts receivables (AR), bad debt rate, and clean claim rate.

Staff training gaps and high turnover

Lack of healthcare revenue cycle management staff training, insufficient knowledge, and higher turnover are significant challenges in revenue cycle management healthcare, leading to financial loss.

Authorization Issues leading to claim denials

Insufficient authorization for patient and clinical data before claims submission leads to excessive claim denials, which affects the revenue cycle in healthcare.

Technology Integration Challenges in RCM

RCM brings technology integration challenges such as technological overload, compatibility, and data security issues. This can slow down claim processing and cause mistakes that hurt revenue cycle performance.

Rising Tech Costs & Changing Regulations Make RCM Complex

As you expand your small healthcare organization, at some point in time, you may encounter rising technology costs for billing and frequently changing regulations. These could pose complexities for your in-house team in implementing effective revenue cycle management in healthcare. 

That’s why, in the past decade, most practices have relied on outsourcing RCM services such as medical billing, coding, denial management, and AR follow-up to optimize financial growth. Third-party RCM services have access to industry experts and advanced-level tools and technologies for Flawless billing purposes. Hiring them assists practices in freeing their in-house RCM team and focusing more on patient care while letting experts handle their revenue.

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