Revenue Cycle Management (RCM) software captures, submits, tracks, and manages the claims-side practice financials for payer-based services in order to maximize a healthcare organization’s revenue cycle efficiency and improve the billing, coding, and accounts receivable processes.
The revenue cycle in value-based reimbursement is arguably the most critical piece of a healthcare practice’s viability in both the short and long term, directly and indirectly enabling the staff to work more efficiently, the managers and owners to effectively make the best decisions, and the physicians to provide the highest level of quality care.
Timing is Everything in Billing
Though some argue it begins at the setting of a patient appointment, the measurable revenue cycle begins at the point of care (when the claim timer begins) or more specifically at the point of charge capture (when the RCM experts get their hands on it) and ends with the successful collection or unsuccessful conclusion of the claim.
Every claim or charge has an insurance company time limit or expiration date after which no amount of troubleshooting or adjusting can change the outcome. Some will move smoothly through the process (clean claims) but many will requiring finessing, adjusting, fixing, finding, troubleshooting, or forcing through to the payout point within the allowable time frame.
Ever changing healthcare regulations and reimbursement models, compliance issues, audits, bureaucratic hurdles and red tape, human errors, time constraints, technology limitations, filing mistakes, delays, limited resources, software issues, and even global pandemics are all RCM challenges that can have a dramatic impact on reimbursement financials.
But at the end of the day, the biggest impacting factors that a practice or provider can control when it comes to giving their claims the best start is the charge capture and coding after the point of care. Higher coding efficiency and faster charge capture can have a significant impact on bottom line financials while driving higher time efficiency models as well.
Clinician Revenue Cycle Management Services
As mentioned above, a provider often has very little impact on the claim review and denial portion of the revenue process after the charge has been captured. In fact, there is so little transparency in the process that once providers submit their billing, they often have no idea what the individual results may be, seeing payments months later with no clarity on which claims were paid and which were denied.
The lack of transparency shows in a muddled mess of insurance eligibility issues, failed patient payments, A/R process stuck points resulting in good claims going unpaid, unmet contract rates, questionable and erroneous denials, lost and missing claims, and other gray areas results in a process highly advantageous to the insurance companies, which results in distinct disadvantages for physicians and medical practices.
Claimocity RCM was designed to even the playing field and take back all the revenue that insurance companies collect when doctors leave it on the table.
Our billing team and system creates unrivaled transparency, lowering the veil between the providers and the insurance bureaucracy payout system so that doctors and practice managers can track claims from the point of care (or charge capture) to the conclusion while generating cleaner, clearer, and better data to make more effective decisions with.
Patient Responsibility and Collections
Patient responsibility is a significant and often uncontrollable issues in the RCM process. Not only is patient responsibility for healthcare costs rising but unpaid medical debt is a massive economic issue with bottom line impacts. If a patient doesn’t pay their portion, an encounter value goes down, and when this is combined with an insurance payout that comes in less than the contracted rate, promising financial encounters can consistently become low value payouts.
One of the ways to combat this are patient pre-registration and front-loading the payment process.
Patient pre-registration is helpful in gathering and utilizing advanced medical information and demographics (including the insurance information necessary to evaluate coverage, additional insurance, maximum allowable visits, patient financial responsibility, and the upfront information necessary to evaluate claim denials) which enables a good RCM company to better estimate a patient’s responsibility and likelihood to pay, which can impact how an encounter is coded and processed to maximize revenue while maintaining code integrity and efficiency.
Medical Revenue Cycle Management
Medical revenue cycle management is more art form than science, requiring a complex blend of experience and efficiency to know how to structure, troubleshoot, steamroll, and finesse different claims through the payout process in order to generate the highest clean claim and net collection rates and lowest denial rates while tracking claims and financials in a manner conducive to actionable reporting and physician performance analytics.
In addition to being experts in the art of billing and collections, a skill set that comes from decades of specialized experience, Claimocity has a huge staff of coding and billing specialists with the sheer robust manpower to make the dozens or even hundreds of calls necessary to troubleshoot and push through a single stuck claim. Our teams work in shifts around the clock to provide coding and billing support at any hour, constantly working the accounts receivable process from multiple angles.
Charge Capture Revenue Cycle
One of the most relevant forms of modern RCM is the charge capture revenue cycle, which is the direct result of the billing evolution from traditional paper billing methods to electronic and mobile charge capture software methods.
The evolution of the phone to a smart device capable of processing complex billing software on the go is changing the revenue cycle game.
Mobile charge capture enables a quicker start to the RCM process by capturing the claim much closer to the point of contact, giving the billing company or service more time to process, manage, troubleshoot, and collect before the expiry date set by the insurance company.
Not to mention the increased revenue efficiency that comes from the mobile charge capture ability to reduce lost or missing claims, catch human errors associated with paper billing, and convenience of being able to process billing from a pocket smartphone without all the burdensome paperwork and unnecessary administrative burdens.
Factors that Impact RCM
Healthcare workers and billers usually operate on limited resources and have very little control over the claims process but there are some areas that can be emphasized by the organization in order to generate higher revenue efficiency models. A few of these internal factors include practice and provider productivity, patient volumes, patient pre-registration, and collecting fees for services are focal areas that providers can improve to drive strong RCM results.
Other factors that often impact revenue management are fragmented administrative workflows and information sharing is critical for streamlined billing. Bottlenecks and gray areas in the revenue cycle can come from poor communication processes, and improving front end and back end communication on coverage eligibility during the patient intake process can facilitate a useful understanding of payer coordination, historical reimbursement averages, and likely payment collection amounts.
Tracking claims is a highly underrated portion of the healthcare revenue cycle management process, though often while the data may be collected, very few software options actually present the collected information in a user-friendly reporting format that a physician or practice manager can use to evaluate actionable insights and make more effective data-driven decisions going forward.
Neglecting the claim tracking portion not only increases the likelihood of accounts receivable bottlenecks and stuck points, but ignores information that can be used to determine where revenue flow problems originate to facilitate updating SOPs and best practices regarding specific procedures or codes to help increase understanding and awareness to reduce recurrences.
Healthcare Revenue Cycle Management
Claimocity focuses heavily on designing software solutions for hospitalists and clinicians who perform encounters in acute care or sub-acute step-down facilities. Our healthcare revenue cycle management services are the backbone of the company and are available as stand alone billing services or in combination with integrated EHR, practice management, scheduling, compensation management, mobile charge capture, or any other available smart software tools your practice needs.
Additionally, the Claimocity healthcare RCM is built as a perfect solution for office-based practices like urgent cares, emergency departments, surgery centers, clinics, and other specialty based healthcare facilities.