Life Cycle of a Medical Bill (Revenue Cycle 101)

Life Cycle of a Medical BillThere are five ‘phases’ in the life cycle of a medical bill: Pre-appointment; Point of care; Claim submission; Insurance payment or denial; and Patient payment. This post will overview each of these phases, and could even be considered to be a “101-level” course on Revenue Cycle Management.

With high deductible health plans on the rise, the recent explosion of telehealth appointments due to COVID-19, and many other factors in play, it’s more important than ever for everyone to understand the life cycle of a medical bill, and how the process works. The healthcare revenue cycle is relevant not only to those who work in healthcare, but to the patient, too.

The revenue cycle is the series of processes around healthcare payments—from the time a patient makes an appointment to the time a provider is paid—and everything in between. One way to think of it is in terms of the life cycle of a medical bill. Although there are many ways this process can play out, this post will lay out a common example below:

1. Pre-appointment
For most general care, the first stage of the revenue cycle begins when a patient contacts a provider to set up their appointment. Generally this is when relevant patient information will begin to be collected for the eventual bill, referred to on the financial side of healthcare as a claim.

At this point a provider will determine whether the appointment and procedure will need prior authorization from an insurance company (referred to as the payer). Also, the electronic health record (EHR) used to help generate the claim is created, and will begin to accumulate further detail as the provider sends an eligibility inquiry to check into the patient’s insurance coverage.

2. Point of care
The next step in the process begins when the patient arrives for their appointment. This could include when a patient arrives for an initial consultation, an outpatient procedure, or for a follow-up exam. This could also include a Telehealth appointment.

At any of these events, the provider may charge an up-front cost. One example of this is a co-pay, which is the set amount patients pay after their deductible (if they are insured), however, there are other kinds of payments that fall into this category, too.

3. Claim submission
After the point of care, the provider completes and submits a claim with the appropriate codes to the payer. In order to accomplish that, billing staff must collect all necessary documentation and attach it to the claim. After submitting the claim to the payer, the provider’s team will monitor whether a claim has been been accepted, rejected, or denied.

[ Note: Medical coding refers to the clerical process of translating steps in the patient experience with reference numbers. The codes are normally based on medical documentation, such as a doctor’s notes or laboratory results. These explain to a payer how a patient was diagnosed and treated, and why. This information helps the payer decide how much of an encounter is covered under any given insurance plan, and therefore how much the payer will pay. ]

4. Insurance payment or denial
Once the payer receives the claim, they ensure it contains complete information and agrees with provider and patient records. If there is an error, the claim will be rejected outright and the provider will have to submit a corrected claim.

The payer then begins the review process, referred to as adjudication. Payers evaluate claims for accurate coding and documentation, medical necessity, appropriate authorization, and more. Through this process, the payer decides their financial obligation. Any factor could cause the payer to deny the claim.

If the claim is approved, the payer submits payment to the provider with information explaining details of their decision. If the claim is denied, the provider will need to determine if the original needs to be corrected, or if it makes more sense to appeal the payer’s decision.

Following adjudication, the payer will send an explanation of benefits (EOB) to the patient. This EOB will provide a breakdown of how the patient’s coverage matched up to the charges attached to their care. It is not a billing statement, but it does show what the provider charged the payer, what portion insurance covers, and how much the patient is responsible for.

5. Patient payment
The next phase occurs when the provider sends the patient a statement for their portion of financial responsibility. This stage occurs once the provider and payer have agreed on the details of the claim, what has been paid, and what is still owed.

The last step occurs when a patient pays the balance that they owe the provider for their care. Depending on the amount, the patient may be able pay it all at once, or they might need to work with the provider on a payment plan.

 

The above example represents one way the lie cycle of a medical bill can play out. Some of the ‘phases’ are often repeated. Because of the complexity of healthcare payments and the parties involved, there is not always a ‘straight line’ from patient care to complete payment. That’s why we call it the revenue cycle, and there are companies that provide systems for its management.

