By Ann Knutson, CPC-A
The healthcare revenue cycle includes all administrative and clinical functions that involve capturing, managing, and collecting the provider’s/facilities revenue. The cycle includes three distinct parts of the practice/facility that’s referred to as the front-end, middle, and back end. Unfortunately, most of the time there is little coordination between the three areas which can lead to more claim denials and lost revenue for the practice/facility. Therefore, adding a revenue integrity team to your practice/facility dramatically improves operational efficiency, compliance measures, and reimbursement rates. Members of the team must have extensive knowledge of and be familiar with the complete healthcare revenue cycle.
In order to foster collaboration between all three areas of a practice/facility that affect the revenue cycle, specific training needs to be implemented for staff, along with coding and documentation education for providers.
Specific staff training includes:
- Keeping up to date on billing requirements, such as coding guidelines, billing regulations, and insurance payer policies.
- Reimbursement updates, such as data showing rate of reimbursement vs. denials/rejections.
- Key performance indicators, such as data regarding common billing or coding errors leading to claim denials and rejections.
- Job expectations, such as all billing employees must know every aspect and function of their job in detail.
Provider education involves:
- Chart reviews to verify proper documentation.
- Quarterly meetings regarding coding guidelines, payer rules, and the importance of medical necessity.
Furthermore, creating templates and tip sheets for billers, coders, and providers improves operational efficiencies, clean claim submission, and proper provider documentation. It also decreases claim denials and puts everyone in the practice/facility on the same page.
In addition, the collaboration between coders and the accounts receivable team is crucial to improving reimbursement rates, the outcome of claim appeals, and compliance with regulations. It can also help to reduce the number of claim denials and rejections. Plus, medical coders are able to share their expertise regarding regulations and proper coding with the Accounts Receivable (AR) team members. This helps the AR team with reconciling claim rejections and denials along with properly submitting appeals. On the other hand, the AR team can inform coders of the current codes or coding combinations that are being rejected or denied by payers. With this vital information, coders can make the required coding and billing changes as they enter the charges and submit the claims. This can greatly improve the rate of clean claims submission. (AAPC, 2021)
Therefore, it’s in the best interest of a practice/facility to implement a revenue cycle management team that is familiar with the entire revenue cycle, fosters collaboration between all areas of the practice/facility and providers, and maintains open communication between all departments in order to maximize revenue cycle efficiency and reimbursement. For assistance with maximizing your revenue cycle efficiency, please contact us at MedCycle Solutions.
For more information about maximizing revenue cycle efficiency, please visit www.aapc.com.
Ann Knutson, CPC-A is an Accounts Receivable Specialist at MedCycle Solutions, which provides Revenue Cycle Management, Credentialing, Outsourced Coding, and Consulting Services to a number of healthcare providers in a variety of specialties. To find out more about MedCycle Solutions services please visit www.MedCycleSolutions.com.
HIPAA Training Standards Every Business Associate Needs to Know
Per the HIPAA Privacy Rule and HIPAA Security Rule, both Covered Entities and Business Associates, must require HIPAA training for all workforce members that access protected health information (PHI) or electronically protected health information (e-PHI) in any of its forms and should be provided “as necessary and appropriate for the members of the workforce to carry out their functions within the [organization].”
According to the Rule, training must be provided “to each new member of the workforce within a reasonable period of time after the person joins the [organization’s] workforce.” Along with all other annual compliance requirements, HIPAA training is arguably the most important. Your workforce members are your first line of defense in the event of a Breach and must be able to identify your organization’s designated HIPAA Security Officer, and have a firm understanding of the HIPAA Privacy and Security Rule. Training should also highlight the organization’s Technical, Administrative, and Physical Safeguard objective security requirements. It is best practice to provide ongoing security awareness training and, in addition to the mandatory annual training, the Privacy Rule also highlights what’s known as “periodic” training. The goal is to ensure workforce members’ knowledge of HIPAA compliance is not forgotten.
It’s advisable that HIPAA training is given to all employees as new hires during the new employee orientation period, and before new employees are exposed to or work with individually identifiable health information. This includes officers, agents, employees, temporary employees; like students, interns, volunteers, and salespeople. At a minimum, training should cover the basics of HIPAA, the basics of privacy and security requirements and restrictions, and policies and procedures. All new hires need to be provided HIPAA training and a post-test on the material covered within the training course to ensure comprehension of relevant and appropriate HIPAA policies and procedures. Security Officers should be trained on the Breach Notification Rule, Minimum Necessary Rule, and the Organization’s policies and procedures.
The HIPAA Privacy Rule states that “An [organization] must document that the training as described [in the HIPAA Text] has been provided.” Failing to do so will be seen as “willful neglect” and will result in HIPAA violations including monetary penalties as high as $1.5 million dollars. A minor violation may only result in a corrective action plan requirement, whereas a significant data breach attributable to a lack of training will be viewed more seriously.
