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Managing the Revenue CycleTips & Tools
Rozmin Bapat, CCS-P, CPC, CPMA
Revenue Cycle Management (RCM)
• Revenue cycle management (RCM) is the process of managing claims, payment and revenue generation. RCM encompasses everything from determining patient insurance eligibility and collecting co-pays to properly coding claims. A well-designed RCM system is able to communicate with the EHR and accounting systems to streamline the billing and collection cycles.
Managing the Revenue Cycle
• The Old WaySee
Patient
File Insurance
Claim
Post Payment
Bill Patient
Collect Payment
Managing the Revenue Cycle
• What’s wrong with the old way?• No Insurance verification
• Nothing collected upfront
• Depending on insurance to cover the payment
• Hassle of billing and making collection efforts from patients
BOTTOM LINE
TIME AND MONEY LOST FOR THE PRACTICE!!!
Managing the Revenue Cycle
• The New WayObtain
complete demographic and insurance information from patient
Insurance Verification
Patient Demographic
Entry
CodingClaims Submission
Payment Posting
A/R Follow-up & Denial
Management
1 of 7
Obtain complete
demographic and insurance information from patient
• Who is responsible?• Front Desk• Information must be collected
at the time of making the appointment
• Before the patient arrives in the office
2 of 7
Insurance Verification
• Who is responsible?
• Insurance Coordinator
• Determine eligibility
• Verify benefits
• Copay, coinsurance and deductibles met
• Referrals
2 of 7
Insurance Verification
• Who is responsible?
• Insurance Coordinator
• How much is the patient portion?
• Ask about authorizations for certain procedures.
• Have a standardized verification form.
3 of 7
Patient Demographic
Entry
• Who is responsible?
• Front Desk
• Enter accurate demographics
• Current insurance
• Current address and phone number
• Scan in and update all changes
3 of 7
Patient Communication
• Who is responsible?
• Insurance Coordinator
• Communicate to the patient what they owe upfront
• Have the allowables from patient’s insurance available
• Collect, Collect, Collect
• Patient is the second largest payer in most offices
• 20% – 35% of revenue is patient’s responsibility
• Huge deal for practice’s bottom line
• Difference between a thriving and a sinking practice
4 of 7
Coding
• Who is responsible?
• Coding Staff
• Know coding guidelines
• Know payer guidelines
• Accurate coding
• Sending clean claims
4 of 7
ICD-10Coding
• Who is responsible?
• Coding Staff
• Dual coding before implementation date
• Learn on the job
• Measure productivity
• Always train and educate staff
5 of 7
Claims Submission
• Who is responsible?
• Billing Staff
• Visual scanning
• Scrubbing
• Setting up system to prompt incorrect entries
• Explosion codes
• Modifiers
6 of 7
Payment Posting
• Who is responsible?
• Coding and/or billing staff
• Electronic Remittance (ERAs)
• Electronic Funds Transfer (EFT)
• Post from paper EOBs
• Send secondary & tertiary claims
• Automate
7 of 7
A/R Follow-up & Denial
Management
• Who is responsible?
• Billing Staff
• Working Denials
• Clearinghouse• Catch errors before payer denials
• EOB denials• Fix easy errors right away
7 of 7
A/R Follow-up & Denial
Management
• Choose one day a week to work denials
• Register on insurance websites for faster claim status updates.
• Use your clearinghouse, Availity, Navinet for multiple insurances
• Call insurance companies and document all conversations in the claim window
7 of 7
A/R Follow-up & Denial
Management
• Look at unpaid claims every two weeks
• File appeal if needed
• Know Medicare and payer guidelines for filing appeals
7 of 7
A/R Follow-up & Denial
Management
Patient Collections: Do’s and Don'ts*** Collect Upfront***
• Payment Plan (Do’s)• Down payment• Schedule of payments• Definitive end date
• Payment Plan (DON’Ts)• Don’t offer unlimited time• Don’t take just any amount• Don’t let patients talk to physician about payment
7 of 7
A/R Follow-up & Denial
Management
Patient Collections• Collect balance when making appointment
• Collect when patient comes in
• Online payment options
• Send statement• Limit the amount of statements sent
• Have a plan for patients who cannot pay• Send to collections• Bad debt write-off• Dismissal from practice (review the consequences)
Managing the Revenue CycleIt takes a village!!
• Office policies and procedures manual
• Standardized forms and scripts• Everyone needs to be on the same page!
• Cross Training• Divides the burden• Cost-effective• Everyone in the office should have the same philosophy• Empowers the employees
Thank you!
