Do you find it difficult to track patient visits, code diagnosis, and treatment, and submit clean claims timely? Is it taking too long for the insurance company to reimburse the amount for the services rendered to the patients by your practice?
There are several factors that go behind running a successful medical practice. It includes hiring and maintaining skilled healthcare professionals, demand for treatments or services (often based on the geographical location and demographics), facilities and amenities provided, quality care delivery and good patient engagement. But these measures need to be complemented well with sound financial outcomes. According to the CAQH index, the lack of automation for claims processing costs the health care industry more than $11 billion each year.
What is revenue cycle management in healthcare?
Revenue cycle management (RCM) is the financial process by which healthcare practices manage medical coding and billing solution, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.
Effective RCM is critical for the financial health of healthcare organizations, as it ensures that they are receiving payment for the services they provide. As per MGMA report, practices with effective revenue cycle management have an average denial rate of 3%, while those with poor RCM have a denial rate of 10-14%. The revenue cycle can be complex and time-consuming, involving multiple stakeholders, including patients, healthcare providers, insurance companies, and billing companies.
How does revenue cycle management work?
The goal of rev cycle management (RCM) is to identify any points of friction in the provider’s revenue cycle and resolve them. The revenue cycle begins as soon as a patient reaches out to the healthcare provider to schedule an appointment and it ends when the final payment for the appointment & treatment has been collected. With a streamlined revenue cycle process, care providers can optimize their operational costs and improve net patient revenue.
By optimizing revenue cycle management, healthcare providers can not only boost their financial performance but also improve patient outcomes and regulatory compliance. An inefficient rev cycle can cause significant financial strain on the practice and may even impact patient care.
Steps in streamlining medical billing process
The healthcare revenue cycle consists of multiple steps. This also means that there are some chances for errors to occur in the entire process. Even minor errors in the rev cycle can result in delays in reimbursement from insurers and patients or even lead to a complete halt in reimbursement.
1.) Pre-authorization and eligibility verification
Upon scheduling an appointment, healthcare providers collect essential information such as insurance details and eligibility verification to build a patient account. Accurately completing this patient intake step is a crucial component of the RCM process, even if the patient has an existing account with the provider. Failure to obtain eligible insurance or accurate information can lead to denied claims later in the rev cycle. Consequently, providers may experience delays in reimbursement payments leading to more work for the provider, who must then re-examine the patient’s information to correct the errors that were made.
2.) Charge capturing and medical coding
Charge capturing is a critical aspect of the RCM process, involving the transcription of medical services into billable charges using alphanumeric ICD-10 medical codes. These procedure codes serve as the basis for determining reimbursement amounts by health insurance companies. Inaccurate medical coding may lead to insurance claim denials, causing delays in provider reimbursement and additional costs in investigating and appealing denied claims. Effective and efficient revenue cycle process prioritizes the accurate input of medical codes to prevent claim denials altogether.
3.) Claims submission
After a patient’s medical services have been accurately coded, the claim is forwarded to the insurance company for approval. Revenue cycle management guarantees timely claim submission by closely monitoring and managing the claim cycle throughout the process. This is one of the important steps where the medical coding team codes ICD-10 and CPT against specific procedures/ treatments or diagnosis, which is later verified by the scrubber. They verify that a procedure performed is associated with a diagnosis code that justifies the medical necessity along with variables such as gender, age, date and place of service and any required modifiers. But this is not without its challenges. For example, in pain management groups, there are several revenue roadblocks like billing ambiguities over add-on levels for bilateral procedures, insufficient benefit verification for procedures (RFAs and MBBs, DMEs) and UDS. Any errors during this process can lead to denied claims and delayed payments.
4.) Payment collections
Following the approval of the patient’s claim, the provider receives reimbursement from the insurance company based on the patient’s eligibility and how accurately treatment and services rendered are coded by the medical coding experts. If any balance remains after insurance reimbursement, the provider is responsible for contacting the patient to collect payments. Revenue Cycle Management (RCM) accelerates medical billing processes by simplifying claims processing. Furthermore, because RCM prioritizes back-end tasks, like insurance eligibility verification, patients are informed from the outset about their out-of-pocket expenses, avoiding any delays in payment collection.
5.) Medical service review
Effective RCM encourages healthcare providers to analyze clinical treatment data, enabling them to identify areas in the rev cycle where errors commonly occur and develop strategies to minimize expenses. This, in turn, can help boost revenue while empowering practices to build a better patient experience.
Conclusion – How data-driven RCM with Jindal Healthcare can improve outcomes!
Using our proprietary AI-based solution HealthX 2.0, experts at Jindal Healthcare analyze your Electronic Health Records (EHR) and provide data-driven insights to identify patterns and insights that can improve decisions, and outcomes and optimize billing process. This analyzed data is presented through visually appealing PowerBI dashboards that empower you to monitor, assess, and set performance benchmarks for your revenue cycle. This invariably helps you save operational costs, submit clean claims, streamline denial management, reduce accounts receivable (A/R), accelerate reimbursements and most importantly, provide quality of care.
Make real-time data-driven decisions to transform your revenue cycle. Contact us!