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Basic notions you need to know about Revenue Cycle Management for your practice


Within the RCM process, it’s essential to have some basic notions that can help you organize your strategy. For example, you can start by having a defined workflow with your process notes from patient registration through every appointment or claim until it is paid in full (and remember! your process must be understandable and easy to follow).


Contextualizing a bit, Revenue Cycle Management (RCM) refers to the process of managing the financial aspects of a healthcare practice or organization, from the initial patient encounter to the collection of payments for services provided. It involves various activities to optimize revenue generation and streamline the reimbursement process. Here are some basic notions you should know about RCM:


1. Patient Scheduling: The revenue cycle begins with scheduling patient appointments. Efficient scheduling practices can help maximize patient volume and reduce no-shows, ensuring a steady flow of revenue.


2. Patient Registration: Collect patient information such as demographics, insurance details, and medical history to implement proper billing and reimbursement.


3. Insurance Eligibility Verification: verify the patient's insurance coverage before providing services and determine their eligibility for specific procedures.


4. Coding and Documentation: Accurate coding ensures proper reimbursement and compliance with billing regulations.


5. Charge Capture: This involves capturing all billable patient services to avoid missed charges and revenue loss.


6. Claims Submission: Claims should be submitted to insurance payers for reimbursement promptly and in compliance with payer requirements to minimize delays and denials.


7. Claims Follow-up and Denial Management: Identify and resolve any issues that may lead to claim denials or delays. Denied claims should be analyzed, corrected, and resubmitted promptly to ensure timely payment.


8. Patient Billing and Collections: Establishing effective billing processes and clear communication with patients helps improve collections of co-pays, deductibles, and non-covered services.


9. Payment Posting and Reconciliation: Payments received from insurance companies and patients are posted to the respective accounts, and any discrepancies or payment errors are reconciled. This ensures accurate accounting and financial reporting.


10. Reporting and Analysis: Regular reporting and analysis of revenue cycle performance metrics are essential for monitoring the practice's financial health.


Effective RCM practices can enhance revenue capture, improve cash flow, minimize claim denials, and streamline the overall billing and reimbursement process for healthcare organizations.


In addition, by tracking your key performance indicators (KPIs) you can measure your actions' front-end and back-end performance and how effective you are in collecting. According to the Medical Group Management Association standards, the most important KPIs to assess your practice performance are:


  • Clean claim rate: summit and get approved by a clearinghouse before the claims reach the payer.

  • Denial rate: by finding gaps in your process you can decrease the avoidable denials by implementing analytical skills. For example, are you paid in 30 days? Getting paid for most of your claims in 30 days means that most of your processes are doing well.

  • Net collection rate: check these KPIs to assess your practice performance and make sure you're not leaving money on the table, which means you are being paid the correct amount.

Implement in your practice a management system to track the number of claims that are not submitted and are pending to be billed, technology is an excellent asset to help you go through your cycle process.


The revenue cycle management in companies can benefit from outsourcing, some practices even outsource their entire process, and for some others, it's just one part of it. As part of the medical revenue service, you can improve the good use of your team's time by constantly evaluating the processes that can be outsourced.


Partnership options


When negotiating medical liens after settlement, some companies provide RCM but only until the claim hits a certain age bucket. This is where you start questioning if your practice can handle that age bucket to make sure that you’re able to collect those dollars, or if you better turn it over to someone else to advocate for you, if that's the case, find a partner with the best qualifications to fit that need.


Sometimes a successful partnership with a third-party RCM vendor is necessary, as well as establishing communication that works as if your biller is physically sitting in your office; here you have the opportunity to define the best channel for your needs: email, management system, weekly meeting, and so on.


Minimize denials and payer appeals


When you implement Revenue Cycle Management for your practice and you start getting a lot of denials due to patient registration, eligibility, or missing referrals, you can proceed to take a step back and figure out what didn't happen correctly in the processes, then you can constantly be evolving and making it better.


Outsourcing allows you to have an entire team dedicated to coding, and keeping up with payer rules and regulations. Taking this type of aid into account for your processes will not only be reflected internally in your practice, but it can also signify a positive advance for the experience of your users.


Balancing patient satisfaction and care against financial performance


Users' experience is always a challenge, choosing the right time and channels to communicate with your patients can help your practice to enhance an outstanding balance. Usually, the sooner you're able to communicate with them, the better the relationship will be.


Is Revenue Cycle Management impacted by artificial intelligence (AI)?


AI has come a long way and it's here to stay, in the Revenue Cycle Management process AI serves as the tool that will tell you how many claims are not submitted, it also helps you appeal faster and even converts your paper explanation of benefits into an 835 file making your job easier, smoother and quicker.


Whatever your approach to the Revenue Cycle Management process, you will always want to make sure that each partner you decide to bring into your practice meets your needs.


Basic knowledge about Revenue Cycle Management can help boost your brand both in performance and in the perspective of your customers. With constant measurement and monitoring of the cycle, the practice can be positively impacted, and an already established process can be defined for future decision-making.


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