Revenue Cycle Management - RCM is a comprehensive approach that evaluates, improves, and manages all components in obtaining
patient encounter information and applying it to ensure patient safety, while creating a simplified, integrated workflow designed to optimize and
expedite reimbursement.
Revenue Cycle Management (RCM) Key Components:
- Patient Registration
- Eligibility Verification
- Authentication Check
- Claim Generation
- Claim Submission
- Medical Coding
- Charge Entry and cash posting
- A/R Denial Management
- A/R Collections and follow-up
- Medical Billing
- Charge Capture & coding
- Patient Follow-up
- Third Party payment compliance
Patient Registration
Appointment and Scheduling. The system be able to enter patient demographics information and register a patient, followed by appointment scheduling in the healthcare facility.
Note: This feature is available in our system, patient demographics are collected both at creating an appointment for a patient and while creating a new patient.
Eligibility Verification
The system be able to do an Insurance eligibility check or verification which also covers an Authentication check.
Authentication Check
Claim Generation
System be able to generate claim for a particular patient for the services provided.
Claim Submission
System be able to accept professional and institutional claims in any format. The claims should cross the extensive system of edits and be able to track claims to eliminate loss of claims by reporting when claims are received, delivered and accepted by the payers. The documents or forms will be examined for billing errors and the generation of EOBs (Explanation of Benefits). The claims are submitted and filed with the insurance company and the amount receivables and follow-up process is conducted.
Note: Claim Generation and submission are both present as system features. Claims are generated for different file formats and forms e.g. Form 1500 (Professional), Ub04 (Institutional). Edits feature is also available.
Medical Coding
Medical coding is to experience an increase in returns and a reduction in the number of denials as comply with the ICD-9-CM Official Guidelines for Coding and Reporting, AMA Guidelines from CPT-4 Code Manual, & CMS (HCFA) Guidelines [CCI (Correct Coding Initiatives)] and [LMRP(Local Medical Review Policies)].
Note: This feature is available with our system. Medical coding i.e. adding CPT and ICD codes or service lines for claims.
Medical Billing
Medical Billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The level of service, once determined by qualified staff is translated into a standardized five digit procedure code drawn from the Current Procedural Terminology database. The verbal diagnosis is translated into a numerical code as well, drawn from a similar standardized ICD-9-CM database. These two codes, a CPT and an ICD-9-CM, are equally important for claims processing.
Note: In our system the procedure and diagnostic codes are determined and are sent by formatting the claims as a ANSI 837 file and using Electronic Data Interchange to submit the claim file directly to as payer through a clearing house.
Charge Entry and Cash Posting
System be able to process charges for multiple specialties and be able to work according to regulations related to Medicare, Medicaid, Managed Care, Third Party Liability, Workers Compensation, Preferred Provider Organizations and Indemnity Insurers.
Cash posting includes comprehensive financial services offering superior payment convenience and flexibility. This includes the collection of co-payments, co-insurance, and deductibles while enabling the
scheduling of automatic payments from a patients credit card*.
Note: Cash posting is handled by our system by collection of co-payment, balance amount, primary and secondary insurance and payment statements.
A/R Denial Management
Denial management Process tracks every claim that has denied and can report this by payer, by CPT, by physician and by diagnosis. This information is presented in a manner that allows fast identification of trends. With this powerful combination in hand, the Practice / Provider of medical service can then utilizes claim rules and edits that are specific enough to dramatically drive up the first pass claim acceptance and stop the flood of denied claims.
Note: Our system allows running Edits on claims. However, the habitual violators of Clean Claim Rules need to be identified and pursued. The data and analysis will allow many opportunities for process improvements and revenue enhancement for the practice.
A/R Collection and Claim Follow-up
- 14% of all claims submitted to the payers are denied and have to be resubmitted, appealed or written off by providers.
- 50% of denied claims are never re-filed.
- 50-70% of denied claims have higher chance of being recovered.
Note: Claim follow-up includes sending and re-sending of claims. Our system supports re-sending claims but not on priority basis but on first come first serve basis.
The submission and re-submission of claims will be on priority basis
- High Dollar high age - These claims would be processed on priority as the claims need to be followed up before we exceed the filing limit.
- High Dollar low age - Next focus would be on high dollar claims with low age as the chances of collection are higher.
- Low Dollar low age - These claims have higher probability of collection. However, need many more resources to follow-up.
- Low Dollar high age - These claims are given last priority as these claims have less chances of collection and need high number of resources to follow-up.
Charge Capture & Coding
Charge capture and coding is same as Medical coding and medical billing. In charge capture the physician can record procedure and diagnosis codes on their mobile devices and transfer information.
Patient Follow-Up
Third Party Payment Compliance
This follows if a payment gateway is integrated in our system. The system has to be complying with norms according to the PCI-DSS (Payment Card industry Data Security Standards). These standards are created to help payment card industry organizations that process card payments prevent credit card fraud through increased controls around data and its exposure to compromise. The standard applies to all organizations that hold, process, or exchange cardholder information from any card branded with the logo of one of the card brands.