Is it not true to accept that the revenue cycle in medical billing needs a big push to rejuvenate
itself from the falling petals? Right from the beginning of the pandemic, it has been challenging
for the healthcare industry and revenue cycle companies to manage their business like ever before.
Sometimes, the reasons for the loss are never expected and continues the same without any change.
When healthcare professionals require proper billing assistance, the revenue cycle in medical
billing has better ideas to improve the proficiency and results for the business growth.
So, it needs to rise from where it was slowed down! There’s no doubt in saying that a robust revenue
cycle in medical billing can boost your practice’s efficiency and patient convenience, most
importantly, maximize your practices’ revenue. First of all revenue cycle is different from medical
billing. As you all know, the entire process starts from the patient’s appointment to when the
patient’s balance for that episode of care is $0.
It might seem very simple, yet a complex process. There are multiple steps where your failure begins
to attack your reimbursements. So, understanding each step in detail can make your revenue cycle in
medical billing work super quick to improve the entire progress. This article explains the steps in
RCM and how it can revitalize itself from the beginning.
Let’s have a look at important steps of the revenue cycle in medical billing.
Steps of Revenue Cycle in Medical Billing:
The below steps might look very familiar to your business practice, but not that simple to put into
place without expertise. They are:
Claim Pre-Adjudication Steps
Insurance Eligibility Verification
Patient Demographics Entry
Estimation of Co-pays and Patient Responsibility
Charge Capture
Claims Creation & Scrubbing
Claims Submission
Clearinghouse Edits
Payer Acceptance
Payer Adjudication
Claim Post Adjudication Steps
ERA Remittance
Communication and Correspondence
Denial Management
Payment Posting
Balance Transfer to Patient
Accounts Receivables Management
Daily or Monthly Reporting and Analytics
It might be repeated by keep in mind that accurate billing and timely follow-ups are essential. Most
of the payers require to complete the payment within 35 to 45 days.
It means that it’s possible with complete accuracy in the documentation and claim filing.
Understanding the process can indeed help you identify broken links and resolve issues that lead to
denials.
Every step and stage of the revenue cycle in medical billing is crucial to ensure that healthcare
professionals benefit from timely reimbursements.
Eligibility and Patient Demographics – Collect information at every visit:
An essential step of the revenue cycle in medical billing is to collect information on the patient,
including the reason for the visit.
Any errors while gathering the data or the information might lead to denials and rejections, which
is the most significant issue in the medical billing industry.
Automation also works in a lot of cases. Especially the office staff can be trained in the
automation process as it becomes a quick way to verify the insurance policies and coverage.
You need to support this process by implementing a better EHR solution or software that could
automatically check eligibility and create the patient’s chart from the data returned by the payer.
Charge Capture and Coding:
Charge capture is one of the other crucial factors when it comes to the revenue cycle in medical
billing.
It is where the healthcare professionals, other physicians, and medical billing staff use the record
information about the services rendered to the patient.
Once the information is recorded, it’s translated into a claim and is submitted to insurance
companies for revenue payments.
There are multiple code sets used during this process. They are used for different purposes. They
include:
ICD-10 diagnosis codes that describe a patient’s condition or injury, as well as social determinants
of health and other patient characteristics.
Current procedural terminology (CPT) and healthcare common procedure coding system procedure codes
(HCPCS) are the ones that indicate the actions which were performed by the healthcare provider in
administering care during an encounter.
Charge capture codes are to connect physician order entries, patient care services, and other
clinical items with a chargemaster code, a list of the prices for each service.
Professional codes are used to capture physician and other clinical services delivered to connect
the services with a code for billing.
Facility codes or place of service codes are used to account for the cost and overhead of providing
healthcare services, such as charges for using space, equipment, and supplies.
You are recommended to use AI for the revenue cycle in medical billing to enter all the billing
data.
Creating Claims and Scrubbing- Do it right for the first attempt
Coding wants your medical billing staff to gather information from the medical record and other
documentation for the billing process.
These codes are used especially to generate insurance claims, which are handled by outsourcing
companies or third-party payers.
Superbills:
A superbill is considered the primary source of data used to create claims and a list of procedures
performed by the healthcare professional.
Forms for submitting claims:
Claims are usually created by dragging the information from the superbill, either by hand or
electronically.
CMS 1500 is a form introduced by Medicare and is also used by most insurance companies.
Medicaid and other parties might use other forms that are entirely based on their purposes.
Claims scrubbing:
While preparing for claim submission, you must be aware of errors known as claim scrubbing.
It helps to ensure that all the information is complete as well as accurate. It must include
patient, provider, and visit information, and procedure, diagnosis, and modifier codes.
The primary purpose or goal is to achieve clean claims and eradicate denials and rejections. This
scrubbing process is also automated.
Claim Submission:
Clean claims usually save time. You should be aware of the timely filing limits that your insurance
companies follow.
If a claim is denied due to late claim submission, You are not eligible to appeal a claim.
Medicare must be submitted within one year of the date of service. Timely filing limits may vary
from payer to payer.
The clearinghouse aggregates mountains of electronic claim information, almost all of it managed by
software.
Clearinghouse Corrections: Final Chance to avoid Denials:
The clearinghouse acts as a mediator between practice and insurance companies.
The file generated is uploaded to the clearinghouse to perform its series of edits.
Clearinghouse edits present the last opportunity to ensure the integrity of a claim before it gets
to the payer. Hence denials are prevented.
When a clearinghouse finds an issue in the claim, it automatically rejects it.
To reduce clearinghouse rejections, be conscientious about scrubbing claims and correcting errors in
charges.
If most of your claims are getting denied, choose the assistance that does all your back office
duties by leaving timely reimbursements in your pockets. Outsourcing the revenue cycle in medical
billing has been an excellent option for many, and so for you!
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