Revenue Cycle Management (RCM)

Highly Neglected Revenue Cycle Processes

For most providers, the revenue cycle process means submitting claims and wait for payer reimbursements. These providers are under the impression that if they submit the claim, it will get paid but that’s not the case. Revenue cycle management includes really crucial processes like provider credentialing and contracting, Benefits verifications, prior authorizations, and out-of-network billing to name a few. Practice owners neglect such crucial revenue cycle processes as they don’t have to do proper billing knowledge and they try to do it all. In this article we discussed, the highly neglected revenue cycle processes, their impact on revenue collection, and why providers are neglecting them.

Impact of negligence in revenue cycle processes:

Eligibility and Benefits Verification

As mentioned earlier, most providers feel if a patient has active coverage, then their insurance will cover services provided but that’s not the case. Doing eligibility and benefits verification is the backbone of revenue cycle management. Benefit reports will provide details coverage report, and how the payer can provide reimbursements, patient responsibility and if any prior approval is required. You can take benefits reports from billing software or from provider portals.

If you want detailed benefits report you can call the insurance carrier and talk to the rep. The insurance rep can share detailed eligibility report with you and can reply to your questions like which procedures codes are payable and reimbursement rates for them. Train your staff on how to get and read benefits report. This activity will ensure all your patient visits are getting paid (either by the payer or by the patient).

Prior Authorizations

Prior authorization is another revenue cycle process which is neglected the most. Most providers are under the observation that if a patient has active insurance that means their services could get covered. Now a days most of the patients are buying high deductibles plans, which is increasing patient portion to great amount. Under new fee-for-service plans, not all services are covered, you have to communicate with the insurance company and get their approval to perform certain procedures.

Most practices avoid doing prior authorizations, due to a lack of specialized billing experts. Most of the denials received due to lack of prior authorizations can be appealed. Without proper prior authorizations in place, providers are leaving a lot of money on the table.

Provider Credentialing

Provider credentialing is the practice of ensuring that providers have all of the necessary training and experience to safely, efficiently, and effectively practice medicine. Provider credentialing exceptionally time-consuming process and needs experts who understand all the documentation part. In credentialing you have to maintain credentials with both government and commercial payers, including Council for Affordable Quality Care (CAQH) quarterly re-attestations.

Every payer has their unique credentialing guidelines, which need to be followed for quicker credentialing. You will have to access payers in your area of service and accordingly start preparing for credentialing. Not paying attention to provider credentialing while starting your practice could cost your practice a lot.

Payer Contracting

Of all the things your practice has to do, negotiating payer contracts could be the most tedious and arduous part of running a healthcare practice. A large part of the success or failure of your practice could depend on the partnerships or lack thereof you have with payers. You can outsource provider contracting services to a medical billing company who can take the stress of managing payer relationships and negotiating contracts. Medical billing companies can review existing payer contracts, make recommendations for fees and reimbursement, and keep track of the negotiation progress from start to finish.

Worker’s Compensation

Workers’ compensation collections can be incredibly difficult to manage for providers due to the special terminologies, unique collection forms, and many legal obstacles. Workers’ comp is extremely specialized and does not follow a single set of rules, as every U.S. state has its own laws and regulations. That can cause a lot of headaches for any billing department. While it is very difficult to manage, there aren’t that many cases of workers’ comp, as it only accounts for up to 5% of a hospital’s accounts receivable, so healthcare providers rarely allocate additional funds to hire a workers’ comp expert.

Out of Network Billing

Out-of-network billing can provide a big revenue stream for your practice because they allow you to bill as much – or as little – considering you are not bound by the terms and conditions of a payer contract. However, not having on-hand expertise can delay payments. With a service provider like CareCloud, everything from sending claims and posting payments, to negotiating the payment from the payer and working with the payer, to paying the negotiated amount, is handled externally. This frees up even more time and money for you to allocate toward bettering patient outcomes. When it comes to out-of-network billing, utilizing a team of experts who can help you maximize your revenues is a no-brainer.

Handling revenue cycle management requires expertise in medical billing and coding as per the medical specialty.  When providers try to handle revenue cycle management on their own, then they might end in neglecting the crucial revenue cycle processes. By outsourcing, you can collect reimbursements for all offered services and at the same time, you can provide quality patient care.

Medical Billers and Coders (MBC) is known for providing complete revenue cycle services. Our services include charge entry, payment posting, denial management, accounts receivable, medical coding and provider enrollment & credentialing. To know more about our services, contact us at info@medicalbillersandcoders.com / 888-357-3226

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Medical Billers and Coders

Catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.

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