Revenue Cycle Management (RCM) Is a Process | XyberMed

Revenue Cycle Management (RCM) Is a Process

Revenue Cycle Management (RCM) is the backbone of the healthcare industry. It manages providers' finances and keeps them running on a daily basis; several organizations are involved in the process to make it a success. The role of U.S. medical billing services and front desk staff is undeniable. We will look at how each of these departments improves payments for physicians and other clinicians.

What is revenue cycle management?

Revenue Cycle Management or RCM is a process that deals with financial cycle management.

RCM works at the functional core of a healthcare organization, whether it is a small medical practice or a large hospital. Every institution, by law, has to follow certain procedures to remain profitable, so the process of delivering care is constantly moving forward. Following this current argument, it is worth mentioning the main stakeholders in this process: physicians, patients and payers.

Physicians and patients are directly part of the care delivery process, but payers participate in it as a driver and are key players. Revenue motivates both physicians and patients. The healthcare industry skyscraper comprises several basic building blocks to execute an end-toend revenue cycle management process.

If there are gaps and/or outstanding receivables, they directly affect a practitioner's revenue.

Aftershocks from a sluggish revenue cycle can cause long delays in outstanding physician claims.

Medical billing services in the United States play a critical role.

An effective revenue cycle management process in medical billing is what most medical practices strive for. Most of the time it is the medical billing and coding companies responsible, assuming they have the necessary experience and skills. It is interesting to compare medical billing services in the United States to an anchor. They connect providers to payers like an anchor connects a ship to shore.

To run a productive healthcare RCM process, it is imperative to engage an experienced billing service. Whether you choose to outsource medical billing or use an in-house specialist, a slight deviation from a certain level of care could mean failure of the entire process. Submitting claims at the right time leads to faster reimbursements. It requires certain skills and a combination of novice and veteran billers.

steps in revenue cycle management While there is no substitute for high-quality care, the importance of following the 9 steps of revenue cycle management is literally undeniable.

As explained in recent publications, AI or Artificial Intelligence will drive the efficiency of a revenue cycle management system by acting as the physicians' digital employee.

Revenue Cycle Management - ReferalMD Photo by Kindel Media on Pexels.

Let's look at the revenue cycle from start to finish to educate ourselves in the best interest of care and healing.

RCM software or a medical billing outsourcing company.

The first step in claims management is to decide whether to install RCM software in-house. Or turn the task over to a revenue cycle management company? Don't worry, because it all becomes easier when you outsource medical billing services with qualified IT staff to file claims, work on denials and appeal on your behalf.

To find a billing company that suits their practice, physicians often search the phrase "medical billing companies near me" on Google. This will bring up a list of nearby companies.

It makes sense to look for revenue cycle consulting companies near you when you don't have IT-savvy staff in your medical practice. When running a small practice with a capable IT team to support, it is ideal to run RCM software configured on local servers. However, larger organizations or those lacking trained staff find medical billing services in the U.S. to be the best practice.

Pre-certification or patient pre-authorization What does it consist of? When a patient arrives, he or she undergoes pre-authorization.

Through this process, the physician's office pre-approves the patient for certain treatments and prescription drugs.

In this step, payers or insurance companies decide whether or not prescription drugs, procedures, services, or equipment are medically necessary. Based on the decision, they will reimburse for the services provided. The preauthorization phase has exceptions in the case of a medical emergency.

Pre-authorization does not necessarily mean that the health insurer will cover its cost, so the process is iterative and requires ongoing verification. It is always a good idea to double-check any coverage concerns with the insurance company. This is true for both providers and patients.

Insurance Eligibility and Verification The process is frankly demotivating over the phone because it requires a lot of patience.

Therefore, an established function must be part of the RCM software to address it. Artificial intelligence could play a pioneering role in this recognition phase, as it will automate the function.

Once patients have received care, the Explanation of Benefits (EOB) statement incorporates all the details of the services or treatments paid on their behalf by the insurance company.

Charging and coding When the patient presents at the office, the visit is transformed into a set of codes. There is a high probability of human error in these codes, so competent medical coders are the key players in this process. The codes have to follow a certain set of rules and match the CPT guidelines and the latest ICD-10 coding system.

Copayments and deductibles Every health plan comes with a deductible and copayment. Some have high deductibles and some have low deductibles. Whatever the amount, patients pay the copays at the doctor's office before going home. The deductible is the amount set in a health plan that must be paid before the insurance company begins to pay for those health services.