An efficient RCM process in medical billing can enhance medical practice revenues.
The primary job of any medical practice is to provide the best medical care to ensure positive results. However, bogged down by numerous administrative procedures that include insurance verification, charge entry processing, claim submission process etc, it is becoming increasingly difficult to keep a firm focus on what matters the most, restoring the health of the patient.
Enter medical billing specialists at this stage. These are trained professionals who ensure that billing, coding, claims processing happens smoothly in a process called revenue cycle management (RCM). Read on to take a closer look at what is the RCM process in medical billing. To understand the RCM process, we will have to begin by telling you what are the steps in medical billing process. Let’s go step by step to understand the process in detail.
Process involved in Medical billing
1. The patient makes an appointment
The RCM process kicks in at the time that a patient himself or his family seeks an appointment at a medical care facility. Upon receiving the call, an employee from the medical care facility provides a confirmation of the appointment, gets the details and makes a record of the demographics and the insurance information of the patient in the RCM software that is installed inhouse, if the medical care facility is small or is outsourced to a revenue cycle management company if it is a larger organisation or a hospital network in question, this job is outsourced to a RCM company.
2 Insurance Verification Process
Once you confirm the appointment and get the patient information. We should validate the patient insurance information either by checking online and calling the insurance directly. Also get copay, deductible and out of pocket information. Only if the insurance is active we could confirm the patient appointment otherwise call patient and inform them what is wrong and get clarified. In this stage we have to get the pre authorization too if the procedure required.
3. The patient’s arrival
Once the patient arrives for the appointment, he undergoes some pre-checkup and updation of medical records according to his specification and prescription drugs, procedures, services and all information has been recorded. The best practices here is, collect all copay, deductible and previous visit balance billing if any. This would avoid lot of billing process and billing life would be easier. Once these payments are made, they are recorded in the RCM system, under the patient’s account.
Tip: Patient payment information has to be conveyed to patient during the appointment confirmation stage itself.
4. Creation of superbill.
The doctor examines the patient and specify all diagnosis and treatment information into filling out a superbill on the RCM system. This could be either paper super bill or electronic super bill which doctor enter the CPT and DX in the RCM software itself.
5. Review of the superbill and entering the charges
The medical coding or RCM specialist reviews this super bill at this stage, to ensure that the correct ICD codes, CPT codes and modifiers have been used according to patient visit notes (Medical records). In case any changes are required, the doctor is informed and to make the modifications as necessary. Most of the providers only entering description of the services and Diagnosis. Hence choosing right ICD code matching with CPT code is key element here.
6. Claim submission process
After the superbill has been entered by the RCM team, the billing software kicks into action and sends it to the clearing house for a final review. If there are any mistakes in codes at this stage, the clearing house sends the claim back as rejection. Only if the claims have been successfully passed through and reach the insurance with acknowledgment report make the claim submission process complete. If all the codes match correctly and patient is active during that time, the bill is sent on further for processing of claims. If the insurance company finds errors or a lapse at this stage, the claim would be denied at this stage. A good RCM company under the supervision of a qualified medical billing specialist has a 98-99% success rate in the first pass claims acceptance ie clean claims.
7. Payment posting and denial management
Once all the approvals are in place, it is time for the insurance company to make the payments. Post claims acceptance and processing, the practice receives that payment. After the receipt of the payments the RCM team reconciles the payment under the patient’s account. Posting under correct patient and correct DOS is main requirement here. If we choose anything wrong, the system balance would not tallied correctly and that give us indication to choose the right patient and DOS, CPT.
Tip: Choosing the correct denial would reduce the lot of unnecessary work. Educate the team in that manner.
8. AR & RCM process.
This would be most complicated process in RCM process as we don’t have anything to enter or do the quality check-up but need to take the action on non-paying claims. Not all the claim which we submitted to insurance would automatically paid hence we have to run the report of non-paying claims (Aged claims) and do the follow up with insurance is main process here. Unless we call the insurance and ask the status some of the claims will not be paid at all. Hence follow up with insurance is must process.
Tip : The good practice is review of unpaid claim every 15 days. Some action has to be taken on every 15 days in each and every single unpaid claims
Why following medical billing process improve the revenue
Trusting a reputed medical billing service provider who follows the correct process may seem expensive but it is what efficiently streamlines the RCM process for your practice to navigate through the complicated medical billing procedures. These service providers provide end-to end services right from reviewing patient eligibility and payments, recording, coding, reviewing and final submission for a smooth claim processing.
With an efficient RCM partner at your service you never have to worry about unnecessary financial losses due to lapses in the medical billing process. Further, with 24×7 back end support, you can rely on an expert to guide you through and solve technological glitches if any in the system. In this hyperconnected age, if you are a medical care practitioner it makes financial sense for you to invest in either efficient RCM software or outsource the process to a medical billing services provider at the earliest.