Revenue Cycle Management

Revenue cycle management is one of the most important aspects of the Physician Practice Manager’s (PPM) job.
The cycle begins with the scheduling of an appointment and is followed up with obtaining accurate information regarding the patient’s demographics. Verification of any insurance benefits would be performed at this time to make sure all services are covered. Health care providers record all documentation related to the visit, which the coder and biller review for accuracy. This data is transformed into codes which get transmitted to the various payers for reimbursement. Payments are posted when checks and explanation of benefits (EOBs) are received. Denials are acted on immediately due to time constraints imposed upon by payers and denials also point out trends that may generate from the provider, biller, coder or insurance carrier. Management of denials is critical in a healthy medical practice. At the end of the month, and accounts receivable report is printed and the PPM reviews the ageing of the transmitted claims and calls on any claims that are over thirty days old.

In summary:

• Patient calls for an appointment and is greeted by a pleasant and efficient staff member
• Patient demographics are obtained and information is verified prior to appointment
• After the provider documents the visit, all charges are captured and sent to payers for reimbursement
• Payments are posted when explanation of benefits are received and all claim denials are acted on immediately due to time constraints imposed on by the individual insurance carrier
• Denial trends are monitored and reported
• At month end, an aged accounts receivable report is reviewed and unpaid claims are followed up on to see why there is a delay in payment

Different Revenue Cycle Management

Most problems with reimbursement are due to inaccurate information collected when an appointment is scheduled. Poor revenue, particularly in a busy group practice, can be due to inadequate collections at the front desk during the patient’s visit. There are enough technological issues that can impact a practice’s cash flow so poor patient information should never be the reason for non-payment of a claim – yet more often than not- it is the exact reason a claim is denied.

Medical providers must be detailed in their documentation in every aspect of the patient encounter. With ICD-10-CM soon approaching, specificity and laterality are even more important for a provider to document. Depending on the type specialty, referrals and prior authorizations should be familiar within each individual practice.

A clean, completed claim form contains accurate patient demographics and insurance id numbers and group numbers. Place of service where the visit took place should be on the claim and specific diagnosis and procedure codes should reflect the visit with added modifiers if required. The name of the provider should be on the claim and linked to the group name, if applicable. The pay-to address should also be reflected on the claim form.

There are many edit processes and reports that take place with an electronic claim transmission. There is first a scrubber report which kicks out any errors that will not allow a claim to go to the clearinghouse if there are errors. These corrections can be done immediately and re-transmitted. Once the clearinghouse receives the claim, it goes through an additional edit and will kick out any problems before being sent to the insurance carrier. Often times it may be a missing digit on a diagnosis code or invalid procedure code. Once these errors are corrected, the claim is forwarded to the insurance carrier.

The reports from the insurance carrier are the most crucial. Practice managers must focus on any payer denials as these represent an electronic explanation of benefits (eob) denial and no paper eob will be sent to the practice. Due to time constraints in filing, payer reports are crucial to review.

When studying denial trends, it is important to communicate with all parties involved in the billing issues at hand. Clearinghouses and practice management software typically track where the most problems occur.

Running a monthly accounts receivable report will show the PPM which claims have not been paid within 30 days. Again, due to time constraints in filing and appealing claims, this is not an area to be overlooked. Never, ever, have a claim sitting in A/R over 45 days without a paper trail explaining “why” the claim is sitting there.

In the PPM course, there are numerous ways to utilize the A/R depending on what you are looking for. You can calculate how many days they are in A/R, denials by payer groups, bad debt management, when and how to use a collection agency. Monitoring productivity reports are a valuable tool in managing revenue cycle management as well. The report is broken down by provider which provides basic information to base decisions on.

Learn how to study payer mixes and types of reimbursement. All this information is key when managing monies coming into the office based on services provided by various health care clinicians. Visit http:www. and learn more about the benefits of being a certified physician practice manager. The program offers tools to help the PPM understand the various reporting methods to be a successful practice.

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