In the intricate world of healthcare, where the primary focus rightly rests on patient care and outcomes, the significance of revenue cycle management (RCM) can sometimes fade into the background. Yet, understanding and efficiently managing the overall revenue cycle management function is crucial not just for the financial well being of healthcare practices, but also for sustaining their ability to provide quality care.
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The Balancing Act: Patient Care and Financial Vigilance
Often in medical environments, the spotlight is on patient experience and care delivery. While these are undeniably central to a healthcare provider’s mission, the importance of solid financial performance cannot be overstated. A thriving practice is a balanced one, where outstanding patient care and robust financial health go hand in hand.
The truth is, a weak RCM process can strain a practice’s resources, leading to challenges in maintaining the quality of patient care. For clinics, urgent care centers, emergency departments, or hospitals, a robust RCM process isn’t just a financial need—it’s the cornerstone of their long-term success and sustainability.
The Anatomy of a Healthy Revenue Cycle Management Function
A healthy RCM function is akin to a well-oiled machine, encompassing several critical stages of the patient journey. From registration and clinical documentation to medical coding, billing, and payment processing, each phase needs careful attention and optimization.
The first step in the revenue cycle is where accuracy and completeness of patient information are crucial. Incorrect or incomplete data at this stage can lead to claim denials and delays later on.
Comprehensive and accurate documentation is foundational. Each stakeholder, from the physician to supporting nursing staff must properly document care delivered. This best practice not only helps to support quality patient care objectives but also helps to ensure that services delivered are properly coded for, along with related evaluation and management levels, so that proper reimbursement can occur.
Expert medical coding is critical to each healthcare operation. Expert medical coding facilitates proper reimbursement goals while also ensuring the practice follows all appropriate compliance mandates. Having an in-house team or an outsourced medical coding function that can keep the healthcare operator abreast of the latest guidelines from CMS and other payers is vital to ensuring accurate billing, compliance and helping to minimize denials.
Billing and Claim Generation
Finally, ensuring that claims are created correctly and properly dispositioned through a modern claims clearinghouse is important. This last leg of the process requires precision, proper technology infrastructure and a staff that is well versed on the overall process.
A healthy RCM function is also an innovative one. Over the last many years modern RCM companies have increased the ways in which patients can pay for their care. New payment mechanisms such as text to pay, payment plans and web based models have helped to offer more diversity and help healthcare operators collect more of the rising patient responsibility for care.
Focusing on Process and Proficiency in RCM
QueueLogix believes that improving the RCM and maintain a high performing function can be distilled down into two main pillars: process optimization and aptitude.
Every great business or organization has taken the time to document and outline each and every process that is important to them. Processes don’t need to be complicated, or sophisticated, but they do need to be documented and well understood by everyone within the organization. Today’s modern healthcare organizations have many stakeholders. These same organizations have numerous contributing technical systems such as EMRs, laboratory systems, imaging, scheduling, registration, practice management and the list goes on. Between the many stakeholders and the numerous technological systems, if a healthcare operator does not have a well defined process around RCM then it will suffer. The impact of this can be seen in reduced reimbursement, cash flow impacts, and compliance concerns. QueueLogix believes each organization should work with a qualified RCM entity or internally to make sure their processes are well defined and functioning.
This happens when organizations either don’t bill for the care they delivered or they don’t bill correctly. Both are bad and cost real dollars to an organization.
Cash Flow Impacts
Some organizations will develop delays in their medical coding and claim creation process. This disrupts cash flow and can create scenarios where an organization is not able to collect any money for the care they deliver (i.e. timely filing issues)
Following relevant CMS, and payer guidelines, are more important today than ever before. Increased scrutiny by government entities means each healthcare operator must ensure both their clinical documentation and the way in which they arrived at their medical coding and billing outcomes can be fully accounted for.
The second pillar for peak RCM performance for a healthcare operator is ensuring a high performing team is in place with a talent and natural desire to deliver the best results they can. This team can be internal or outsourced. The team should be knowledgeable and also assisted through best-in-class technology. Working with a team that is talented and has the education, knowledge and capability to deliver best in class RCM results can supercharge a healthcare operation and their overall financial performance.
Unlocking Overlooked Areas in RCM
Several areas in RCM often go unnoticed but can significantly impact its overall performance. For instance, patient registration, if managed meticulously, sets a positive tone for the entire cycle. Likewise, ensuring thorough clinical documentation not only aids in patient care but also fortifies the coding and billing process. And in coding, staying abreast of changing guidelines can be the difference between swift reimbursements and tangled denials.
Other areas of the revenue cycle that are often overlooked but can make significant differences in the financial performance of a healthcare operator include:
Proper Configuration of Charge Master
Make sure what you and your healthcare operation are charging is representative and customary. Many times organizations will not have changed their charge master in many years, or it will be improperly configured, leading to issues in reimbursement.
Suspended Chart Review
If an organization is taking extra effort to be compliant they may naturally be suspending charts for a variety of reasons such as missing signatures from clinicians or unclear notes. The risk in having suspended charts is that these charts can quickly become cash flow disruptors to organizations. A high functioning RCM entity will have a good communication pathway to ensure suspended charts are quickly identified and rectified so they can be processed and billed.
In conclusion, the efficacy of a healthcare provider’s revenue cycle is as vital as the health of the patients they care for. By focusing on optimizing processes and ensuring capability and aptitude is present, healthcare providers can establish a robust RCM function. This not only guarantees financial stability but also reinforces their commitment to providing exemplary patient care.