Each year, healthcare providers perform millions of procedures on patients, from simple check-ups to complex surgeries. To collect revenue for these services, health systems must work with patients, doctors, and health insurance companies. This process of revenue collection for healthcare organizations is called Revenue Cycle Management.

If a healthcare provider wants to be successful in the long term, it is so important that their revenue cycle management efforts are running smoothly. Doing so can boost their financial well-being and ability to properly care for patients.

What is healthcare revenue cycle management?

Healthcare revenue cycle management (RCM) is the process by which health systems bill for services and generate revenue - from a patient’s first appointment all the way through to the payor’s acceptance of final payment.

Steps in the Revenue Cycle Management process (in more detail later in article) include, but are not limited to:

• Claims: Turning in and submitting medical billing fee claims to insurance companies
• Coding: Assigning the proper medical coding to procedures
• Charge Capture: Turning medical services into billable charges
• Collections: Collecting patient payments for outstanding balances

Difference between RCM and Medical Billing

While the term Medical Billing may be restricted to some of the major components of the healthcare industry, RCM is a sum composite of all the processes that are involved in managing a healthcare provider's revenue to ensure that they get reimbursed appropriately and in a timely manner. It is important to note here that the management of revenue for healthcare providers can be for providers in an outpatient setting or in a hospital setting. Healthcare organizations across the country use revenue cycle management to manage finances successfully.

11 Steps of Revenue Cycle Management

So what exactly does revenue cycle management consist of? The steps below outline the Revenue Cycle Management Process end-to-end:

1. Patient Scheduling

Revenue Cycle Management begins with a "patient encounter" that, in ideal circumstances, the patient schedules in advance. Exceptions to this might be in an Urgent Care or Hospital Emergency Department setting.

2. Benefit and Eligibility Verification

At the time of scheduling, the patient's insurance information is captured so the provider may verify benefits and determine insurance coverage. In this way, if necessary, a financial planning engagement can be arranged in advance of medical services rendered and appropriate patient contributions can be collected at the time of service.

Pre-authorization substep

During the Benefit and Eligibility verification, the patient’s insurance carrier may inform the provider that they need to submit a pre-authorization to provide and be reimbursed for services to the patient. The Authorization consists of submitting a request with accompanying Medical Records in order for the Insurance company to guarantee reimbursement for a number of visits for the patient. 

3. Patient Encounter

The patient encounter is where the provider and patient discuss the patient’s healthcare needs and develop a treatment plan as well as deliver treatment. The details of this encounter are captured in the patient’s chart electronically via an electronic health record (EHR) or paper record. The encounter begins when the patient arrives. Then, the provider’s administrative staff conducts a patient intake. This includes confirming all patient demographic, insurance information, and medical history. They may also at this time make copies of insurance cards and driver's licenses if the encounter is face to face.

4. Medical Transcription (optional)

Instead of directly documenting information in the patient’s chart, the provider dictates notes that are sent off to a third party who transcribes these notes into a medical record that can be uploaded or saved to the patient’s chart. 

5. Medical Coding

Coding consists of reviewing the documentation of the patient encounter and translating it into Procedure Codes and Diagnosis Codes. Procedure Codes (CPT) are 5-digit medical codes that represent the services that can be rendered by a medical provider. Diagnosis Codes (ICD10) – are the disease classifications that document the conditions or illness that brought the patient in for treatment. Many healthcare practices will leave this step to outsourced medical coders.

6. Charge Capture / Claims Generation & Submission

This is the central core of the Revenue Cycle. All services rendered translated into the appropriate CPT and ICD10 codes are tied together with the patient demographic and insurance information as well as the rendering provider and facility information to create a claim that is submitted to an insurance company for payment.

7. Cash Posting/Payment Posting

Payment Posting is a medical billing process of recording communication of insurance decisions against the claim on a line-by-line basis. Should there be a patient share of cost after the payment is posted these amounts will be transferred to the patient so that patient statements can be sent out to collect this amount.

8. Secondary Billing

If a patient has multiple insurances, then once the primary insurance has adjudicated the claim the balance is transferred to the secondary insurance for payment. Many insurance payers also automatically cross over the balance to a secondary or tertiary payer if they have the information in their system.

9. Patient Billing

If the claim adjudication results in a denial, it is posted on the claim, allowing a medical billing expert can review the reasons for non-payment and take the necessary steps to appeal and get the claim re-processed as appropriate. Should this be due to non-covered services then the balance amount is transferred to the patient to request patient payment. This is also referred to as Patient Billing or Statement processing.

10. Accounts Receivable

Accounts Receivables (AR) stands for the outstanding amount that is pending/not yet come in for a provider for the services they have rendered in the past. It is a measurement of charges not yet collected. The purpose of the AR team is to collect partly/underpaid pending or denied insurance claims.

The key to accounts receivables is follow-up, which can take two forms: a) Insurance follow-up, which is to collect payment from the insurance company and b) Patient follow-up, which is collection of any outstanding payment that is the patient's financial responsibility (copays, coinsurance, or other out-of-pocket medical costs).

11. Denial Management

The process of Denial Management begins on receipt of denial of a claim that was underpaid or had improper coding.

It follows payment/cash posting. It is done by analyzing the reason for denial/underpayment and following up with the carrier/patient telephonically.

Medical billers conducting the Revenue Cycle Management process may do some or all of the steps outlined above. 

RCM Metrics You Should Care About

Proper Revenue Cycle Management means performing at or above baseline in several core RCM metrics. A few metrics that medical billers should care about include:

• Total medical claims reimbursement per week
• Average days to get paid on average 
• Denial rate, and 
• Accounts Receivable from Insurance and Patients over 60 Days

RCM dashboards

Proper RCM dashboards can complement metrics by allowing you to visualize how your health organization’s RCM process is performing. RCM Dashboards are critical to seeing the performance of your RCM in real-time. Different visualizations of the dashboard, such as by doctor, date, or insurance, can be helpful in maximizing insurance reimbursement for your healthcare practice. An example of one of Athelas’s Revenue Cycle Management Dashboards can be viewed below.

Conclusion

Revenue cycle management is an integral part of a healthcare organization’s success. It can be hard to do each component of RCM well by yourself - that’s where Athelas comes in.

Athelas provides industry-leading Revenue Cycle Management services. Athelas has helped dozens of healthcare systems achieve triple-digit growth in their medical billing and payment collections.

Athelas RCM focuses on giving world-class service, maximizing reimbursements, and delivering actionable insights into the financial health of your practice.

Want to learn how much more your practice could earn with optimized RCM?

Talk with one of our RCM strategists.