What is Revenue Cycle Management? Workflow Process /Benefits

Introduction 

What is Revenue Cycle Management? RCM is the process of recognizing, gathering, and managing the revenue from the payers out of the service that you’ve offered them. The necessary element for the effective RCM process is to offer quality healthcare service to the patients and maintain financial viability to the company. 

The revenue cycle management has made it significant for the healthcare service providers to move towards holistic patient care and valued reimbursement. If the care providers don’t pay attention to the billing system, then it would lead the company towards financial losses. Poor finances would disrupt the balance and leads to poor service quality. Therefore, it’s important for the organization to streamline its operations for financial stability. 

Insight into Revenue Cycle Management 

When we talk about revenue cycle management (RCM), then it is much more than just processing billings. It performs various other functions like revenue generation, billing and medical coding, patient payments, denial management, and processing claims. It won’t be wronged to say that RCM is the lifeline of any healthcare organization. Many healthcare professionals misunderstand RCM as some type of medical billing practice firm. 

The workflow process starts at the registration time where you check the eligibility of the patient’s insurance and gather the co-pays information. The process is when you attach the correct code to claims by using the ICD-10 system and then sending it out on time. 

If the billing system is efficient, then it proves the success of revenue cycle management. You can achieve efficiency and effectiveness by using the right management system and EHR practices, or you can outsource the RCM work to any reliable and trustworthy vendor.  

Workflow Practice of Revenue Cycle Management 

Some of the main steps in the workflow of revenue cycle management (RCM) are as follows; 

Scheduling & Eligibility Verification 

The workflow revenue cycle starts when patients make an appointment with the healthcare practice. The front desk should have the capability to deal with both returning and new patients. For instance, if patients are new, then collecting their demographic information accurately and verifying their insurance. 

If the desk makes mistakes, then the insurance company would reject the claim. If you’re dealing with the returning patients and they’ve made some changes, then you should verify the details and remind them of their pending payments. 

Clinical Documentation

According to the CMS requirements and guidelines, the clinical documents of patients should be complete. You should combine patients’ documents with your daily decision-making process, in order to make sure that their record follows the coding standards of ICD-10. 

Superbill

Super is a very critical stage in the workflow of RCM. The information in the superbill would tell you how to pay physicians for their services like procedure they performed on the patient and the length of diagnosis and performing all the processes by ICD and CPT codes. 

Obtaining Co-Pays & Payment 

The front desk should collect the co-pays information at the registration time. You can ask the patients to clear their payment status before leaving the facility in case of peak rush hours and patient emergency situations. 

Billing & Coding 

The physician should have the following certifications and systems in place like practice management system, vaccine management administration system, CMS, and certified EHR. It would make them follow the code of ICD-10. Due to the complicated coding, the practitioners should recruit professional coders to make sure quick claim processing. 

The most crucial step in the workflow stage is developing the claim accurately, and the revenue stream depends on the acceptance of the claim submission. It’s important to keep in mind that you should add the accurate details of claims and submit them on time. 

Processing Claims 

We’re living in a very competitive business environment, and healthcare service providers have to process and deal with pending and rejected claims. The thing that impacts the revenue stream of the company is delayed reimbursement claims because of the denied claims. Various members in the channel like clinical staff, biller, coder, front desk staff, and providers should add accurate details in order to avoid delays. 

Receiving Payment 

The workflow process of RCM ends when service providers receive payment for their offered services. The ERA would inform the providers and offer the necessary details in case of rejected claims. After that, the cycle of processing claims starts and it consumes a lot of time and resources. 

Benefits of Revenue Cycle Management System 

Some healthcare service providers buy and use the RCM software, and others outsource the work according to the codes of ICD-10. The RCM software is usually the product of Practice Management. 

The application of RCM works alone and synchronizes with the EHR (Electronic Health Record) of the company. It helps you in managing and storing the billing record of patients, and lowers the time between reimbursement, billing, and seeing the patients. Most importantly, the RCM system helps you to have a comprehensive view of the patient population by shifting from fee-for-service to value-based reimbursement. Some of the main benefits of the RCM system are as follows; 

  • Reviewing the revenue shortfall and opportunities 
  • Comprises of error detection features that help you track and correct the unpaid claims 
  • Checking the copay requirements and status of patient’s insurance 
  • Make sure the reimbursement of medicare patients
  • Reminding employees to enter and verify all the information in order to save time from denied and claim revisions 
  • Offer insight on the denial of claims 
  • Automating various processes like contacting the insurance companies regarding denied claims, payment reminders, and making appointments

Challenges to Revenue Cycle Management 

The cycle of RCM starts when a patient makes an appointment, and it ends after the collection of payment successfully. The whole process comprises various steps, and the efficiency of the process depends on the accuracy of all the stages. The possibility of human error arises because of the following reasons; 

  • Misspelling 
  • Missed information 
  • Duplicate data
  • Medical billing error 
  • Miscommunication 
  • Coding complication 

All of these errors lead to a loss of revenue for the company. 

  • Other than that, the changing reimbursement model and healthcare regulations are making timely reimbursement difficult. 
  • Often, it needs necessary software applications and well-equipped staff to finish the reporting process on time 
  • Healthcare services usually have limited resources 

Conclusion: What is Revenue Cycle Management? Workflow Process /Benefits 

After an in-depth study of what is revenue cycle management, its workflow process comprises various steps, benefits, and challenges of RCM; we’ve realized that RCM plays a significant role for healthcare organizations. If you’re planning to invest in the RCM system, then keep in mind its benefits and challenges and make the decision accordingly.