Revenue cycle management (RCM) is the commercial process that uses medical billing software, which healthcare facilities use to track Patient care episodes from registration and appointment scheduling to the final payment of a balance.

In simple terms it refers to the process of tracking the payments for the services rendered at a provider’s office, from the time of scheduling an appointment by the patient to the time of fulfillment of the payment by the payer or the patient themselves. RCM combines business and clinical sides of healthcare by collaborating patient health records, payer information, administrative and billing information.

The revenue cycle includes all the administrative and clinical functions that contribute to the capture, management and collection of patient service revenue, according to the Healthcare Financial Management Association (HFMA).

Vital Steps Of The RCM Cycle?

• Preregistration: Collecting Preregistration Information, Such As Insurance Coverage, Before A Patient Arrives For Inpatient Or Outpatient Procedures.
• Registration: Collecting Subsequent Patient Information During Registration To Establish A Medical Record Number And Meet Various Regulatory, Financial And Clinical Requirements.
• Remittance Processing: Applying Or Rejecting Payments Through Remittance Processing.
• Charge Capture: Rendering Medical Services Into Billable Charges.
• Claim Submission: Submitting Claims Of Billable Fees To Insurance Companies.
• Coding: Properly Coding Diagnoses And Procedures.
• Patient Collections: Determining Patient Balances And Collecting Payments.
• Third-Party Follow Up: Collecting Payments From Third-Party Insurers.
• Utilization Review: Examining The Necessity Of Medical Services.

Tracking Accounts Receivable

A facility’s accounts receivable should be monitored and reviewed every day. The system should have a consistent flow of claims, with blockages and bottlenecks eliminated. Verify that claims have been received and what amounts are on the aging report.

When a claim has been in the system for 60 days, a direct phone call to the insurance payer is needed. This is done in order to check the status of the claims while also recording the claim number and date of expected payment.

This verification process is essential in order to make sure claims are not forgotten and eventually write off. If informed that the claim has been paid healthcare providers should record the date of payment, check/transaction number as well as the amount paid. If a check was issued, verify the mailing address and whether it was cashed. Certainly, appeal any claim that was unexpectedly denied.

Check The Network And Insurance Coverage

Sometimes denials are generated due to the fact that there may be a problem with a patient’s insurance benefits. Deductibles, secondary v. primary insurance and copayments can all affect the status of a claim.

Missing prior authorizations for the medical procedure or if the health professional is out of network can also create problems. In addition, always verify the patient demographics and credentialing status of the healthcare provider.

No health professional wants to unexpectedly fall out of network due to an oversight in paperwork. They should monitor their information and status on all of their insurance panels. This includes the Medicaid, Medicare and the CAQH.

Take A Look At The Provider’s Insurance Contract

Many patients, as well as some health professionals, are not aware of the large degree of variance in healthcare practitioners agreed upon reimbursement rates. Location, medical specialty and the volume of claims can impact the reimbursement rate from insurance providers / payers.

Health professionals need to know the specific details of their individual insurance payer’s contract. These contracts often explain the coverage policies surrounding prior authorizations, procedures, referrals, etc.

Payer contracts are legal documents and are fully negotiable. Healthcare providers should focus on effectively negotiating their payer contracts in order to maximize net profit. They need to demonstrate the value that their services bring to insurance plan members.

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