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.