The medical organization or medical office must ensure that all providers have the required medical licenses and other credentials that allow them to practice medicine and provide the services. RCM services use automated tools that can help with this.
The medical organization must ensure the provider has the appropriate contracts with insurance companies.
The medical organization collects important patient information before providing any service. That information includes name, medical history and information about patient insurance coverage.
In this step, the medical provider schedules the medical appointment with the patient.
After scheduling, the medical organization needs to confirm that the patient is eligible for insurance benefits and the particulars of those benefits.
An insurance company will not approve payment for some medical services without prior approval from the insurance company. Medical organizations must understand when they need prior authorization and communicate with the insurance company to provide the required information to get that authorization.
The medical organization determines and records the appropriate medical code – a series of numbers and letters — corresponding to every type of medical service. Medical codes exist for the medical procedure and the patient’s illness or injury. Codes for the medical procedure are called Current Procedural Terminology, or CPT, codes. Codes for the patient’s illness or injury are called International Classification of Diseases, or ICD, codes. The accuracy of these codes is vital for insurance payment.
The medical organization, or its RCM service provider, records the medical codes for the service, along with detailed charges for each service and relevant insurance information. Many organizations have a charge review process to ensure accuracy.
The medical organization or its RCM service submits all needed information about the medical service to the insurance company or other payer. This will include patient details, medical codes and other relevant information.
This step deals with denials or partial denials of claims from payers. The medical organization, sometimes with help from its RCM service or RCM staff, analyzes the denials to understand the payer’s reasons for the denial. That may include incorrect information the patient or medical organization provided or a need for more information about the patient or service. The organization will then gather that additional information or determine corrections to make.
After understanding the reasons for any denial, the medical organization should provide the payer with additional or corrected information that supports the claim. It submits the additional information to the payer in the manner the payer requests. The organization must monitor all denials and quickly respond with the appropriate information.
After the medical organization receives the appropriate payment from the insurance company or other payer, the patient may owe a balance for the service. The organization will then send a bill to the patient for that amount.Healthcare providers can use AnodynePay for convenience of sending E-statements to their patients, and practices can even keep a record of all the statements in the practice portal.
Collecting what patients owe on a medical bill can be more challenging and complicated. Medical organizations must closely track what patients owe, send reminders and provide easy ways to pay so the organization can collect the funds as quickly as possible.
When the medical organization gets payments from either the payer or the patient, it must immediately record those payments and monitor whether the payer or the patient owes additional money. Organizations can use special software to make much of this payment posting automatic.
Medical organizations will want to use RCM software to understand key metrics and key performance indicators, or KPIs, surrounding their billing and payments. Or the RCM service they hire will provide that information. Those metrics help the organization understand any inefficiencies in its revenue cycle. This allows the organization to achieve “revenue integrity.” That means a medical organization is most efficiently and effectively delivering good care while getting paid fully for all its services.
The metrics will also help the organization understand whether it is collecting money owed to it as quickly and efficiently as possible. Experts know that many operations within the U.S. health system are not efficient
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