Although revenue cycle management is a difficult procedure, it is crucial to the successful operation of your medical business. To guarantee that a claim is error-free, attention to detail is required at every level. When this occurs, a claim only has to go through the process once, which greatly speeds up the time it takes for claims to be paid, but a mistake might result in an irregular flow of payments. Working with specialists is essential for this reason.
The Medical Billing process is no different from other businesses in that it requires strict adherence to particular procedures in order to operate efficiently and continue expanding.
If the ten steps listed below are properly carried out, they may improve income generating.
Patient registration is generally only done for brand-new patients, during which we collect details such the patient’s age, sex, address, and phone number. Additionally, insurance-related details such policy IDs, insurance company names, etc.; nonetheless, we strongly advocate a fast check each time a patient comes into the clinic. As the information is recorded on the insurance claim and any inaccuracy might result in a denial or rejection, which would further delay the payment, it allows for the maintenance of correct data and keeps the system up to date with the information.
Insurance Verification: Before any services are rendered, it is important to confirm with the insurance company that the policy is in effect, that the requested services are covered, and that any authorization requirements have been met. This information is crucial in determining whether the patient will be responsible for payment through insurance or out of pocket. The information is often available on insurance websites, but information obtained over the phone may be used to challenge claims in the event that they are denied.
Encounter: Term for a patient and provider encounter during which the patient describes the issue and the provider assesses the patient’s condition in order to reach a diagnosis that will aid in the patient’s recovery. It is a session that has been recorded using either audio or video technologies. Claims may be completely prepared if the information is well-documented and the session is well-recorded.
Professionals that specialize in medical transcription listen to the session that was recorded and enter information into a medical script that will later be utilized to complete and maintain the patient’s medical records. This procedure must be error-free since the updated papers are then utilized in follow-up visits, the provider consults them while providing treatment, and any inaccurate information might risk the patient’s medical history and lead to poor decision-making. Not only that, but the document is also utilized for invoicing reasons, thus any errors there will also affect the claim.
Medical coding: In accordance with the American Medical Association’s guidelines, a team of experts reads the document created from the recording and converts pertinent information, such as where the service was provided, the reason for the visit, the steps the provider took to treat the current condition, etc. into numeric or alphanumeric-codes. It is necessary because, firstly, they are simple to comprehend and, secondly, it is a legal necessity.
Charge Entry: As one of the phases in preparing the claim form that must be presented to the insurance company, the cost of providing the service or the maximum amount that can be collected is added to the charges coded by the coding team. Without the stated value, one cannot be paid for it. Professionals keep an eye on the system to ensure that the right value is added since a mistake might result in the claim’s payout being lowered.
Reported Transmission: The claim is now prepared to be submitted for reimbursement after being successfully created by adding patient information, provider information, services given, etc. We can now send data electronically thanks to technology. When claims are filed by EDI (Electronic Data Transfer), they must pass three stages in order to be approved by the insurance company. The processes are as follows:
A. Scrubbing: Depending on the setup, EHR Software will check to make sure all the fields on the claim form are filled in and will look for specific coding-related errors.
B. Clearing House: A third-party vendor in charge of EDI conducts checks on the patient information, including the policy’s active date, the claimant’s name and DOB, and any potential coding problems.
C. Insurance Rejection: Before approving a claim for adjudication, insurance runs a brief check, much like clearing houses, to make sure the patient information is accurate, the policy is current, and there aren’t any obvious coding errors.
Any errors or mistakes discovered at any of these levels result in claims being returned with a rejection message. These levels may be cleared by claim with the aid of any checks and adjustments depending on the information provided.
Denial Management: Only claims received within the allotted time period will be processed by insurance. After the claim has been approved, they put it through a procedure called adjudication. After running it through a number of checks, they determine whether to pay the claim or reject it; sometimes, they pay part of the claim while rejecting the remaining costs. A professional processing of rejections prioritizes the claim with time remaining for insurance filing and remaining recoverable amount to ensure optimum revenue generation. They track rejections to identify patterns in denial and take remedial action to guarantee that future claims won’t be rejected.
Account Receivables: These experts deal with insurance claims that are rejected and still not paid, even though appropriate steps have been done to make the claim pay. They put a lot of effort into persistent follow-up with insurance providers, gathering data about the rejection, looking into it, and collaborating to keep payments coming in. For upcoming claims, they provide accurate information to groups like Coding, Insurance Verification, and Charge Posting. They are in charge of processing and keeping track of any contact with insurance.
Payment Posting: When the insurance company decides to pay a claim, they release the funds in the form of a paper check or an electronic fund transfer, which is typically done in bulk. They also share a summary known as an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) along with the payment (ERA). It is the responsibility of the professionals processing the payment to record the transactions in the EHR and total the money received.
All of these services—as well as others—are offered to healthcare professionals nationally by P3Care at very low pricing. The ten most important tasks in the healthcare revenue cycle are summarized in the list above. The majority of the tasks that follow this process, such as patient statements, financial reporting, and payment reconciliation, are derivatives. Only a successful completion of these key tasks, along with accurate data entry and persistent follow-up with payers, can guarantee the best financial performance for any medical practice.