WHAT IS REVENUE CYCLE MANAGEMENT (RCM) | XyberMed

WHAT IS REVENUE CYCLE MANAGEMENT (RCM)?

Revenue Cycle Management (RCM) refers to identifying, collecting, and managing practice revenue from payers based on services provided. A successful revenue cycle management process is essential for a healthcare facility to maintain its financial viability and continue to provide quality care to its patients.

The move toward value-based reimbursement and more holistic patient care has forced healthcare providers to take a closer look at how they approach revenue cycle management.

Poor billing practices can lead to financial losses and jeopardize the ability to deliver quality care. Improving and streamlining basic operating procedures can help providers remain financially viable.

REVENUE CYCLE MANAGEMENT CHALLENGES: The revenue cycle begins when the patient makes the appointment and ends with the successful collection. However, there are many intermediate steps that must be completed accurately and efficiently to ensure timely payment. Opportunities for human error due to coding complexity, miscommunication, medical billing errors due to duplicate data, and missing information or misspellings can result in lost revenue.

Constantly changing healthcare regulations and reimbursement models can make it difficult to receive timely reimbursements. This can also increase the demand on staff time and often requires appropriate software technology to complete the necessary reports. Healthcare providers often work with limited available resources. For providers to achieve RCM success, it is often necessary to focus on improving the efficiency of administrative tasks.

FACTORS THAT CAN AFFECT RCM: The provider has little control over payment from the claims review and denial process. Long waits for billing and claims to be processed for provider payments can result from denied claims due to insurance eligibility issues and increased efforts to combat healthcare fraud and abuse.

However, there are some internal factors over which the provider may have some control.

Productivity, patient volume, and fee-for-service collection are areas providers can focus on to

improve their RCM. Among the issues that can disrupt the RCM process are: COLLECTING PAYMENTS FROM PATIENTS: Patient responsibility for healthcare costs is increasing. If patient payments are collected during, or prior to, their service, the risk of non-payment is completely avoided. Although this is often a difficult task because many patients have difficulty paying high deductibles and are unaware of their financial responsibility.

Pre-registration of the patient is essential to obtain the most accurate medical history and insurance information in advance to reduce claim denials. This can allow for anticipating the payment process by collecting data on insurance coverage, additional insurance, their maximum allowable visits, and determining the patient's financial responsibility.

FRAGMENTED ADMINISTRATIVE PROCESSES: The front end and back end of the practice often have different priorities. If information is not shared, it can result in claims denials. Improving communication during patient intake regarding coverage eligibility can help with payer coordination, and claims reimbursement and can improve collections.

Focus on initial administrative tasks to streamline claims and help uninsured patients understand their coverage options with the insurance exchanges. Revalidation of patient insurance information is often overlooked at subsequent visits and can result in denial of eligibility.

ELIGIBILITY ISSUES: Communication with health insurance companies is a key component. Neglecting to manage the claims process after submission can result in claims that are pending, rejected or denied, or those that were never received. Following up on claims to determine where problems originate, such as determining if there are problems with specific procedures or codes, can help increase awareness and reduce recurrences.