Billing and Revenue Cycle Management (RCM) Solutions

Medical billing and revenue cycle management are the lifelines of any practice. According to, ‘Medical billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider or medical billing company (interaction between a health care provider and the insurance company (payer).’

However, revenue cycle management is a deeper subject. As per, ‘Revenue cycle management (RCM) is the process that manages claims processing, payment, and revenue generation. It entails using technology to keep track of the claims process at every point of its life, so the healthcare provider or medical billing company doing the medical billing can follow the process and address any issues, allowing for a steady stream of revenue. The process includes keeping track of claims in the system, making sure payments are collected and addressing denied claims. RCM encompasses everything from determining patient insurance eligibility and collecting co-pays to properly coding claims using CPT and ICD-10 codes. Time management and efficiency play large elements in RCM, and a physician’s or hospital’s choice of an EMR can be largely centered on how their RCM is implemented.’

The processes involved in the billing and revenue cycle management process begins with patient visit, followed by patient registration, eligibility and benefits check, data entry and patient demographics, referral and authorization, coding and billing, charge entry, capture and posting, claim submission, clearing house denials, payment posting, denial management, secondary filing, accounts receivable, appeal procedure, patient billing and patient/payer follow-up and finally payments. Other factors that affect the revenue cycle management can be categorized into internal and external factors. Internal factors include provider capacity/productivity, patient volume, and fees for the services rendered. External factors include insurance claims from private and government payers, payments from patients (copays, deductibles, self-pay) and other collections.

The current healthcare system with late payments from patients, or lesser reimbursements from payers, or the constantly changing codes, guidelines and regulations tend to create bottlenecks which could have otherwise been a smooth process. However, there are three factors which can be enhanced to create a strong and healthy revenue cycle.

Workflow: Critical to communication, time, and appropriate coding, the front and back office billing functions must be interconnected leading to enhanced revenues.

Team: An experienced billing team is probably one of the drivers to success. Their knowledge in latest codes and rules heavily impacts the billing process as they apply their principles and experiences to

create benchmarks for practices and engineer payer regulations creating an upward increase in cash flows.

Technology: The revenue cycle can be optimized with the use of latest software and systems. Healthcare providers usually purchase and install revenue cycle management systems to store, manage and bill patients for services rendered by physicians. Medical billing software or a practice management software are usually used for effectively tracking claims processes and revenue generation. An efficient RCM system interacts with other hospital systems such as electronic health record systems and billing systems thereby reducing the time taken for providing, billing and receiving payments for the services. These systems tend to reduce paperwork and lengthy tasks, earlier handled by the front desk and administration. Patients are sent automatic reminders, insurance is verified electronically, and the use of credit cards ensures safe and timely payments. The patient visit is recorded in electronic medical records and can be used at the time of billing (concrete documentation), charge capture is appropriate making the task of coding (diagnosis and procedure codes) easier for billers to verify. Claims can be submitted electronically, first to the clearinghouse for a check, and then to the insurance agencies. Claims can be tracked and the payment posting expedites the billing process. Regular alerts are sent to patients from the system reminding them of check-ups and balance. For payers too, alerts are sent for payments or for specific inquiries if claims are denied. The denied claims can also be reduced as patients are given the options of online payments. Some healthcare organizations tend to buy analytics software to set and review their revenue goals. Reports can be generated through these systems to review the trends, mistakes and the areas of improvement.

With revenue cycle and workflow processes in place, increasing payments and reducing bad debts is imperative to the financial success of the healthcare center. Integration of the aforementioned assets can define a safe and healthy billing path and clear the way for optimization of revenues.