Revenue Cycle Management Reforming The Traditional Approach
8th, Mar 2023
A siloed approach to Revenue Cycle Management (RCM) may not be the best bet when it comes to improving a healthcare organization’s incoming cash-flow. Instead, a system that binds all the independent functions together is more lucrative.
While the primary mission of every healthcare facility is to safeguard patient well-being, robust fiscal health is also very essential for sustenance and growth. A handful of functions within the medical and clerical areas form the cogs of the revenue system. Each of these functions, work in silos to achieve a common goal – to ascertain the highest possible rate of return for the organization. The three most important pieces of the revenue machinery are:
1. Patient Connect
The first touchpoint for a patient is perhaps most vital for any setup. A well-established front-office can help avoid patient dissatisfaction, scheduling hiccups, no-shows and claims denials to a certain degree. During a patient’s first visit, it is critical to capture specific information accurately so that it can all be tied together later to form the basis of the related claims. Such information includes:
- Demographics: Social Security Number, Identity proof, Address and Date of Birth
- Insurance: Policy details and carrier information
Based on the information collected, co-payments and deductibles can be taken care of right at the beginning. It is also possible to include applicable discounts and settle any prior unresolved charges. An efficient ‘Patient-Connect’ system can, therefore, help curb a great deal of unnecessary effort later during the claims adjudication process.
2. Medical Services
As the treatment process commences, the second crucial piece of the revenue cycle kicks in. During this phase, it is essential to collate:
- Medical Documentation – This includes symptoms observed, the diagnosis made, the course of action for treatment, drugs prescribed, and finally the outcome of it all.
- Codes for services rendered – Precise medical documentation leads to appropriate coding per the ICD 10, CPT, and HCPCS protocols.
All the information collected and processed as part of the treatment process feeds into the final claims settlement process. As a result, the degree of the meticulousness of this process can make or break the success of the overall outcome.
3. Claims Settlement
After the patient goes home, the final leg of the revenue cycle begins. The claims adjudication phase is where the data gathered in the previous two stages comes in handy. The broad aspects of claims settlement are:
- Claims Submission to ascertain timely presentation of claims to the parties involved.
- Contract Management to ensure adherence to contractual agreements as part of the payment process
- Denial Management to resolve denied claims by following the appeals process.
- Payment Posting and Adjustment to avoid extra penalties due to posting delays and to check the veracity of the amounts billed to patients and insurance companies.
- Collections Follow-Up for unsettled amounts either with the insurance companies or the patient.
- Analyzing Denied Claims to understand the reasons behind denial to prevent these in future.
As is evident, all the three fragments of the revenue cycle puzzle are significant and need to be addressed with great care. Even though these functions act independently, it is clear how profoundly the output of one affects the others. Wouldn’t it, therefore, be more efficient to re-engineer this model so that all the functions work seamlessly together instead?
Mirra Healthcare (TPA) can help you achieve this revised, uber-efficient approach by offering a complete set of services that work holistically, in tandem to iron out all the creases in your revenue management system. Outsourcing your revenue cycle processes entirely to Mirra helps you focus on patient health while trained professionals handle every nuance of your facility’s financial health. This way, both facets can be given the time and focus needed to guarantee success.
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"In 2021, Ultimate Health Plans (UHP) partnered with Mirra Health Care (Mirra) to develop a software platform to support processing Claims, Customer Service, Eligibility, Enrollment, Premium Billing, Encounter Processing and a Provider Portal for our Medicare Advantage Plans. Mirra collaborated well with our operations and compliance teams to successfully design and implement a system that was innovative, efficient, and compliant with all Medicare and Florida Medicaid guidelines and requirements all within the scope of our required timeline. We greatly benefitted from the Mirra Project Management Team’s regular communication with Stakeholders through monthly meetings and recurring weekly breakout-focused calls, which were geared towards troubleshooting and goal alignment. Mirra was able to quickly maneuver and adapt their systems to our needs, resulting in successful implementation and go-live. Mirra continues to support our compliant operation and growth in the ever-changing healthcare industry rapidly and effectively updating their systems with new Medicare and Florida Medicaid rates and guidelines to ensure seamless compliance and efficiency. I have absolutely no reservation in recommending their systems to any Payer searching for improvement in their operational efficiency."
NANCY GAREAUCEO of Ultimate Health Plans