A Guide to Revenue Management Cycle

A Guide to Revenue Management Cycle

In the healthcare industry, the growth is constant. With technology aiding this growth it is of utmost importance that hospitals focus on their finances if they want to expand their business. Being able to treat their patients and earn profits while doing allows them to do so. Medical billing is one such important aspect that must be paid close attention to. The process of medical billing is heavily influenced by Revenue Cycle Management (RCM). Without proper management of the revenue cycle, hospitals will not be able to manage their finances. 

In the healthcare industry, an optimized revenue cycle management system is considered to be the key to success. It not only helps in managing the finances of the hospital but it also ensures that the claims do not go undenied. The medical billing services play an important role right from the very beginning when the appointment of the patient is scheduled to the end until the payment gets cleared. 

Brief Understanding Of RCM

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Understanding the intricacies that lie in the revenue cycle management process will help you get a brief comprehension of the workings of a hospital. In layman’s terms, RCM can be described as a process that looks after the financial side of things. At the core of any hospital no matter how big or small it is, RCM helps in the management of things in a much easier manner.

The law suggests that for an organization to grow it is of utmost importance that they earn profit instead of bearing losses therefore, it would be unwise to ask medical professionals to multi-task if you want your organization to grow.  Medical billing outsourcing company focus on the accounts receivables and how it affects the medical practitioner’s income. 

The entirety of the RCM has three main stakeholders; the patients, the physicians, and the insurance payers. While the patients and the physicians take part directly in the process of care delivery, the insurance payer tends to be the crucial part of the entire process yet they do not participate directly in the care delivery. 

Every medical practice out there tries to achieve an effective RCM so as to maximize its profits. It is the outsourced medical billing company that has proficient medical billing staff who can achieve a productive RCM process. Without an experienced medical billing outsourcing company, you will not get the desired results. The majority of the time using in-house staff for the medical billing procedures not only can cost you a lot of time and money but also, they will not have the same level of skill set as the third-party medical billing companies. 

A Comprehensive Summary of all the Steps Included in RCM

Understanding the working of the RCM will help you deliver your promise to a better healthcare experience to your patients.

1. The role of RCM software

One of the primary steps when it comes to the management of the claims is deciding whether or not you should go for the in-house RCM software or do you want to completely hand over this work to the medical billing outsourcing company. It is of course easier to work with skilled professionals who can easily work on denial management, file claims, and overall optimize the entire working of the RCM.

If you are interested in searching for the best medical billing company that suits your company’s needs then you could easily do that on the internet by simply putting in “medical billing companies near me” to make things a lot easier. 

2. The process of pre-authorization

The patient goes through the process of pre-authorization where the physician pre-endorses the patient with required drugs and treatments. The insurance company decides on whether the services, procedures, prescription drugs, and pieces of equipment are a necessity for medical treatment or not. Based on this the reimbursement gets cleared for the rendered services. 

3. The verification of insurance along with charge and code

RCM software is catered in a manner that will help in understanding whether the patient is eligible for the medical insurance or not for the kind of treatment they are receiving. AI plays a trailblazing role here. After the care delivery process is done with patients get the EOB statement (Explanation of Benefits) that has all the information about the services rendered.

One of the most crucial things, when medical insurance is concerned, is to ensure that the ICD-10 coding system is being followed. Without the use of the correct codes, the possibility of claim denials becomes higher. 

4. The file claims

The process where the claims are submitted is an important one since reimbursement is dependent on it. If by any chance there are any errors the denials rate increase which is a loss for the hospital itself. After the medical billing professionals prepare the medical claims, they get filed with the respective insurance company through a clearinghouse. They ensure that the claims are free of any errors. 

5. The process of reimbursements and managing denials

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Once the medical bills are approved by the insurance payers, the acceptance process becomes smoother where you are guaranteed a proper sum of money. In case of claims that are flawed such as not putting the full information of your patients, or the codes are missing then the claims denials will become inevitable.

For the medical claims that have to face denials, they are resubmitted after the codes are scrubbed. The appeal or resubmission process requires the medical billing staff to recheck it with all the coding guidelines.

5. The collection process

When the reimbursement gets reduced from the insurance payers, the plan does not cover all the medical services. Therefore, it is the responsibility of the medical billers to send back the payments that are outstanding to the patients for a follow-up process. It is the duty of the medical billing staff to do continuous follow-ups until the patient completes their pay-up.

With all the steps that have been mentioned above, the RCM process gets streamlined because of these important steps. It is important to follow each of these steps in a proper manner to lessen the denial rates and increase the profits of your medical organization. This is where a reliable and experienced medical billing company like Synergy HCLS can help you out.