Healthcare Revenue Cycle Enhancement

Exposing how gaps in revenue cycle management are resulting in lost revenue first begins with fully understanding the healthcare revenue cycle of medical billing and reporting. For most healthcare providers and practices, the cycle goes something like this:

1. Patient registration. One of the first steps in the healthcare revenue cycle is collecting vital information from the patient, such as their name, birthday, why they are visiting and their insurance information.
2. Eligibility and financial responsibility. After the patient’s basic information has been collected, your staff must closely review the patient’s insurance information in order to determine which treatments and visits are covered (and which are not). While pre-authorization doesn’t guarantee that a procedure, treatment or prescription will be covered by the insurer, it does generally give insight into coverage and costs for the patient. The patient should be notified if certain procedures, treatments or services are not covered beforehand in order to reduce the likelihood of delayed payment.
3. Claim submission. Using information from the superbill report (including the clinical diagnosis and procedure codes), the medical biller must prepare and submit a claim to the patient’s insurance company. Claim submissions must meet strict formatting and compliance standards, and be double-checked for accuracy to avoid denials due to clerical errors. Once reviewed, the claim must be submitted electronically to a clearinghouse or directly to the insurer (in the case of high-volume payers like Medicaid).
4. Claim monitoring. Throughout adjudication, which is when insurers and other payers determine if a claim is eligible for payment, the medical provider must continually monitor the claim to determine if it is accepted or denied. Rejected claims may have to be resubmitted if caused by a submission error.
5. Patient statement. Once the insurer has accepted or denied the claim, your billing team will have to prepare a statement for the remaining balance that must be paid by the patient. This statement typically includes a detailed list of services delivered and a list of procedures performed, as well as the amount that was paid by the insurer and what the patient owes. This step is typically quite time-consuming as patients often have questions about how much they owe and why.
6. Payment posting and follow-up. Medical billers must also frequently follow up with patients about paying off their balance or setting up a payment plan. If a patient’s bill goes unpaid and becomes delinquent, they may have to submit it to collections.
7. Denials management and reporting. The key to optimizing your revenue cycle and medical billing is maintaining detailed records of how many claims were denied, why claims were rejected, what percentage of claims are unpaid and other important data. This benchmarking and reporting can help you streamline your entire RCM process—from patient registration to payment posting.

From start to finish, the medical billing cycle can range anywhere from a few days to several months. The longer this cycle stretches out, the greater the risk that mistakes, errors and inefficiencies will cut into your bottom line.