Medical billing mistakes can be easily made but have drastic repercussions on the overall profit of the healthcare organization. Returned claims with errors, denied claims, rejected bills, incorrect coding, and insufficient data are just a few of the many woes of poor revenue cycle management in healthcare. Almost 30% of medical bills are prone to medical billing errors. As common as these issues are, as complex as the system may be, the solution is at hand. As we sort through the commonality of medical coding errors and how to prevent them, how to correct medical billing errors, and steps in the medical billing process, certain areas reveal a gaping hole. Improper medical billing can be mitigated through healthcare revenue cycle management solutions.
As medical billing and coding errors increase in frequency, patient experience is diminished, profits are adversely affected, and the overall revenue cycle for healthcare is shunted. Efficient provider revenue cycle management can evade these outcomes through accurate claims management, offered through practice management solutions.
How We Built a Successful RCM System?
At OSP, A Texas-based mental health center wanted to automate the manual medical billing process. Paper-based practice management and the RCM cycle in medical billing were causing a loss of revenue and diminishing the quality of care. The main challenge for OSP was to bring in the digitization of the clinic’s daily practice and revenue operations.
We built a comprehensive revenue cycle management healthcare solution to offer:
The Process – Steps of Healthcare Provider Revenue Cycle Management
Step 1: Revenue Cycle Management (RCM) is initiated when healthcare providers get patients to make the first appointment for medical services.
Step 2: Once the appointment is made, health staff begin the process of scheduling, eligibility verification, patient information collection, and account establishment. This Pre-registration process is a critical element of medical billing and revenue cycle management.
Step 3: When the patient arrives and completes the appointment, it is now time for claims submission. The provider will identify the type of treatment from ICD-10 codes and create a claim. Accurate coding is critical toward health revenue cycle management.
Step 4: Once the claim is created, it is submitted to the relevant payer for reimbursement. The insurance company will evaluate the claim and, if all goes well, the health provider is reimbursed for the service. This completes the revenue cycle management healthcare process.
The Challenges – Traditionalism in Provider Revenue Cycle Management
- Healthcare compliance and regulations are continually changing and evolving. It is, therefore, difficult for health facilities to maintain a stable physician revenue cycle management policy.
- Due to system hurdles, collecting the payments from patients before or at the point of service has become increasingly difficult.
- Non-payment of medical bills by the patient increases the number of deductibles and creates a financial strain on the healthcare organization.
- Striking a balance between ensuring that debts are collected while also preventing patients from seeking out competitive medical providers is complex.
- Manual eligibility processes are prone to errors, and patients often do not understand their coverage options.
- Tracking a claim through its entire lifecycle is a time-consuming process and requires additional staff for solely this purpose.
- If not caught immediately, errors in billing can cause significant back and forth and delay the entire payment process.
- Unidentified errors result in denied claims, which lead to a lack of revenue and decrease the bottom line of the health facility.
- Training health staff toward physician revenue cycle management has turned into a pain point for healthcare organizations due to the job’s complexity.
The Future – Essential Features of Healthcare Revenue Cycle Management Solutions
1. Cloud Presence:
The future of healthcare provider software solutions is cloud-based solutions. A revenue cycle management solution is no exception. A solution on the cloud means that the health facility’s IT department no longer has to worry about space and bandwidth issues toward accessibility. Cloud computing in healthcare provides 24/7 accessibility of the solution without restrictions of space and hours. Medical records management is simplified when there is no stress about limits on data and accessibility. Another significant advantage of cloud-based RCM software is accessing electronic health records, even if the local system fails. This maintains patient data security from being lost through secure back-ups. Finally, if the system needs to be accessed across multiple locations, cloud-based access to integrated healthcare solutions is the best option.
2. Comprehensive Training:
RCM healthcare provider solutions should offer holistic denial management RCM training for the system for multiple functions. Training of healthcare staff in the organization should be organized in batches, and the revenue cycle management vendors should be prepared to offer the same. Organize the training in a manner that places the tech-savvy and relevant staff at the top of the list to address gaps in understanding at a later stage. Revenue cycle management services for healthcare should offer a demo of the customized software to ensure that all the services required will be present in the final version. This will eliminate development delays along the way. Additionally, incorporating healthcare analytics solutions within the RCM software will ensure advanced capabilities for the healthcare organization.
3. Highest Value Submission:
The goal of every healthcare organization is to maintain high profitability through healthcare automation. An essential factor in achieving this goal is ensuring that claims are submitted at their maximum value through medical informatics. Revenue cycle management for healthcare providers can be successful based on the criteria of highest value submission. When this policy is embedded into the RCM software, it can neutralize the effect of potential reductions in reimbursements since the value of the claim is at its highest potential. A well-integrated hospital-based physician RCM solution can better track claims values and not allow errors to slip through the cracks. Manual intervention is minimal, claims are processed faster through electronic data exchange, and the healthcare facility can expect a better bottom line.
4. Eligibility Verification:
The manual task of patient eligibility verification is cumbersome. Patients are routinely moving across different insurance coverage providers or to other plans. An automated and advanced RCM solution will swiftly manage the eligibility of patients with minimum manual intervention required. Data transactions can be conducted online to limit the complex processes of phone calls with patients and insurance agencies. Provider solutions for revenue cycle management hold automated checks of authorizations; patient responsibility amounts to optimally analyzing co-payments.
5. Tracking and Modification:
During the coding process, there is always a possibility of errors. Coding error possibilities are much higher when the process is undertaken manually. Incorrect coding rectification takes a long time and can affect overall healthcare management. Therefore, one of the most preferred providers revenue cycle management solutions features is automated coding and tracking. The process of automated coding restricts the possibility of errors. Even if there is a case of incorrect coding, real-time tracking and monitoring of status will highlight the error right away. Prompt modifications can then be undertaken for immediate rectifications.
6. Denial Alerts:
Another essential feature of futuristic RCM solutions is denial alerts. The easiest way to mitigate denials is to opt for an automated feature of predicting denial possibilities on the RCM platform. Through this capability, denied claims are flagged for immediate resolution, and any member of the medical billing team can quickly resolve the matter through re-coding. Through this ability of provider revenue cycle management solutions and healthcare interoperability, worker productivity increases, and a seamless payment processing flow is maintained across the organization.
7. KPIs and Reports:
An analysis of the revenue cycle management system is an analysis of the overall health of the organization. Therefore, periodic reports and Key Performance Indicators (KPIs) can be considerably beneficial when they are readily available for staff meetings and other purposes. A revenue cycle management provider software that can offer these reports in an automated and periodic fashion can boost the financial health of the practice to a large extent. Other factors, such as population health management, can also be included in these reports for additional gain. Weekly reports and KPIs can consist of relevant documentation, an analysis of timely completion of billing-related jobs, insurance protocols, and financial reports.
Provider revenue cycle management solutions have evolved to a large extent to accommodate the dynamics of healthcare organizational financial needs. Provider solutions in revenue cycle management can now streamline the entire lifecycle of financial, medical processes and provide accuracy like never before. Multiple technological advancements are deployed to track claims, collect payments, and resolve denials. Consequently, these solutions contribute significantly to generating a continual flow of revenue. As hospitals and other healthcare facilities actively incorporate provider solutions for revenue cycle management, it would be prudent for every health facility to analyze its particular demands. A customized solution is generally the best fit.
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Riken's work motto is to help healthcare providers use technological advancements to make healthcare easily accessible to all stakeholders, from providers to patients. Under his leadership and guidance, OSP Labs has successfully developed over 600 customized software solutions for 200+ healthcare clients across continents.