Revenue cycle management, or RCM, is one of the most important business functions for many providers. It’s what “keeps the lights on” for small practices and what helps maintain healthy operating margins for large health systems.
Regardless of the number of claims a billing team sends out, though, it’s crucial for revenue cycle management processes to be simple and efficient from start to finish. Understanding how to improve revenue cycle management should be a regular focus, something to continuously work on. Otherwise, providers may be leaving money on the table – not to mention hindering the patient experience or possibly contributing to staff burnout.
The fundamentals of strong revenue cycle management
There are many roles and responsibilities that go into getting a single claim to the right payer and paid in full – let alone submitting multiple claims every day, while also correcting denials, finding additional active coverage, and capturing new patient information. Revenue cycle management is a complex process, but there are several best practices all billing teams use to ensure success.
Eligibility verification is the crucial first step. This is when a provider confirms a patient has patient has active coverage, which means health insurance that the provider can bill rather than seeking full payment from the patient. This is ideal for the provider because patients usually don’t have the means to pay for their bills in full out of pocket, but health plans do.
Claims submission comes next. After the patient has received treatment, the billing team is responsible for submitting a claim to the right payer with all the correct codes to identify the kind of treatment delivered. There are about 10,000 medical billing codes1 to choose from, so billers have their work cut out for them to ensure they’re using the right codes every time.
Finally, if a claim is denied, billers can rework the claim to correct mistakes and refile it for payment. This is referred to as denial management.
However, as straightforward as eligibility verification, claims submission, and denial management may sound, there are many challenges that can come up throughout the process and additional steps providers can take to improve their revenue cycle management success.
How to improve revenue cycle management
The best way to improve revenue cycle management is to break the process down into multiple components, then focus on making each step as efficient as possible. Consider everything from the very first patient interaction to the final payment, and think about staff engagement and billing resources, too.
Simplify patient access
Patient access is the entire new patient process. As mentioned above, eligibility verification is a part of it, but this is not the only step.
Patient access also includes verifying patient demographics such as first and last name, current address, and Social Security Number. Additionally, it’s best for providers to search for any coverage beyond what the patient has provided for verification. It’s common for patients to have secondary or even tertiary coverage that they are either unaware of or have not disclosed. That’s a second and a third potential payer to send claims to!
The best part? This doesn’t have to create more work for front-of-house teams. Managing all the details of patient access is easy with the right software to store patient information, verify demographics and coverage, and get ahead of potential downstream revenue cycle mistakes.
Understand payer rules
Speaking of potential mistakes in the revenue cycle, let’s consider payer rules. Medicare, Medicaid, and commercial payers all have their own rules regarding what codes to use and how to submit claims. And, those rules can change at any moment.
For many billers, keeping up with all the changes to payer rules can feel like a second job, especially for those in large provider organizations who work with multiple payers. For those who are equipped with a claims submission tool that figures out payer rules on their behalf, though, it’s much easier to ensure every claim is being sent to the right payer and adhering to the latest requirements.
Inovalon’s revenue cycle management software does this for you. With our payer relationships, we’re able to update our in-app guidance to align with the latest updates, so users can be confident their claims are created according to each payer’s rules, every time.
Improve payment collections processes
While it’s great to know claims are submitted to payers correctly, patient financial responsibility can still make up a significant amount of reimbursem*nt potential. Patient responsibility may be their co-pay with coverage, or they may not have active coverage to offset their balance. Either way, it’s up to billing teams to capture patient payments.
A great way to improve this part of the revenue cycle is to give patients options on how to pay. At minimum, it’s smart to have credit/debit card payment capabilities available in addition to accepting cash or checks. To increase chances of capturing payment further, consider offering payment plans or touchless payment such as Apple Pay. Some providers even establish patient payment portals so that patients don’t have to be onsite or pick up the phone to pay; they can simply login whenever is convenient for them and pay their balance.
Workflow automation
Another common way to improve revenue cycle management is through workflow automation. This can occur during patient access, claims submission and denial management, payment collection processes, and more.
To automate patient access, implement a coverage discovery tool that can search for all active payers at once and replace the need for individual payer inquiries. During claims submission and denial management, workflow rules such as grouping claims by type of payer or assigning them to a specific biller can turn a digital “pile” of thousands of claims into an organized set of claims for each person to focus on. To support patient payment collections, let technology take care of creating templated patient statements and sending bills by email and standard mail.
There are many opportunities for automation throughout the revenue cycle. The only thing most billing teams have to do is identify where technology can make the biggest positive impact on their RCM workflows.
Staff engagement and training
As valuable as technology is, it can’t fully replace the value of staff members. Every front office and back office person plays a key role in improving RCM processes – and they need to know it. Staff engagement begins with making each person’s value clear, then giving them the tools they need to succeed.
For every newly automated workflow, provide multiple opportunities to train and get familiar with the updated processes. Offer periodic continued training to help reinforce long-standing processes; such engagements are great opportunities for further innovation as well. Additionally, make training the #1 priority for new billers, office administrators, team managers, and any other person involved in the claim lifecycle. The more that a team is engaged and empowered to succeed, the more effective they’ll be.
Focus on the patient experience
Finally, it’s important to remember that even during revenue cycle management, the patient comes first. There are many steps throughout the RCM process that can positively or negatively impact the patient experience.
During patient access, printed forms that take too much time to complete may make a poor first impression. Instead, give new patients the option to provide their information via an online patient portal ahead of their visit. This allows them the flexibility to provide necessary information for treatment on their own time and saves time during their appointment.
Offer payment options when it’s time to collect and consider investing in branded healthcare statements that make it easy for patients to understand what they owe. Stress the value of educating patients on their coverage and payment expectations as well, as this can potentially help offset any potential billing surprises and make them more engaged in taking care of what they owe.
Transforming your revenue cycle from start to finish
Knowing how to improve revenue cycle management is more about identifying what part of the revenue cycle to prioritize than it is about turning your entire RCM workflow on its head.
The basics of RCM will always be the same: verify eligibility and patient demographics, create a claim with the appropriate codes, send the claim to the applicable payer. However, there are plenty of opportunities within those steps to develop simplified, more efficient processes that keep the patient experience at the forefront. Introducing workflow automation, offering additional staff training and resources, and investing in systems that can consolidate various claims and files into one place are all worthwhile options to pursue in the search of better revenue cycle management performance.
Contact us for more information on how Inovalon can help improve your organization’s revenue cycle.
1 “What Are the Different Types of Medical Coding Classifications?”, Medical Billing and Coding, accessed 8/3/2022, https://www.medicalbillingandcoding.org/qnas/what-are-the-different-types-of-medical-coding-classification-systems/
