Revenue cycle rcm

Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.

1. Revenue Cycle Management US HEALTHCARE

2. RCM - Revenue Cycle Management Revenue Cycle Management is the process used by healthcare industry in the United States to track the revenue from Insurance company and / or patient. The Revenue Cycle Management process begins when a patient schedules an appointment and it ends when the healthcare provider has accepted all payments . Errors in Revenue Cycle Management can lead to the healthcare provider receiving delayed payments or no payment at all.

3. Revenue Cycle Overview: Basic Steps in Processing an Insurance Claim

4. Front Office : Patient’s appointment – Patient visits the Provider’s office Insurance info received and copied – Receptionist collects patient’s insurance ID cards and keeps a copy HIPAA & AOB signed by the Patient – Patient signs all necessary documents RCM - Phase 1

5. Provider’s Entity : Medical services performed – Provider sees the patient and performs medical services Medical records generated – Reports related to the medical service by the provider generated Patient checks out of the facility – Patient leaves the Provider’s office RCM - Phase 2

6. Billing & Tracking Patient’s data received and Account created – Provider sends Medical records to the Medical Billing Company. Claim generated & submitted – Generate Claim through Software and submits to Insurance company Tracking of claim – Claim is tracked through Websites and RM RCM - Phase 3

7. Payment & Follow-up Payment or denial received with EOB – Post adjudication we receive payment/denial along with EOB Posted to Patient’s account and unpaid claims followed up – Post payment/denial as per EOB Balance due forwarded to patient – Statement sent to patient if there is a patient liability Full payment received or forwarded to Collection – Close the account if full payment received or forwarded to Collection agency if full payment is not received. RCM - Phase 4

8. Methods of submitting a claim: Different methods exist for processing insurance claims. The most common are as followed: Paper Claims - After posting charges in Software and submitting to the insurance payer on legacy paper CMS-1500 (Centers for Medicare & Medicaid Services) claim form. Electronic claims transmitted from Software. We partner with a Clearinghouse to submit claims to the appropriate payer in the correct format . Direct Data Entry (DDE) into the payer’s system. Specialist of billing industry would log directly into the insurance company’s system and key in the information needed to process the claim.

9. Claim Adjudication: Claims adjudication is a term used in the insurance industry to refer to the process of paying claims submitted or denying them after comparing claims to the benefit or coverage requirements.

10. Components of an EOB An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to Providers explaining what medical services were paid or denied . There is no standard format for EOBs from insurance companies, but information contained in each one is usually the same.

11. Claim Inquires and Follow Up Procedures: The following are some reasons for making inquiries : There was no response to a submitted claim within 45 days or a time frame indicated by the AR Analysis Payment received but the amount is incorrect EOB shows that a professional or diagnostic code was change Additional information / records are required

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13. Thank You Santanu Patwari