Revenue Cycle Management
Review and Analysis & Appeals
Denial Management
If a claim is denied or underpaid, the reasons are reviewed, and steps are taken to address the issues. If necessary, an appeal is filed with the insurance company to correct the errors or provide additional documentation to support the claim.
Verification of Information & Consent Forms
Patient Check-In and Documentation
When the patient arrives, their information is verified again to ensure accuracy. The patient signs consent forms for treatment and financial responsibility.
Insurance Payment & Patient Billing
Payment Posting
After the insurance company processes the claim, they make payments to the healthcare provider, which are then posted to the patient’s account. If there is any remaining balance after insurance payments, the patient is billed for the outstanding amount.
Demographic Information Collection & Insurance Verification
Patient Registration
The process begins when a patient schedules an appointment. During this stage, the patient’s personal and insurance information is collected. The patient's insurance details are verified to ensure coverage and determine the co-payments, deductibles, and any other patient responsibilities.
Patient Follow-up & Collections
Patient Collections
If a patient has an outstanding balance, follow-up procedures are implemented, including reminders and statements. In cases where patients do not pay their balances, the account may be sent to collections.
Financial Reports & Performance Improvement
Reporting and Analytics
Regular reports are generated to track the financial health of the practice, including metrics like the time it takes to receive payment, denial rates, and overall revenue. Based on the analytics, practices can make informed decisions to improve their RCM process, reduce claim denials, and increase revenue.
Pre-authorization & Eligibility Check
Insurance Eligibility Verification
For certain services, pre-authorization from the insurance provider is required. This step helps avoid claim denials later. This ensures that the patient’s insurance plan is active and covers the services to be provided.
Claim Creation & Electronic Submission
Claim Submission
The billing department creates a claim based on the coded information and submits it to the insurance provider. Most claims are submitted electronically through an EHR (Electronic Health Record) or billing system.
Documentation of Services & Coding
Charge Capture
During the patient’s visit, healthcare providers document the services rendered. Medical coders translate the documented services into standardized codes (e.g., ICD-10, CPT) necessary for billing. Accurate coding is crucial for proper reimbursement.