Revenue cycle management (RCM) is the
financial process that healthcare institutions employ to monitor patient care
sessions from enrolment and appointment booking to final payment of a balance
using medical billing software.
RCM connects administrative and clinical
data, such as a patient's identity, health insurer, and other private details,
with the treatment a patient receives and their health information.
One of the most important aspects of RCM is
communicating with health insurance companies. When a patient makes an
appointment, the physician's office or hospital personnel usually double-checks
the patient's claimed insurance coverage before the appointment. A healthcare
practitioner or coder categorizes the nature of the therapy using ICD-10 codes
when an insured patient receives treatment for a specific condition and pays
any applicable co-payment. The hospital or care facility then submits the care
summary, along with ICD and CPT codes, to the patient's insurance company to
determine what percentage of the care will be reimbursed by insurance and what
portion will be billed to the patient.
Revenue cycle
As per the Healthcare Financial Management
Association, the revenue cycle encompasses all clinical and administrative
operations that contribute to the capture, management, and collection of
patient service revenue (HFMA).
The revenue cycle entails the following
steps:
Charge capture: Medical services are converted into chargeable expenses.
Claim submission: Making claims to insurance companies for billable fees.
Coding: Diagnoses
and procedures must be coded correctly.
Patient collections: Calculating and collecting payments from patients.
Preregistration: Before a patient comes for inpatient or outpatient services,
preregistration data such as insurance coverage is collected.
Registration: In order to establish a medical record number and meet numerous
regulatory, financial, and clinical criteria, additional patient information is
collected during verification.
Remittance processing: Remittance processing is the process of applying or declining
payments.
Third-party follow up: Receiving money from third-party insurance companies.
Utilization review: Assessing the medical services' relevance.
Factors that affect the revenue cycle
Internal and external factors influence how
revenue is collected, just as they do with any financial concern.
Internal factors such as physician efficiency, patient volume, and service prices can all be influenced by a healthcare organization. External factors, such as patient payments or insurance company claims reviews, are more difficult to alter.
Revenue cycle management systems
To organize and maintain patients' billing
records, healthcare providers frequently acquire and use designated revenue
cycle management systems. As patients progress through the treatment process, a
successful RCM system can minimize the time between providing a service and
collecting payment by connecting with other health IT systems, such as electronic
health records (EHR) and medical billing systems.
An RCM system can also save time in the
healthcare industry by automating tasks that were previously performed by
employees. Administrative responsibilities include notifying patients of
scheduled appointments, reminding payers and patients of outstanding balances,
and contacting insurance with specific concerns when a claim is refused.
RCM systems can potentially save money for
providers by providing insight into why claims are refused. An RCM system, in
particular, can reduce denied claims by forcing healthcare workers to provide
all of the information needed for claims processing. This eliminates the need
for them to amend or resubmit the claim, and it gives providers a better
understanding of why particular claims has been refused, allowing them to
correct the problem. This also guarantees that physicians are fairly
compensated for treating Medicare patients.
To define and track revenue objectives, a
firm can purchase data analytics software and employ dashboards. By sorting
billing data and providing matching reports, the company may see where its
revenue cycle could be improved.
Revenue cycle management solutions now
contain advanced analytics to guarantee that the correct medical codes are allocated
to the correct patient, as well as robotic process automation to expedite the
process.
RCM and value-based care
RCM technologies, according to some
experts, will eventually aid in the industry's shift from fee-for-service to
value-based compensation. Many of these RCM systems include analytics that
allows payers and providers to obtain a more thorough look at their patient
demographic, such as what percentage of their patients have which chronic
diseases, as well as monitor claims data and detect any anomalies.
This is especially significant in light of
the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a piece of
proposed laws aimed at promoting value-based care and reimbursement in
healthcare.
Know More: https://www.veetechnologies.com/industries/healthcare-provider/revenue-cycle-management.htm