RCM Revenue Cycle Managemen
Revenue Cycle Management (RCM) is a vital component of the healthcare system in the United States, employed to monitor and track revenue for healthcare providers stemming from services rendered to patients. This process spans from the initiation of a patient appointment, often prompted by the need for treatment or due to existing health concerns, and culminates in the resolution of services, typically through payment from either the insurance company, patient, or via adjustments agreed upon in contractual arrangements between the provider and the payer.
Outlined below are the key steps involved in RCM:
Appointment Scheduling: This initial phase of RCM sees patients scheduling appointments with providers either through phone calls or online platforms. Efficient appointment scheduling minimizes patient wait times and prevents potential scheduling conflicts.
Eligibility and Benefit Verification: Providers verify patient eligibility and insurance benefits with the payer to ensure coverage for the services planned. Verification can occur via phone, online platforms, or by presenting insurance ID cards during visits. It is crucial to confirm eligibility before services to account for any policy changes.
Registration and Pre-Encounter: During registration, patients complete necessary documentation, acknowledging financial responsibilities and granting authorization for revenue collection. The pre-encounter phase involves securing authorization and ensuring the availability of required resources before service provision, typically completed 24 hours in advance.
Encounter: This phase entails the delivery of services, with healthcare practitioners documenting treatment details via voice recording devices for subsequent transcription.
Medical Transcription: Medical Transcriptionists transcribe recorded treatment details into standardized medical records formats.
Medical Coding: A team of medical coders assigns CPT (Procedure code) and ICD-10 (Diagnosis Code) based on medical records, ensuring accurate coding facilitates payment processing.
Demographic and Charge Entry: Patient demographic and medical code data entry into the Practice Management System (PMS) is conducted accurately to prevent rejection or denial of claims.
Claim Submission: Completed demographic and charge entries are submitted to insurance using either CMS 1500 or UB 04 claim forms, tailored to physician and hospital billing, respectively.
PMS Scrubber or System Scrubber: The system verifies claim data against predefined formats, rejecting submissions with formatting errors.
Clearing House and Payer Rejection: Claims undergo further validation by the clearing house, with rejections often indicating issues related to patient, payer, or provider data. Payer rejection identifies and rectifies missing or incorrect information before forwarding claims for processing.
Insurance Processing: Accepted claims proceed to the insurance company for processing, resulting in either payment or denial. The insurer generates Explanation of Benefit (EOB) or Electronic Remittance Advise (ERA) documents detailing payment or denial specifics.
Payment Posting: Payment posting teams reconcile received EOBs or ERAs with the system, updating payment or denial information accordingly.
Accounts Receivable (AR): In cases where EOBs/ERAs are absent or unclear, the AR team contacts the insurer to clarify and ensure claim payment.
Denial Management: Unpaid or partially paid claims undergo investigation to identify denial reasons. Appropriate actions, such as appeals or coding reviews, are taken to resolve denials and secure claim payments.
Efficient management of the Revenue Cycle ensures accurate billing, timely payments, and overall financial stability for healthcare providers.