Health plan rules and regulations have been constantly changing due to which medical billing; coding and collection processes have become extremely complex. Claims can be denied for various reasons and reimbursements continue to decline. Hence, effective revenue cycle management (RCM) has become all the more important; effectual components being experienced staff, proficient workflow processes, professional EHR systems, and the readiness to learn and adapt (physicians and staff).
Step 1: Verification
The RCM approach begins with patient registration and verification. Once a patient calls for an appointment, the best process is to ensure that the patient registers on the hospital's website while furnishing all demographics and other details (insurance, address etc.). The clearing house must verify this eligibility known as 'batching' two days prior to the appointment. Also, one can use the HIPAA transactions design; enabling its compliance into any HIPAA scheduling system. Automated kiosks/in-office kiosks can also verify insurance eligibility; or use real-time verification through the PM system via the clearinghouse at the front-desk itself.
Step 2: PMS and Charge capture
Select the apt Practice Management System (PMS) as per the healthcare facility's needs (essential/desirable features and its integration with EHR). Give preference to data transfer (patient charges from EHR to PM) electronically. Post charge capture with the apt CPT and ICD-10 codes as per time and schedule. To avoid additional values, use the missing charge report function which mechanizes the cross-check process (in case of holding charge slips for a day).
Step 3: Automatic payment posting and consistency check
Convert paper EOBs to electronic transactions 837s to patient accounts by automatic posting thereby reducing errors, paper work, staff effort and time. Be aware of the latest online services available through vendors, payers and clearinghouses. Managers must use business intelligence tools and benchmarking information to see where the healthcare facility stands in the market (using national remittance data), the consistent issues of denied claims etc. Use metrics in an analytics software to spot the bottlenecks in the revenue cycle which increase lag time, higher days in A/Rs, claim rejection rate and time taken to submit claims etc. which then can be looked at and fixed by a denial management specialist.
Step 4: Claims and Real time billing
Claims need to flow efficiently, be submitted on time (clearinghouse/billing team finally to insurance payer) and electronically. PMS generates automatic claims. Use an Electronic Remittance Advice (ERA) which aids in routing denied claims along with reasons to the staffers' queues to be sorted at the earliest. Also, an ERA gives the details of the amount billed/paid by the insurance and the reasons for payment difference, if any. Offer patients the facility of e-statements and online bill payments. Some healthcare facilities use'payment assurance' software which give an estimate and informs the patient of the financial liability based on their insurance plan.
Automate and use business intelligence to streamline workflows and revenue cycle for spotting and removing bottlenecks in processes, improving financial results and ultimately an enhanced bottom line.Back