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David Dyer
Vice President
RCM Group Services
& Business Development

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As in all businesses, there are many challenges to effectively delivering services; Revenue Cycle Management services are no different. Revenue Cycle Management (RCM) includes everything from verifying patient eligibility and up-front payment collection to coding, claims processing and tracking, and payment posting. There are no secrets to revenue cycle strategy, only basic principles that, when properly followed either by your billing staff or your RCM services provider, will enable you to get better medical revenue cycle results. This will be the first in a multi-part series which will examine these principles.

1. Collect Patient Balances the Same Day of Service

All specialties are unique, and each requires its own tailoring, yet the fact remains that the best receivables strategy is not to have any. Collecting co-pays, patient balances, upfront payment plans, etc., at the time of service (or at least as much as possible), minimizes what many practices have difficulty collecting afterward. Collect up front. Most businesses do.

2. Verify Patient Insurance Eligibility

Even some of the most advanced practices are not using this function. Because we are a provider of services based on collections, much of which comes from insurance companies, it is important for us that we have our clients verify patient eligibility whenever possible. This can be done either before their scheduled visit or at check-in. Follow up efforts (and costly staff resources) greatly increase when a patient’s insurance eligibility is not verified at the time of service.

3. Implement a Triple Clean Claims Scrubbing

Just like quality control on a factory assembly line, it is more productive to build your claims properly the first time. The most effective claims scrubbing involves multiple review processes, often as follows:

i. The first scrub is performed manually by charge entry staff with comprehensive coding knowledge. The team looks at the claim to make sure proper codes are being used, the proper procedures have been ordered, and that the proper modifiers have been included, if necessary. This should be done prior to electronically submitting claims to the clearinghouse.

ii. The second scrub is performed by your Enterprise Practice Management (EPM) software. The strongest EPM software solutions can check your claims against the similar practices in the healthcare community for potential errors before the claims are electronically submitted to the clearinghouse. As more and more edits are accumulated, clean claim rates should continue to improve. Any errors from this scrub should then be manually reviewed.

iii. The third scrub is performed at the clearinghouse level where claims can be cleaned up post-submission but before reaching their final destination with the payer. As with the second scrub, any errors should be manually reviewed.

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Implementation of these revenue cycle management principles should be followed up by inspection to ensure that they are being done properly. The investment in time taken to make sure these processes are properly in place are well worth it.

Check back soon when we pick this back up with a look at proper claims denial management processes.

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