One of EZClaim’s partners, Waystar, aims to simplify and unify healthcare payments. Their technology automates many parts of the billing process laid out above, so it takes less time and energy for providers and their teams, and is more transparent for patients (Click here to learn more about how Waystar automates manual tasks and streamlines workflows.) When the revenue cycle is operating at its most efficient, providers can focus their resources on improving patient care—and that’s a better way forward for everyone!

For more information of how Waystar works together with EZClaim, click here.

[ Article and image provided by Waystar ]

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ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at sales@ezclaim.com, or call a representative today at 877.650.0904.

How to Improve Medical Billing Revenues

Improving Medical Billing RevenuesIt IS POSSIBLE to improve medical billing revenues, and here are a few ways to do just that.

Healthcare practitioners, whether established or just starting out, have many overwhelming tasks: Managing a practice; Seeing patients; Working to staying up-to-date on administrative tasks; The whole host of compliance at the federal, state, and local level; and Overseeing the billing.

One of these that can lead to loss of revenue is not properly managing the medical billing, which can also lead to HIPAA fines and rejected claims. However, there is a solution: a medical billing system that balances the budget and optimizes revenues of medical practice.

EZClaim, an expert in the medical billing software market since 1997, provides a solution that improves the efficiency of an office’s billing process in many ways. The following are the primary reasons.

Reduce Coding Errors
Medical procedures become codes, codes become claims, and claims become revenue. Any error in this process can make claims to be denied, your workload can be increased, and revenue can be lost. To help in avoiding errors, it is essential to use billing software that offers the easiest implementation and access to descriptive diagnosis and treatment codes. EZClaim’s medical billing solution offers ease-of-use in coding, billing, and strong partnerships with Clearinghouses which act as an additional ‘safety net’ for catching errors.

Administrative Support
Most medical practices are a small team of people tackling a wide range of tasks, so when one cannot understand the function of the billing software, accessing reliable support is very important. EZClaim prides itself on having dedicated support experts available, and that was how the company was established. Founder and President Al Nagy has said, since day one, “We are a support company that happens to sell medical billing software.”

Maintain Industry Compliance
It is important to recognize that industry compliance and a practice’s revenue go hand-in-hand. Filing and batching inaccurate and non-HIPAA compliant claims can often be traced back to an outdated healthcare revenue management system. Conquering these tasks requires a focus on multiple fronts: A properly trained billing team, clear office procedures, patient payment policies, and a reliable medical billing company. These are all ways to help buttress against non-compliance and rejected claims.

Streamline Workflow
Recently, a study was done that showed almost 80% of medical bills contain errors. These incorrect medical claims often end up as lost revenue originally, not to mention the additional cost of resubmissions and collections. One of the best ways to resolve this problem for your practice is to make use of both well-trained, experienced billers and coders, combined with a competent medical billing solution that aids in catching these errors. EZClaim software features a library of standard validation, the ability to add custom validation, and integrates with Alpha II for full claim scrubbing.

Follow up
Errors will and do occur, so establishing a system for follow-up on all denials will close the loop and protect against lost revenue. Being consistent with the follow-up process, and having a medical billing solution that tracks these things will help close that gap.

Collections
Finally, probably the most important aspect that optimizes a practice’s revenue is to get paid. Portals and payment collection systems definitely help with this, but having collections integrated into the medical billing system is, of course, the best. EZClaim has pain-free payment processing integrated into their solution, called EZClaimPay. It solves all the problems associated with payment processing: Bank deposits, reconciliation, statements, changing fees, and ‘finger-pointing’ when there is a problem. EZClaimPay’s robust platform will greatly increase a practice’s collections success, and improve their revenue.

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ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at sales@ezclaim.com, or call a representative today at 877.650.0904.

[ Photo credit: Studioarz ]

Revenue Cycle Management Process Webinar

Revenue Cycle Management ProcessFeeling overwhelmed by the complexity of the revenue cycle management process? This webinar will help you identify the most important measures affecting practice revenue, will explain how to make improvements to improve cash flow, as well as how to save your staff time.

