Healthcare Revenue Cycle Management: A Walkthrough

Healthcare revenue cycle management (RCM) is the financial process that healthcare systems use to manage the administrative and clinical functions associated with statements processing, payment, and revenue generation. The process revolves around the identification, management, and collection of patient service revenue.

Like any other business, healthcare organizations have to analyze their bottom line while keeping up with progressive technology transformations, stringent regulatory requirements, countless insurance options, and an ever-demanding consumer base. The front-end of an ideal system typically covers scheduling, registration, financial clearance, and patient collection. In addition to this, the consumer will benefit from pricing and compliance features. The functions in the middle revolve around Health Information Management, charge and clinical documentation integrity, medical coding, case management, utilization review, and other functions. And finally, the back-end functions consist of the billing engine, including claims processing, contract management, denial management, payment posting and accounts receivable follow-up, as well as reporting and benchmarking.

With that in mind, here is a walkthrough of the healthcare revenue cycle management:

1.     RCM Software or Outsource Processing

Deciding how to handle data processing depends on how big or small the medical organization is. If the business is fairly limited in scope and has a good IT team in place, the choice can be to install RCM software on in-house servers. However, if the organization is on a larger scale, the best approach might be to outsource the RCM process to third-party experts.

2.     Patient Pre-Authorization

The next step in RCM is the pre-authorization of each patient. Pre-authorization is defined by the U.S. government as a decision by a health insurer or plan that a prescription medication, procedure, service or equipment is medically necessary.

3.     Eligibility and Benefits Verification

Manually checking for eligibility and benefits for patients can be a grueling and time-consuming process that saps employee morale. Dedicated advanced RCM software can speed up the work involved in verifying if a patient is entitled to a particular benefit.

4.     Claims Submission

Accelerating the flow of revenue into an organization will be easier when tighter control over claims is realized and tools are in place to weed out common errors.

5.     Payment Posting

RCM software can help in this respect not only in the ease it offers for generating billing statements. Healthcare practices can even use the system to send electronic messages to patients. Billing over networks like this is done via Electronic Data Interchange (EDI).

6.     Denial Management

Including this process in the RCM cycle can help recover overlooked revenue due to insurance being filed incorrectly. Correctly executed denial management will boost earnings if money has lately been slow because of problematic claims.

7.     Reporting

The RCM software can be used to generate customized reports including financial data, management information and key performance indicators to recognize if the team is meeting benchmarks and to get an overview of the state of the practice.

                At Symbiosis, RCM is an integral part of the practice management services we provide. Our service offers front and back-office services, hence, placing users in a perfect position to collect data during the patient-treatment life cycle. Collecting and storing all this data gives our clients the opportunity to accomplish improved operational efficiency and financial outcomes by gaining insight into all patient treatment lifecycle milestones. Symbiosis’ revenue cycle management process focuses on cutting costs, repairing the bottom line and seizing new revenue streams. All data is collected in a HIPAA compliant manner. A report is presented to the client at the end of each month which contains patient flow trends, revenue cycle trends, marketing ROI, bottlenecks in the revenue cycle and suggestions to improve it. Moreover, apart from insight into processes and revenue cycles, we also track the ROI(return on investment) from your marketing efforts. Combined with RCM, this gives you deep insight into what works and what doesn’t and most importantly, what needs to be done to increase revenue. Later on, in the blog, we present sample graphs which will be outputs of the report.

Healthcare organizations can avail our RCM services either while operating at Symbiosis locations or otherwise. Our cloud-based solution allows services on the platform to function independently. With additional integrations being added with every update, users will experience efficiency in process management by being able to avoid repetitive manual work and data entry errors.

In essence, RCM providers address back and front-end challenges through a comprehensive set of capabilities that come together holistically, helping to solve business problems across the entire spectrum of the revenue cycle. These capabilities include a range of solutions, from revenue cycle software to technology-enabled services, strategic outsourcing, advisory services, analytics, and education. This approach leverages capabilities based on individual client needs, first identifying business issues and their root causes, followed by implementation of customized, integrated solutions that include one or more solutions to holistically transform your revenue cycle.

Let’s browse through some sample graphs that will be displayed along with respective dashboards in a typical RCM model.

Revenue Dashboard

Accounts Receivable

This is a sample chart depicting a company’s trend in accounts receivables over 5 months. Through Symbiosis’s RCM system similar charts can be generated in different time periods and variables.

Denials

This is a sample chart depicting a company’s overall denial frequency over 5 months. Through Symbiosis’s RCM system similar charts can be generated in different time periods and variables.

Reason for Delays

This is a sample chart depicting a company’s Denial Charges based on a specific Denial Category over the period of 1 month. Through Symbiosis’s RCM system similar charts can be generated in different time periods and variables.

Performance Dashboard

Patient flow

This is a sample chart depicting the frequency of a company’s patients per week over a period of 8 weeks. Through Symbiosis’s RCM system similar charts can be generated for different time periods and variables.

Cancellations

This is a sample chart depicting the frequency of a company’s cancellations per week over a period of 8 weeks. Through Symbiosis’s RCM system similar charts can be generated for different time periods and variables.

Marketing Dashboard

Marketing Spend

This is a sample chart depicting the marketing expenditure for a client over a period of 5 months. Through Symbiosis’s RCM system similar charts can be generated for different time periods and variables.

Marketing ROI

This is a sample chart depicting the marketing return-on-investment for a client over a period of 5 months. The graph above depicts that Google Adwords has the most impact on Marketing ROI and combined with the earlier presented patient-flow graph, the user can now precisely be able to identify the impact of increased spending in marketing and patient flow. Through Symbiosis’s RCM system similar charts can be generated for different time periods and variables.

Want to start your own healthcare practice? Contact Symbiosis today for a free consultation.