Revenue Cycle Management (RCM)

Objective

This session will give an understanding ofwhy messaging is used in healthcare and thegoals that are achieved

This session will cover:

What is Revenue Cycle Management (RCM)

Revenue Cycle Management Process Flow

Basic Questions

Revenue cycle management (RCM) is the process that manages claims processing, payment and revenue

generation.

Revenue Cycle Management is the all-inclusive process of creating, submitting, analyzing, and paying for

healthcare claims.

In order to efficiently manage the revenue cycle, we need a medical billing software or practice management

software that allows you to effectively keep track of the claims process.

The entire healthcare revenue cycle process includes everything from determining patient eligibility, collecting

their co-pay, coding claims correctly, tracking claims, collecting payments and following up on denied claims.

Revenue Cycle Management

Basic Questions

The revenue cycle starts when the patient calls your office for an appointment and your staff captures the

patient's name, phone number, and their insurance eligibility and coverage information

The cycle ends when the balance on their account is zero

Pre-visit eligibility verification is a best practice that every physician office should strive to accomplish

If eligibility verification is not done correctly it results in denial of a claim

Critical Steps in RCM process:

Accurate patient registration and billing information is a critical first step.

Getting the charge posted with the CPT service code and ICD-9 diagnosis code on a timely basis is the next step in the revenue cycle process.

RCM contd..

Basic Questions

RCM Process Flow

Basic Questions

contd.. Scheduling: The revenue cycle starts with appointment scheduling of the patient with physician. The key objectives for scheduling

include:

To verify/Enter the patient’s demographic information and source of payment

To accurately and efficiently schedule the requested service from a written order

To provide excellent physician and patient satisfaction with the process.

Case Management:

• Eligibility & Benefit Verification: Obtain insurance authorization

• Authorization & Referrals : Obtain referral information

Coding & Clinical Documentation:

Responsible for coding or verifying the correct codes for the diagnoses, services, and procedures

Better documentation give physicians a way to catch up on a particular patient's case history as quickly as possible, making them

ready for the appointment immediately

Basic Questions

contd.. Charge Capture: In this portion of the revenue cycle, the charge capture can be viewed from the angles of ensuring that all

encounters are captured and all the services, procedures provided are captured and charges are entered for the procedures/services

rendered.

• Encounter Forms: A document or record used to collect data about given elements of a patient visit that can become part of patient

record each time the patient visits.

Claims Management:

• Claims form submission (837): The claim is submitted by the provider to payer in the form of EDI format

• Claim Scrubbing & Adjudication: The claim is checked for errors in codes (CPT, ICD) and verifying that it is compatible with the payer

software.

• Clearing house or direct claim submission: Clearing house function as intermediaries who forward claims information from healthcare

providers to insurance payers.

Basic Questions

contd..• Payment Automation (835) : It gives the complete explanation of the claim

• Denial Management: It encompasses of any aspect of the revenue cycle that may result in no or low reimbursement. The reasons for the denials can include incomplete or inaccurate insurance information, lack of pre-certification or prior authorization, not capturing all of the tests or procedures etc.

• Remittance Management : A\R follow up

• Medicare Claim Management : COB, A\R follow up

Accounts Receivable follow up:• Appeals: For denials• Patient Statement (EOB) : Related to policy exclusions, Capping

Payer Reporting:• Real Time Reporting • Historical Reporting • Data Analysis