Getting to Know the Healthcare Revenue Cycle Process

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May 15, 2023

Getting to Know the Healthcare Revenue Cycle Process

Providing quality patient care remains the top priority for any healthcare provider. The reality is that it involves more than just treating patients and saving lives. Healthcare organizations also operate as businesses, so it’s important to have successful processes and policies in place for staying financially healthy and maintaining operational efficiency. This is where healthcare revenue cycle comes into the picture. Let us in this blog post, discuss what exactly a healthcare revenue cycle is, the role it plays in today’s healthcare system, and its key components.

What exactly is a healthcare revenue cycle process?

Healthcare revenue cycle management is a driving force that helps a healthcare organization maintain its financial health. A healthcare practitioner cannot provide patient care without being financially healthy. Healthcare RCM is a process wherein the services rendered to the patients are properly billed and duly collected from the insurance companies or the patients. It’s a complete cycle that spans a patient's entire financial experience in healthcare - right from scheduling an appointment to submitting a claim and receiving reimbursements.

Why is revenue cycle management important in healthcare?

Healthcare organizations like any other business need to stay afloat. But, unfortunately like any other business, healthcare organizations can also close due to a lack of revenue. According to a study conducted by the AHA, it is shocking to note that 33% of hospitals are operating on negative margins. And over 100 rural hospitals that render essential services to rural communities have been closed between 2013 and 2020. Therefore, it is indispensable to have a solid revenue cycle process in place to run a profitable practice and direct more of your focus on providing high quality services. Without an effective and efficient revenue cycle management, managing the patient side as well as the financial side of a medical practice becomes an unfair balancing act.

Steps involved in the revenue cycle process

It probably comes as no surprise that a streamlined revenue cycle process is critical to helping practices operate more efficiently and generate greater profits all while delivering excellent patient care. Hence, it is important for healthcare providers to clearly understand the medical billing and reimbursement cycle. Here we go.

Prior-authorization : Prior authorization is a vital step in the revenue cycle process. Some treatments and medicines may require approval from the insurance carrier before you receive them. It is important to note that prior authorization doesn’t mean that the treatment or medication cost will be covered by the insurance provider. However, in the case of emergency situations no prior authorization is required.

Insurance eligibility and benefits verification : This is the next most crucial step in the medical billing process. This is done by contacting the insurance company to understand if the patient’s insurance covers the required procedures. It is important to complete the insurance verification at the time of scheduling the patient or before providing the medical services. Knowing the patient’s eligibility upfront helps you to suggest a course of treatment aligned with the scope of coverage. If you fail to do so, you could end up with an unpaid claim or denied claim, which can ultimately impact your practice’s bottom line.

Medical coding : Coding is another vital part of the revenue cycle management that precedes claims submission. It is the process of converting a diagnosis, a prescription, and whatever procedures performed on the patient into relevant codes, that makes up a crucial part of a claim. Hence, accurate coding paves the way for cleaner claims, faster reimbursements and a positive bottom line.

Claims submission : In order to ensure timely reimbursements medical practices need to file and submit claims properly. So, once proper codes have been assigned to the patient’s medical services, the claim is sent to the insurance company, who then reviews and approves or denies the claim. Electronic claim submission facilitates a more time efficient way to accurately submit claims for quicker reimbursements.

Payment posting : This is yet another crucial step in the revenue cycle management process that involves entering all payments into the medical billing system. It gives a true financial picture of the medical practice, such as insurance payments from EOBs, insurance checks from ERAs, payments from patients, and much more.

Denial Management : Denial management is essential to a healthy cash flow and successful revenue cycle management process. It is a strategic process of analyzing the reasons for claims denials, implementing preventive measures to reduce the overall denial rates and employing strategies to maximize the number of claims paid promptly. Healthcare practitioners lose more than thousands of dollars every year through delayed and denied claims. An effective denial management strategy can help zero down denials and keep your practice from losing revenue.

Why Scribe4Me revenue cycle management?

Running the business side of a medical practice is quite challenging. A survey of hospital CFOs revealed that 38% chose to outsource all or part of their revenue cycle processes, and another 24% are considering doing it. So, partnering with an outside revenue cycle management expert isn’t just an option for struggling providers, but the need of the hour. Outsourcing your RCM to an RCM expert like Scribe4Me can deliver amazing benefits. It can help save costs, manage time efficiently, improve regulatory and payor compliance, ensure timely reimbursements, and maintain better cash flow. Most importantly, outsourcing helps you focus on what really counts – making patients better. Remember, that your revenue cycle management has a significant impact on your bottom line. If you don’t do it well, you might have a hard time staying in your medical business. With Scribe4Me RCM experts you can save both time and money, not to mention maximized claim reimbursements, better cash flow and improved profit margins!

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