What Is Healthcare Revenue Cycle Management

Starting a healthcare practice can be rewarding, but managing finances is essential to its success. With many patients paying for medical services through health insurance policies, revenue collection and management can be a nightmare. Investing in healthcare revenue cycle management software can help you consolidate your practice’s financial aspects, making it easier to run. This simplifies the management of your practice’s operations, allowing you to focus on serving patients.

What is Healthcare Revenue Cycle Management?

Healthcare revenue cycle management refers to the processes used by medical institutions to bill for services rendered. This process begins with the patient’s appointment and ends when payers accept the final payment. Healthcare revenue cycle management assists inpatient and outpatient facilities in managing their finances.

Here are the steps for healthcare revenue cycle management:

Patient Scheduling and Verification

The revenue cycle in a healthcare institution starts when patients schedule their appointments in advance. Scheduling is the first patient encounter, and you must record the patient’s details. During the initial appointment, the patient and medical provider assess existing needs and develop a treatment plan that will be stored in the patient’s records. Exceptions to scheduling include cases where patients may require emergency or urgent care.

When the patient arrives for their appointment, they provide their insurance information, and you will add this to their existing information. You proceed to check with their insurance company to see what benefits the patient is eligible for. Some insurance companies require medical providers to submit pre-authorization forms to confirm that the costs of their services will be covered. You must include a request for reimbursement with your pre-authorization.

Medical Coding

Medical coding experts translate the patient’s records into diagnosis and procedure codes. Diagnosis codes, also known as ICD-10 codes, are disease classifications used by medical professionals to document illnesses that a patient has been treated for. CPT or procedure codes represent services provided to a patient by a medical provider during treatment. Coders must review medical transcripts to determine whether the patient’s health chart information is correctly translated.

Charge Capture

Once the medical practitioner’s services have been properly translated into ICD-10 and CPT codes, they are included in the patient’s insurance information. To facilitate claim creation, the details are consolidated alongside the facility’s information.

When patients pay a portion of the costs, the medical provider must generate patient statements to facilitate the collection of the agreed-upon amount. They acknowledge on the claims form that a portion of the amount was settled with cash. This enables the insurer to deduct as agreed and settle the balance.

Submission of Medical Claims

After you have correctly captured the charge, you must submit claims to the insurer for reimbursement. The claims submission process begins with determining how much you are owed for services rendered. Clean claims require the payer’s account receivables to spend the least amount of time, resulting in faster payments. Here’s how to make sure your claims are clean:

  • Verify that the patient’s information is updated before submitting claims
  • Meet all pre-authorization requirements
  • Follow the right medical coding regulations
  • Perform standard quality checks
  • Know your payers before billing

Allow the primary insurer provider to adjudicate the claim before transferring the balance to the secondary insurer if a patient has more than one insurer. If the information exists in their system, some payers will automatically cross over credits to secondary payers. As a result, a fair billing system is created that meets the patient’s policies with each insurer.

Payment Reconciliation

The claim is posted to accounts receivable once it is submitted. Account receivables represent the unpaid balance for previously rendered services. Updating your balance sheet’s account receivables section enables you to follow up with patients or insurance providers who are late in honoring claims. If a claim is denied, a medical billing specialist can follow up and file an appeal to have the claim processed.

The account must be reconciled once the claim has been processed and fully settled. The process of reconciling payments leads to all accounting balances being current and consistent. This can assist physicians in avoiding losses due to untraceable billing errors.

Invest in Healthcare Revenue Cycle Management Software

Managing your medical practice’s finances protects the practice’s profitability. Investing in healthcare revenue cycle management software promotes accurate medical billing, allowing you to focus on providing medical services to your patients. This will help maximize your practice’s revenue and promote overall growth.