Healthcare Revenue Cycle Management Solutions
AdvantEdge provides comprehensive revenue cycle management and business management solutions for healthcare providers. Our solutions include:
- Medical billing
- Coding: diagnosis and procedure
- Reporting, Dashboards and Business Intelligence (Informatics)
- Practice Management
All are delivered with a focus on the best results for your practice and/or hospital. With ClientFirst service.
Please contact us today to learn more: 877 501-1611 or firstname.lastname@example.org
Revenue Cycle Management
Revenue Cycle Management or RCM typically refers to the entire medical billing process, from beginning to end.
- Capturing, entering, and editing (“scrubbing”) the information needed to create a medical billing claim (to an insurance company or payer). This includes “demographic” information about the patient including insurance coverage details and “charge” information: a combination of CPT and ICD-9 codes determined by the physician or a coder.
- Coding can be performed by the physician, with our without the use of EMR/EHR technology, by a coder in the practice, or by a certified coder working for a medical billing company. Coding rules are complex and change on a regular basis and coding must be done accurately or the practice will face compliance risk. Recent expansions of Medicare and OIG audits have increased this compliance risk.
- Front end edits make sure that all information is accurate and consistent so that the claim will be accepted by the payer (insurance company). The measure used is typically “first pass claims acceptance rate.”
- Claims are filed electronically using medical billing software and EDI technology or on paper. Most payers now accept electronic filing, but some smaller payers still require paper.
- Once payment and the associated information are received, the information is posted. The key information includes the EOB: explanation of benefits. Payments can be posted electronically when received as an ERA: electronic remittance advice, sometimes referred to by its ANSI number: 835.
- When a claim is denied, the denial information, including payer denial code is posted.
- The payment itself is deposited into the practice bank account, either in the form of paper check (still most common) or via Electronic Funds Transfer: EFT. Medical billing companies deposit paper checks received into their client’s bank account. Payers are moving toward EFT payments, but many payers and practices have yet to take advantage of EFT.
- Accounts Receivable management. As claims and patient statements are outstanding, it is critical to monitor the payment intervals. The objective is to assure payment is made on a timely basis. Benchmarks for “Days in A/R” are available from the HBMA, MGMA, and others. Well run practices and medical billing companies also analyze underpaid claims by comparing payments to contracted amounts and flagging exceptions. Follow-up on these situations is critical to achieving strong collections results.
- Denial Management. Where claims are denied, a timely response is required to overcome the objection and resubmit the claim for payment. Denials are frequently assigned to the most experienced billing experts, sometimes by payer, sometimes by reason (denial code), and usually by specialty for multi-specialty practices or billing companies.
- Patient balances typically include co-pays, deductibles, and other forms of “patient responsible” billing. Usually a statement is issued with payment expected within 30 days. Increasingly, credit card and other payment arrangements are expected. This is especially important for patients with so-called High Deductible Health Plans, where the patient due amount can be substantial.
- At some point, usually after two, three or four patient statements and perhaps a phone call, a patient account will be referred to a collections agency. Collections agencies follow state laws regarding collection methods. They collect a substantial commission for their efforts since these are typically difficult collections.
- Reporting is frequently viewed as an integral part of the revenue cycle, since it reflects the results and statistics about practice health, both financial health and operational health (e.g. productivity).
- The revenue cycle does not strictly include medical billing software but it is an inherent tool and support mechanism for any modern physician practice revenue cycle. Practice management software typically spans everything from scheduling to claims filing, A/R management, and reporting. Electronic medical records (EMR) or electronic health records (EHR), while not part of the revenue cycle, do play a role in creating the initial data.
Other aspects of revenue cycle management are easily overlooked by the simple list shown here. For example, important information for billing and revenue cycle management may exist in hospital registration systems (e.g. ADT information: Admit, Discharge, Transfer). Other examples are radiology RIS and PACS systems, and pathology laboratory systems. Another consideration is the staff workflow between the steps. Even if the billing system has a smooth handoff of information (which is not always the case), if staff communication is poor, the workflow may suffer. Of course, there are many other aspects of the end-to-end workflow that must be optimized for each practice or medical billing company.
* Radiologists and pathologists typically see a film, slide or their electronic equivalent rather than seeing the patient directly. In their case, billing begins when their report is completed.