At Live Compliance, we make checking off your compliance requirements extremely simple.
- Completely online, our role-based courses make training easy for remote or in-office employees.
- Short informative video training to meet periodic training requirements
- Depending on the size of your organization training may start as low as $79
Call us at (980) 999-1585 or visit us online at www.LiveCompliance.com/ezclaim
EZClaim is a leading medical billing, scheduling, and payment software provider that combines a best-in-class product with exceptional service and support. For more information, schedule a consultation today, email our experts, or call at 877.650.0904.
The revenue cycle is a crucial component of a medical practice. Revenue Cycle Management (RCM) is the process of managing patient accounts, interacting with payers, processing claims, and collecting payments related to health care services. As the industry becomes more competitive and physicians are expected to perform more administrative tasks on their own, RCM has become even more important for healthcare providers today than ever before. Unfortunately, many practices still struggle with managing their RCM processes in an efficient manner that allows them to focus on what matters most: patient care. Below is a list of common mistakes made by healthcare providers when it comes to RCM.
Below is an overview of the seven key components of RCM and ways to avoid some of the most common mistakes.
Insurance Verification and Authorization
Insurance verification and authorization is a critical step in the revenue cycle process. If this step fails, all other steps must be repeated. This can result in delays, rework, denials of claims and even patient non-compliance.
- Verify that the patient is covered by their insurance plan and will not be responsible for additional costs related to their treatment or procedure (co-pay and deductibles).
- Verify that your provider is in network for each specific procedure with their chosen health plan/policy before completing any work on behalf of the patient.
- Ensure that all documentation supports your claim(s), including diagnosis codes and clinical notes from EMRs or doctors’ offices detailing what was performed during each visit. These details should align with those found on physical charts signed by both patients and providers alike.
- Verify eligibility rules as defined by health plans: has a deductible been met? Is there a copay amount due before benefits kick in? In some cases it may be necessary to contact members directly via phone or email asking them these questions so they know exactly how much they owe out-of-pocket. Our partner TriZetto Provider Solutions offers integrated eligibility verification. Automating this due diligence on the front end ensures that you are not left with the cost of having a biller redo this work, or worse, writing of claims.
Patient Registration and Copay Collection
Patient registration and copay collection are important first steps to ensure that your revenue cycle is functioning properly. Patient service, claims submission, remittance processing, and back-end patient collections are all vital components of the revenue cycle management process.
Without these steps in place, you will not be able to complete the full revenue cycle management process.
Service Coding and Charges
The service coding process identifies the type of service or procedure that was performed by your staff. Accurately documenting and coding charges allow you to:
- Assign appropriate codes for reimbursements from government programs, insurance companies and self-pay patients.
- Determine the level of reimbursement for each code
- Avoid fraud and abuse
Billing and Collections
It is critical to collect payments on time, in full and accurately. If you do so consistently, it will be easier to predict future cash flow needs and improve your ability to manage the revenue cycle.
Timely billing is critical because it allows the practice to collect their fees before they become delinquent. Delinquent accounts must be reported to credit agencies which can negatively impact a patient’s ability and willingness to pay for other services at your facility in the future. Late fees should also be considered for patients who are more than 60 days late paying their bill – this can help generate additional revenue by encouraging prompt payment from patients who may otherwise have ignored their bills altogether.
Accuracy is key when collecting payments because inaccurate claims may result in denied reimbursement by Medicare or third-party payers’ due out-of-pocket expenses for patients who were mistakenly overcharged by providers.
Consistency means that providers need regular updates on where each account stands within its cycle; this helps ensure that both patient satisfaction levels remain high and that everyone receives timely access. Efficiency refers not only to how quickly accounts move through management but also how quickly they get paid so providers know exactly how much money they’ll have coming in each month before making subsequent budgeting decisions.
EZClaim provides great tools to help ensure your collections are timely, accurate, and consistent. EZClaim allows you to keep a credit card on file. With approval to charge up to a specified amount, you can make it convenient for your patients and ensure payments are timelier than ever. EZClaimPay also offers email and SMS text message-based reminders, which have proven effective in increasing payment rates.
Denial management is the process of managing patient denials. Denials can be caused by a variety of reasons, including incorrect CPT codes, missing information, or provider errors. Therefore, it’s important to have ready-to-go processes for handling them and getting paid as soon as possible.
When you receive a denial from an insurance company, there are several things you should do immediately:
- Double-check that all your claims are accurate and complete before submitting them for payment. If there is any ambiguity on the part of the patient or their healthcare provider, this will increase the likelihood that your claim will be denied due to lack of clarity.
- Request that more specific details regarding the denial be provided. This allows better preparation when submitting future claims related to this patient’s care and ensures there aren’t additional denials for similar reasons.
The revenue cycle is a crucial component of any medical practice. It’s also one of the most challenging aspects of running a practice, especially in today’s increasingly complex environment. This article has highlighted some common mistakes that can be made when managing your revenue cycle and how to avoid them.