PRESENTED BYStephanie Cremeans, CPC, CPMA, CPPM, Founder of RCM Insight

Wednesday, November 4th at 11am MT/ 1pm ET

You Will Learn The Following:

  • Creating scorecards to eliminate issues that are preventing payments
  • Identifying and improving processes that improve revenue
  • Organizing staff to monitor and improve the financial process
  • Avoiding the pitfalls of uncompensated care
  • Teaching & training to get results

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About Stephanie Cremeans:
Stephanie has served in various roles in the medical billing and coding field including Revenue Cycle Manager, Consultant, Auditor, Biller and Coder.  Stephanie has a passion for educating providers, coders, and billers how to maximize revenue through proper documentation and effective workflows. She has worked with several specialties including family medicine, cardiology, physiatry, urgent care, GI, pediatrics, OB/GYN, and behavioral health.

Click here to register for the BillFlash Webinar, “Simple Tips to Improve Your Practice’s Cash Flow Process

Medical Billing Verification Strategy

Medical Billing Verification StrategyReserve your place for a webinar that will inform you on how to increase your revenue with a proper medical billing verification strategy.

With increased patient financial responsibility, it’s extremely important to proactively check your patients’ benefits coverage and provide payment estimates to avoid any unexpected costs. By enhancing your medical billing verification strategy and providing patient financial transparency upfront, it increases the likelihood that you’ll rake in more revenue this season.

Join EZClaim and TriZetto Provider Solutions, a Cognizant Company, for a webinar on Thursday, October 29, 2020 at 1 p.m. ET, to discover strategies your practice can catch falling revenue through seamless integration and automation.

During This Webinar We Will Discuss:

• Patient Responsibility Estimation: Quickly obtain patient financial estimates at the point of service to help increase patient revenue, decrease billing costs, and improve patient satisfaction through price transparency.

• Integrated Eligibility: Connect to payers through a single application to get the most up-to-date information on patient coverage, co-pays, deductibles, and more. Proactively verify patient eligibility, for up to 50 patients at a time directly from your EZClaim Premier program.

• Insurance Eligibility Discovery: Submit a real-time eligibility request using minimal data and identify a patient’s insurance carrier in a matter of seconds. Maintain groups of your common payers and easily locate active patients and full eligibility benefits on our website.

RESERVE YOUR PLACE NOW!

ABOUT THE PRESENTERS:

EZCLAIM: EZClaim is a medical billing and scheduling software company that provides best-in-class customer service and support. To learn more, e-mail them at sales@ezclaim.com or call a representative today at 877.650.0904.

TRIZETTO: TriZetto combines innovative, proven products with an exacting commitment to serving our customers, in order to provide you with the tools you need to effectively manage your reimbursement cycle.

EZClaim Launches EZClaimPay, Its New Payment Processing Feature

EZClaim Launches EZClaimPayEZClaim Launches EZClaimPay, a new feature in its medical billing software that makes credit card processing painless!

EZClaim, a company with the mission of elevating its clients to stay in front of the ever-changing landscape of medical billing, announced today the launch of its credit card processing feature and service called, EZClaimPay.

EZClaim released the product in August 2020 as a solution to the ever-changing landscape of payment reconciliation. It was cited by customers as a timely response to a ‘pain point’—credit card payment processing—another example of EZClaim’s devotion to their mission.

Dan Loch, VP of Marketing commented that “EZClaim’s goal continues to be making life easier for medical billers at practices and billing firms.  EZClaimPay is just one more feature within our mission of living up to that goal.” This feature will help companies get in front of the changes in medical transparency that are coming soon.

EZClaimPay provides for consolidated reconciliation (Payment reports; Chargeback management; and Reconciliation reports) and a single point of contact for support (Hardware; Software; and Payments).

EZClaim has developed a robust payments platform—tightly integrated with their software and support—to make accepting credit cards for payment PAINLESS! EZClaimPay makes software and payments better together.

For more details about EZClaimPay, view this web page: https://ezclaim.com/ezclaimpay/

 

ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides best-in-class customer service and support. To learn more, e-mail them at sales@ezclaim.com or call a representative today at 877.650.0904.