As the year draws to a close, it is vital to pay close attention to your practice’s revenue cycle to maintain an operational and financially healthy business. Operational aspects should be a top priority, with careful monitoring as they relate to efficiency in receivables and denials management.
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Explore This IssueNovember 2016
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Healthcare revenue cycle management is the strategy that healthcare organizations use to manage claim submissions and pay the bills. It involves the financial aspect of the administrative and clinical functions associated with claims processing, payment and revenue generation, which covers the identification, management and collection of patient service revenue.
Healthcare revenue cycle management begins at the time a patient makes an appointment, and continues to the point when there is a zero balance on the patient’s account. Coding and billing is a multi-faceted area not limited to the back-end function of the practice. Front-end tasks play an important role in driving revenue management. Tasks related to charge capturing, claims submission, processing payment statements and managing all denials are critical steps. The extent to which your practice has a handle on these key areas directly affects the practice revenue stream, because the goal is to reconcile the account balance expediently.
Building a healthy bottom line is necessary to reduce the portion of your revenue that is lingering in your accounts receivable (A/R). The four steps to achieve a more efficient revenue cycle in the practice involve workflow, use of technology, qualified team members and communication.
Tasks related to service billing are key activities in the revenue cycle workflow. Ongoing tasks, such as verifying insurance, collecting co-pays, coding appropriate diagnosis and procedure codes, submitting claims and managing payments/collections, are all linked in achieving a streamlined workflow. Even one small kink in the process can affect the revenue cycle and create chaos.
All the information necessary to complete each task for all patient encounters must be captured. To keep the workflow revenue cycle running smoothly, each practice area should focus on the following steps for a successful daily operation:
Step 1—Front Office
- Pull the daily schedule and charts in advance of the patients’ arrivals;
- Always verify patient information upon check-in; for established patients, verify and update patient and insurance information as needed; for new patients, collect all necessary data and prepare the patient chart;
- Validate insurance eligibility;
- Complete all patient HIPAA compliance; and
- Collect any co-pays and resolve any outstanding balances for established patients.
Step 2—Medical Assistants, Labs Technicians and Nurses
- Review charts and escort patient to exam room;
- Complete patient intake and vitals (collect as much information as necessary); and
- Complete any necessary labs for that visit.
Step 3—Physicians, NPs and PAs
- Complete patient history and exam;
- Make sure documentation in the medical record is thorough; and
- Discharge patient.
Step 4—Billing and Coding
- Review chart sheet thoroughly (ICD, CPT, modifiers and HCPCS); and
- Finalize and submit clean claims.
Step 5—Claims Processing
- Process payments and clear account;
- Denials received should be handled immediately:
- Review chart;
- Request appeal;
- Resubmit claim; and
- Monitor appeal decision and proceed accordingly (if payment is received, reconcile account; if service is denied and the patient is responsible, mail the patient a statement).
The use of technology has been embraced by most physician practices as an integral part of office efficiency and productivity. Practice management systems and standard electronic transactions can speed up the claim processes and save your practice time and money. Receiving electronic remittance advice (ERA) and electronic funds transfers (EFTs) for claims payment can be much faster than using traditional mail and helps with keeping the revenue cycle current.
ERA can be used to provide timely details about claim payments and claim status from private health plans; EFT is the electronic transfer of funds directly to your bank account. Most physician practices currently submit claims electronically through a medical records system, so adding other electronic transactions is the next step to streamline your revenue cycle. Electronic transactions also help your practice to be environmentally conscious while optimizing your revenue cycle by reducing paper usage.
Qualified Team Members
One of the most important indirect drivers of your practice’s revenue cycle management comes from having an experienced and trained billing team. Ensure all office staff understand the importance of the revenue cycle and the impact of their roles on the overall operations of the practice. Errors ranging from incorrect demographic information to incomplete documentation from the physician can result in claim denials, which can cost up to $40 in staff time to resubmit per rejection. Practice administrators and managers should create a culture that recognizes every staff member has a role in maintaining a well-run revenue management system.
The role of the coding and billing staff in your practice is critical; they not only need to know how to code, but to understand best practices for documentation and billing guidelines to avoid denials and/or audits. The daily performance of the coding and billing staff has a direct impact on your revenue cycle; therefore, it is critical they have access to educational resources to stay current on all payer regulations, coding changes, and industry changes that could have an impact on the success of your practice’s financial health.
Having credentialed and certified staff members in a rheumatology practice is a plus. Keep in mind, the American College of Rheumatology offers the Certified Rheumatology Coder certification, which was created to enable coders to demonstrate superior knowledge in coding for rheumatology services. For more information, visit the ACR practice page.
Effective communication with the practice staff that oversees your revenue is an important component to achieve a successful revenue management cycle and resolve problems in a timely manner. Staff members that clearly understand their role and purpose in the practice team will be able to efficiently and effectively complete their daily tasks.
Creating revenue cycle processes and protocols is important to keep everyone trained and informed. It is considered good practice to hold open weekly or monthly meetings with the practice staff to review and discuss the financial reports, including accounts receivables, collections and revenues. The meetings should also cover:
- Emphasis on procuring appropriate patient information (e.g., confirmation of the patient’s birthdate and the correct insurance information);
- Be cognizant of and obtain preauthorization for any visits or procedures before the visit is scheduled;
- Make sure documentation in the medical record is thorough; and
- Understand reasons for any denials received for submitted claims.
Performing quality assurance and keeping the practice’s staff informed can ensure that staff follow internal protocols and complete their tasks efficiently and effectively.
For optimal revenue cycle management, it is important to review daily processes to ensure everything is working smoothly. Many other work-related performances are taking place on a daily basis for everyone, but it is better to improve revenue cycle management through a preventive approach by checking and updating the practice processes on a regular basis. Taking the time to have all the pieces working together proficiently will ensure the practice goals are productive and strengthen the revenue cycle.
For additional information or training on revenue cycle/denials management, insurance, coding and billing, contact the ACR practice management department at firstname.lastname@example.org or 404-633-3777.