Healthcare Revenue Cycle: A Complete Guide

Navigating the complex world of healthcare finance can be daunting, but understanding the intricacies of the healthcare revenue cycle is crucial for the success of any medical organization. 

In this complete guide, we'll delve into the essential components of the healthcare revenue cycle, offering valuable insights and best practices to help you streamline your financial management process, maximize reimbursements, and boost the quality of care provided to your patients.

What is the Healthcare Revenue Cycle?

Revenue Cycle Management (RCM) in healthcare is a critical financial process that enables healthcare systems in the United States to effectively track and manage patient revenue. It starts their initial appointment or encounter to the final balance payment. 

The revenue cycle begins with the patient's appointment or hospital visit and concludes when the provider or hospital receives full compensation for the services rendered.

This comprehensive process comprises seven crucial steps: preregistration, registration, charge capture, claim submission, remittance processing, insurance follow-up, and patient collections. In this article, we will thoroughly examine each of these steps to ensure smooth and efficient RCM in your healthcare organization.

The Revenue Cycle

The revenue cycle consists of seven stems, starting with billable charges and ending with a service review. Let's take a look at each step.

Step 1: Preregistration

Preregistration is the initial and most crucial step in the healthcare revenue cycle process, setting the foundation for a smooth and efficient financial journey. During this phase, medical practices gather essential patient information, such as demographics, insurance details, and eligibility, often in real-time through a clearinghouse while the patient is on the phone. 

This information is then relayed to the patient's insurance carrier and integrated into the provider's practice management system, allowing the provider to determine the patient's coverage, deductible, co-insurance, copayment, and referral requirements, if applicable.

Moreover, preregistration enables practices to establish clear financial expectations with patients, discussing payment timelines and no-show/cancellation policies upfront. 

Step 2: Registration

Registration is a critical step in the healthcare revenue cycle process, as it ensures complete patient information accuracy from beginning to end. During this stage, providers verify essential details such as the patient's address, phone number, date of birth, guarantors, and insurance information, reconfirming these details each time the patient receives treatment.

In addition to collecting copayments, providers—especially specialists—must also confirm that any necessary referrals or authorizations are in place before treating the patient. Failing to do so may result in non-payment for the services rendered. Throughout the registration process, patients sign financial forms and assign insurance benefits, safeguarding the practice against potential financial risks in case of an audit.

Step 3: Charge Capture

Charge capture involves recording billable services provided during a patient's visit. This can be accomplished through automation, where information flows directly into the practice management billing system based on the provider's documentation, or manually, where front desk staff input information or forward it to the billing department for entry.

Both approaches have their pros and cons, with the potential for missed charges in either scenario. For instance, ancillary services are often overlooked, resulting in unclaimed revenue. To mitigate such issues, it is essential to code charges and submit them to the insurance carrier accurately.

Related: Electronic Health Records: Pros and Cons For Healthcare Providers

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Step 4: Claim Submission

Claim submission, a crucial step in the revenue cycle process, involves sending claims with pertinent information, such as charges, CPT codes, and diagnosis codes, to the insurance carrier after the charges have been recorded. The revenue cycle team carefully reviews the information to ensure that the diagnosis supports the procedure performed and that multiple services are correctly separated and coded.

An essential aspect of claim submission is claim scrubbing, which ensures that claims are clean and accurate before being submitted to the insurance carrier. Clean claims result in faster payments and improved efficiency. The process entails sending claims from your practice management system to a clearinghouse, which acts as an intermediary, receiving claims and forwarding them to various payers.

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Step 5: Remittance Processing

Remittance processing, the fifth step in the revenue cycle, involves receiving and managing payments from insurance carriers. After submitting claims, practices receive remittances through an explanation of benefits, which detail the fees for the provided services. 

During this stage, allowable are established – the amounts that providers have negotiated with insurance carriers for specific services.

A common pitfall during remittance processing is the "post and go" approach, where electronic posting becomes the standard practice without further review. It can lead to issues when carriers fail to make payments or errors occur within the practice management system, which may go unnoticed. If no one monitors the process or examines the reports, practices might miss opportunities to appeal and rectify mistakes.

To avoid such scenarios, it's crucial to have a robust system in place for reviewing remittance processing and ensuring accurate payments. By regularly monitoring and analyzing the process, healthcare organizations can maximize their revenue potential and maintain financial stability.

Step 6: Insurance Follow-Up

Insurance follow-up is a vital step in the revenue cycle process, ensuring timely and accurate payments from insurance carriers. It involves monitoring the status of submitted claims, identifying any delays or discrepancies, and addressing outstanding issues to facilitate prompt reimbursement. 

Proactive communication with insurance carriers is essential during this phase to resolve any claim denials, underpayments, or requests for additional information.

Regular follow-ups expedite the payment process and help identify recurring issues or trends that may negatively impact the practice's revenue. By diligently tracking and addressing these concerns, healthcare organizations can optimize their revenue cycle performance and maintain financial stability.

Implementing a systematic insurance follow-up process, which includes setting clear timelines for follow-up actions and assigning dedicated personnel to manage these tasks, is crucial to ensuring a seamless and efficient revenue cycle. 

Step 7: Patient Collections

Patient collections, often considered the most challenging aspect of the revenue cycle process, play a crucial role in maintaining a healthcare organization's financial stability. The optimal time for collecting patient payments is during their office visit. As such, it's highly recommended that front desk staff receive training on collecting payments during service, ensuring efficiency, and minimizing potential delays.

To prevent an accumulation of uncollected payments, it is essential to establish a standardized policy for collecting copayments and deductibles, which sets clear financial expectations for both the practice and the patient. By implementing and adhering to this policy, healthcare organizations can streamline the patient collections process, reducing the likelihood of payment disputes or backlogs. 

Related: Where To Practice: The Top High-Paying States For Doctors

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How Can Daily Care Resolutions Help You Manage Your Healthcare Revenue Cycle?

Daily Care Solutions, founded and spearheaded by Dr. Lanre Shittu, is pivotal in managing healthcare revenue cycles by addressing a gap in the Locum Tenens market. Dr. Shittu established a group that prioritizes the needs of the clinical workforce, initially focusing on hospitalist care before expanding to include a diverse range of specialties.

With a solid commitment to delivering consistent, high-quality service to hospital partners, Daily Care Solutions significantly contributes to optimizing healthcare revenue cycles.

By offering contracted hospital services, Daily Care Solutions provides hospitals with experienced practitioners, flexible staffing solutions, and quality assurance to cater to their patient's needs. 

This comprehensive approach ensures seamless operations and enhances the overall efficiency of revenue cycle management, ultimately contributing to healthcare organizations' financial stability and success. By partnering with Daily Care Solutions, hospitals can effectively navigate the complexities of revenue cycle management while maintaining a steadfast focus on patient care and satisfaction.

Related: Healthcare Consulting: Benefits for Patients And Providers

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