Is it not true to accept that the revenue cycle in medical billing needs a big push to rejuvenate itself from the falling petals? Right from the beginning of the pandemic, it has been challenging for the healthcare industry and revenue cycle companies to manage their business like ever before.

Sometimes, the reasons for the loss are never expected and continues the same without any change. When healthcare professionals require proper billing assistance, the revenue cycle in medical billing has better ideas to improve the proficiency and results for the business growth.

So, it needs to rise from where it was slowed down! There’s no doubt in saying that a robust revenue cycle in medical billing can boost your practice’s efficiency and patient convenience, most importantly, maximize your practices’ revenue. First of all revenue cycle is different from medical billing. As you all know, the entire process starts from the patient’s appointment to when the patient’s balance for that episode of care is $0.

It might seem very simple, yet a complex process. There are multiple steps where your failure begins to attack your reimbursements. So, understanding each step in detail can make your revenue cycle in medical billing work super quick to improve the entire progress. This article explains the steps in RCM and how it can revitalize itself from the beginning.

Let’s have a look at important steps of the revenue cycle in medical billing.

Steps of Revenue Cycle in Medical Billing:

  • The below steps might look very familiar to your business practice, but not that simple to put into place without expertise. They are:
  • Claim Pre-Adjudication Steps
  1. Insurance Eligibility Verification
  2. Patient Demographics Entry
  3. Estimation of Co-pays and Patient Responsibility
  4. Charge Capture
  5. Claims Creation & Scrubbing
  6. Claims Submission
  7. Clearinghouse Edits
  8. Payer Acceptance
  • Payer Adjudication
  • Claim Post Adjudication Steps
  1. ERA Remittance
  2. Communication and Correspondence
  3. Denial Management
  4. Payment Posting
  5. Balance Transfer to Patient
  6. Accounts Receivables Management
  • Daily or Monthly Reporting and Analytics
  • It might be repeated by keep in mind that accurate billing and timely follow-ups are essential. Most of the payers require to complete the payment within 35 to 45 days.
  • It means that it’s possible with complete accuracy in the documentation and claim filing.
  • Understanding the process can indeed help you identify broken links and resolve issues that lead to denials.
  • Every step and stage of the revenue cycle in medical billing is crucial to ensure that healthcare professionals benefit from timely reimbursements.

Eligibility and Patient Demographics – Collect information at every visit:

  • An essential step of the revenue cycle in medical billing is to collect information on the patient, including the reason for the visit.
  • Any errors while gathering the data or the information might lead to denials and rejections, which is the most significant issue in the medical billing industry.
  • Automation also works in a lot of cases. Especially the office staff can be trained in the automation process as it becomes a quick way to verify the insurance policies and coverage.
  • You need to support this process by implementing a better EHR solution or software that could automatically check eligibility and create the patient’s chart from the data returned by the payer.

Charge Capture and Coding:

  • Charge capture is one of the other crucial factors when it comes to the revenue cycle in medical billing.
  • It is where the healthcare professionals, other physicians, and medical billing staff use the record information about the services rendered to the patient.
  • Once the information is recorded, it’s translated into a claim and is submitted to insurance companies for revenue payments.
  • There are multiple code sets used during this process. They are used for different purposes. They include:
  1. ICD-10 diagnosis codes that describe a patient’s condition or injury, as well as social determinants of health and other patient characteristics.
  2. Current procedural terminology (CPT) and healthcare common procedure coding system procedure codes (HCPCS) are the ones that indicate the actions which were performed by the healthcare provider in administering care during an encounter.
  3. Charge capture codes are to connect physician order entries, patient care services, and other clinical items with a chargemaster code, a list of the prices for each service.
  4. Professional codes are used to capture physician and other clinical services delivered to connect the services with a code for billing.
  5. Facility codes or place of service codes are used to account for the cost and overhead of providing healthcare services, such as charges for using space, equipment, and supplies.
  • You are recommended to use AI for the revenue cycle in medical billing to enter all the billing data.

Creating Claims and Scrubbing- Do it right for the first attempt

  • Coding wants your medical billing staff to gather information from the medical record and other documentation for the billing process.
  • These codes are used especially to generate insurance claims, which are handled by outsourcing companies or third-party payers.

Superbills:

  • A superbill is considered the primary source of data used to create claims and a list of procedures performed by the healthcare professional.

Forms for submitting claims:

  • Claims are usually created by dragging the information from the superbill, either by hand or electronically.
  • CMS 1500 is a form introduced by Medicare and is also used by most insurance companies.
  • Medicaid and other parties might use other forms that are entirely based on their purposes.

Claims scrubbing:

  • While preparing for claim submission, you must be aware of errors known as claim scrubbing.
  • It helps to ensure that all the information is complete as well as accurate. It must include patient, provider, and visit information, and procedure, diagnosis, and modifier codes.
  • The primary purpose or goal is to achieve clean claims and eradicate denials and rejections. This scrubbing process is also automated.

Claim Submission:

  • Clean claims usually save time. You should be aware of the timely filing limits that your insurance companies follow.
  • If a claim is denied due to late claim submission, You are not eligible to appeal a claim.
  • Medicare must be submitted within one year of the date of service. Timely filing limits may vary from payer to payer.
  • The clearinghouse aggregates mountains of electronic claim information, almost all of it managed by software.

Clearinghouse Corrections: Final Chance to avoid Denials:

  • The clearinghouse acts as a mediator between practice and insurance companies.
  • The file generated is uploaded to the clearinghouse to perform its series of edits.
  • Clearinghouse edits present the last opportunity to ensure the integrity of a claim before it gets to the payer. Hence denials are prevented.
  • When a clearinghouse finds an issue in the claim, it automatically rejects it.
  • To reduce clearinghouse rejections, be conscientious about scrubbing claims and correcting errors in charges.

If most of your claims are getting denied, choose the assistance that does all your back office duties by leaving timely reimbursements in your pockets. Outsourcing the revenue cycle in medical billing has been an excellent option for many, and so for you!

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