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Revenue Cycle Management (RCM)

The document provides an overview of the 12 key steps in the revenue cycle management (RCM) process for healthcare organizations. It begins with pre-registration of a patient appointment and ends with collections. The major steps include eligibility and benefits verification, medical coding, charge entry and billing, claim transmission, claims processing, payment/denial posting, account receivables tracking, and collections if needed. RCM aims to streamline the process for healthcare providers to receive payment for services rendered.

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senthil kumar
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9K views

Revenue Cycle Management (RCM)

The document provides an overview of the 12 key steps in the revenue cycle management (RCM) process for healthcare organizations. It begins with pre-registration of a patient appointment and ends with collections. The major steps include eligibility and benefits verification, medical coding, charge entry and billing, claim transmission, claims processing, payment/denial posting, account receivables tracking, and collections if needed. RCM aims to streamline the process for healthcare providers to receive payment for services rendered.

Uploaded by

senthil kumar
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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REVENUE CYCLE MANAGEMENT

(RCM)
WHAT IS RCM?

In simple terms, RCM refers to the steps that healthcare


organizations must take to receive payment for services rendered.
Historically viewed as a straightforward back-office function, RCM now
touches every aspect of a practice.
STEPS IN RCM

• STEP 1: Pre-Registration • STEP 8: Clearing House


• STEP 2: Encounter • STEP 9: Insurance Processing
• STEP 3: Medical Transcription • STEP 10: Payment/Denial Posting
• STEP 4: Medical Coding • STEP 11: Account Receivables
• STEP 5: Charge Posting • STEP 12: Collections.
• STEP 6: Claim Form
• STEP 7: Claims Transmission
PRE REGISTRATION
Revenue Cycle Management (RCM) starts with the patient’s appointment. A patient can get
a doctor’s appointment on call, online or by visiting the provider office/hospital. This
appointment can be for the same date or future dates as well. Once a patient sets an
appointment, necessary information like patient demographics, insurance information and
reason for visit, etc are taken.

ELIGIBILITY AND BENEFITS VERIFICATION


After the patient’s appointment, patient eligibility and benefits are checked with patient
insurance to verify that the services that patient will get are covered or not by insurance.
Other things like patient co-pay, coinsurance, deductible, prior authorization (if required) are
also obtained at this time.
ENCOUNTER
After eligibility and benefits verification, the patient gets the services from the doctor at
the scheduled time. The services that are given to the patient are recorded on superbill,
EMR or in the form of voice, etc.

MEDICAL TRANSCRIPTION
Medical transcriptionists convert recorded services into the medical records. These
medical records are very important because it is used to support the services that are
performed by the healthcare provider. Insurance companies may also request medical
records to check the medical necessity of the services.
MEDICAL CODING
Medical coders review the complete medical records and convert them into codes. This part
is very important because to get the payment provider has to send the claim form to
insurance that follows specific rules and criteria. On the claim form, patient diagnosis and
services provided are mentioned in the form of codes.

It has 3 Types:
Diagnosis Code which follows the ICD (International Classification of Diseases)
coding system

Procedure Code which follows the CPT (Current Procedural Terminology) and
HCPCS (Healthcare Common Procedure Coding System) is used.

Modifiers are added to the Procedure codes to provide additional information


necessary for processing a claim, such as identifying why a doctor or other qualified
healthcare professional provided a specific service and procedure.
Charge Entry & Billing
Once all the essential information for filling out the claim is gathered, it’s time to enter this
data on the claim form or in the billing software. The claim form can be filled by hand or via
using the billing software. There are a lot of billing software available in the market with
different functionalities.

Claim Form
There are two types of Claim Forms to bill the Insurance. They are

1. CMS 1500 which is used for Physicians Purpose

2. UB -04 Form which is used for Hospital Purpose


CMS 1500 Form
UB-04 FORM
CLEARING HOUSE
The clearinghouse checks all the claims and sends it to correct insurance with the
help of the electronic payer ID. Every insurance has a unique electronic payer ID that is
registered with the clearinghouse.

The claims that have wrong or incomplete information on the claim form are rejected
by the clearinghouse. A claim can get rejected due to multiple reasons. Medical billing
specialists review and fix the claim rejection and resubmit claim to the insurance.
CLAIMS PROCESSING
Once the claim received the Insurance Company from clearing house, the claim was
sent to processing the claim will either got paid or got denied due to incorrect
information. When the claims get processed, the insurance send the processed details
as EOB(Explanation of Benefits) or ERA(Electronic Remittance Advice).
CLAIM TRANSMISSION
After the charge entry, it’s time to send the claim form to the insurance company to get
paid for the services rendered by the healthcare providers.

Claims can be submitted to insurance in three ways.


1.Paper Claim Submission
2.Electronic Claim Submission
3.Online Claim entry on a secure insurance portal.

Paper claims are submitted through regular or certified mails. The provider or
providers office fills out the paper claim form and then submit it to the insurance mailing
address.

For electronic claim submission, clearinghouses are used. In electronic claim


submission, billing software generates an EDI (electronic data interchange) file that is
uploaded on the clearinghouse.

The claims can also be submitted through secure insurance portals. Not all
insurances provide this service but most of the insurance does.
PAYMENT/DENIAL POSTING
Once the EOB/ERA Received from the Insurance, the details in the EOB/ERA was
entered in the billing software by the Posting Team. The Posting Team enters bot the
Payment and Denial Information along with details.

ACCOUNT RECEIVABLES(AR)
Account Receivables are need to Constantly keep track of both electronic and
paper claims. Always be watchful for any major rejections or denials from clearing
houses/Carriers. Constantly watch out for payments and EOBs from major Carriers,
pay-to-Address, Provider Numbers etc. Ensure the AR days meet Industry Standards.

Account Receivables also do Appeals and Refunds while verifying the processed
claims.
COLLECTIONS
Medical collection services is the process in which bad debts and overdue medical bills
are recovered from present or former patients, the similar processes serve private health
professionals and medical institutions.

Initially, Provider send the statement to patient to pay the outstanding


amount/Debt. After 3 patient statements, if they don't receive any response from Patient
then it was move to Collection Team.
THANK YOU

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