Medicine
2016-05-16
The revenue cycle management in the healthcare industry can be considered as managing of claims, payments and revenue generation. A special medical billing software is needed in order to effectively keep track of all business processes (especially, claims tracking). There are twelve main steps for managing company’s revenue cycles (McKesson, 2016). Let’s describe them in more detail.
Physician ordering is the first step. It belongs to the pre-visit part of the revenue cycle management. During this step staff should receive information about eligibility and confirm it.
Patient registration is the next step of the pre-visit part. It includes patient check-in. Staff verifies information about patient and collect possible fees. Prior authorization can be used for services, which are required. Staff should accurately collect all fees, for example, co-payments, co-insurances and deductibles.
Charge capturing is the step of the patient engagement part of the revenue cycle management. This step includes clinical services for the patients and selection of relevant charges in accordance with the medical records.
Diagnosis and procedure coding includes primary and secondary diagnosis. During this step procedure codes are reviewed.
Patient discharge processing is the last in the patient engagement part. It includes account of all procedures that have been provided to the patient and bill generation.
Billing and claims processing. After providing all needed clinical services, the claims management process starts. It includes the pre-billing editing and claims consideration. The charges are accepted into the billing system only if location, provider and other information are accurately reviewed before acceptance.
Resubmitting claims include notification of all payers about charges. They can be third-party payer or direct patient. All required information is checked and must be sent to the payers.
Third-party payer reimbursement posting is a process, when an insurance company pays in accordance with the accepted charges, if there are no adjustments between charges and expected reimbursement. Reimbursement analysis is performed at this step. Also, adjustments for over and underpayments are collected and processed.
Appeals process. During this step all claims must be verified. Great attention is paid to the zero payments. Also claims can be denied for specific reasons (for example, unconfirmed eligibility, the absence of medical necessity, non-covered expenses and others).
Patient billing. All payments, which are posted and denied by the third-party payer reimbursement, are directed to the patients. Additional verification of patients, their payment details is needed at this step. It can be electronic payments or paper based ones.
Self-pay reimbursement posting. All payments, which are made by patients, are reviewed and must be confirmed. It is the last step, which is connected with the using the billing system.
Collections reimbursement posting. Patient accounts are reviewed at this step. Reimbursement analysis is conducted by staff. The last one identifies an expected yield vs. actual reimbursement. As a result, reports with data about cash collected, payers denial rates, total days in AR and other information are delivered to the management of the company. Potential issues and concerns must be considered in this step. It may include audit procedures, which can further improve an activity of the company and its billing software system.
Thus, automating and using revenue cycle can free up much more time for patient care that is more important than administrative procedures (Mag, 2012).
References
Mag, H. (2012). How ICD-10 impacts revenue cycle management - Health Management Technology. Health Management Technology. Retrieved 16 May 2016, from http://www.healthmgttech.com/how-icd-10-impacts-revenue-cycle-management.php
McKesson,. (2016). Hospital Revenue Cycle Management Services. McKesson.. Mckesson.com. Retrieved 16 May 2016, from http://www.mckesson.com/bps/services/revenue-cycle-management-services-for-hospitals-and-health-systems/
