Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

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What Are the Front-End Steps of Revenue Cycle Management?

Here is a summary of the revenue cycle management process leading up to when a patient receives care and how bad data hinders claims management success.

- Revenue cycle management is the progression of events between when a patient makes a doctor’s appointment and when a patient’s money is received and reimbursed for following care delivery.

revenue cycle management claims denials

When a service has been fully paid for and reimbursement has been attained, the cycle ends.

But things like coding complexity, miscommunication, and medical billing errors complicate completion of the revenue circuit.

Here is a brief summary of various revenue cycle steps that generally occur up to the point of a patient receiving medical care and the basic challenges that often present themselves along the reimbursement way.

The first step of revenue cycle management is scheduling a patient for an appointment and registering him or her within a database.

A detailed patient record helps educate a physician about various health issues and concerns early on.

Busier hospitals are opting to make this data collection process virtual, sometimes dependent on the timesaving automation of an iPad or kiosk methodology.

Other offices are incorporating similar time-saving strategies, like taking a patient’s blood pressure and recording his or her weight within the actual waiting room to help streamline the patient registration process.

But bad quality data can lead to future revenue cycle complications.

Even with the aid of streamlined technology, human-based or computer-based mistakes can arise, such as duplicate data and typos.

And in some cases, something as simple as a missing signature in a patient’s chart can lead to claims denial.

“From a revenue cycle perspective, getting the most accurate information up front starts with patient scheduling and patient registration,” said Gary Marlow, Vice President of Finance at Beverly Hospital and Addison Gilbert Hospital.

“That provides the groundwork by which claims can be billed and collected in the most efficient and effective manner possible,” he stated. “The last thing you want is getting a claim submission kicking back to them then having to work their way through the institution.”

“If you get the information up front in as pleasant a manner as possible, it saves heartache for the patient and family if the claim is processed and cleared in a judicious manner,” asserted Marlow.

“The last thing you want is getting a claim submission kicking back to them then having to work their way through the institution,” he said.

The next front-end step of revenue cycle management is patient eligibility verification and authorization.

To help ensure revenue cycle success, it is recommended to check for all patients each and every time they come through the door.

Five simple key questions to ask patients include:

  • Is the patient covered?
  • Is the patient covered other additional insurance?
  • Is the registration information accurate?
  • How many maximum allowable visits are there?
  • How much of the cost is the patient’s responsibility?

Apparently, patients are not being asked these types of questions enough, reported a ClaimRemedi survey.

Eligibility snags are allegedly one of the most common reasons a claim is rejected, the organization said.

Eight percent of claims submitted are reportedly rejected because of eligibility issues.

And 79 percent of surveyed practices said they check a patient’s eligibility. But only about one-quarter reportedly checked this information when subsequent visits occur.

Perhaps making sure all information is acquired before care delivery occurs, and asking the right questions, will help reduce the chance of future problems occurring.

According to ClaimRemedi, it is imperative to both track and monitor the status of all claims after they have sent along to payers to begin the charge process.

But rejected, pended, denied, or never received claims are reality. Managing the claim process instead of letting the process manage you must be a top priority.

One of the main reasons these glitches are occurring may be because of too much variation across the industry.

“The wide variation in how often health insurers deny claims, and the reasons used to explain the denials ... indicates a serious lack of standardization in the health insurance industry," said the American Medical Association (AMA).

Working efficiently and effectively means collecting information at the right time – before services are rendered.

Healthcare providers will continue to struggle with increased performance and limited resources, and must strive for efficient and effective workflows,” stated Karen England, MBA, CPC, Revenue Cycle Consultant at Ingenious Med.

The determination to make these changes is reportedly underway. A survey released last month from Porter Research and Navicure confirmed 9 percent of surveyed healthcare organizations view updating and automating patient collections strategies as a top focus for the remainder of 2016.

This increased focus in coming months will hopefully lead to more valuable revenue cycle management endeavors.

Greater synchronization of the different facets of the revenue cycle will only increase the likelihood of reimbursement delivery, enhance patient communication, and make sure high quality care delivery can remain a top focus.

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