Whether you are a healthcare provider or a patient, RCM is a must process to understand as it can hugely impact your financial decisions. You might already know what RCM is so let’s break it into easy terminologies to enlighten you. 

RCM stands for revenue cycle management. As the name indicates, it is a management cycle that keeps hospital billing and financial tasks in rhythm. That means, the process by following which healthcare facilities streamline their revenue generation, is known as RCM.

As it is a cycle, RCM is completed in 10 steps. Let’s have a look at what these steps are and which activity is performed in each stage:

Patient Registration:

The process begins with the patient’s scheduling. At first, the patient books an appointment either physically or online. At this time, some information related to insurance and the patient’s balance is collected.

Verification:

RCM process proceeds with verification. In this stage, hospital staff make sure the patient has relevant insurance coverage. They contact the insurance organization and confirm the patient’s profile.

Pre-Authorization:

After confirming basic details, hospital staff ask the insurance company to permit specific medical treatments and equipment.

Care Delivery:

When a patient shows up, the medical service is given and at this time, all patient’s services and equipment used are documented to bill.

Coding:

Then a crucial stage arrives. In this stage of RCM, medical treatments are mentioned in the bill in the form of a code. There are certain codes allocated to specific medical services so that it becomes easy for insurance companies to identify what services they have to pay for. These codes are known as CPT Codes. So what exactly are CPT codes? We will learn this in the next section for now let’s stick only to RCM.

Claim Submission:

It is a process when medical bills are submitted to the insurance company for reimbursement.

Claim Approval:

Here the company approves or rejects the claim. In the case of rejection, healthcare staff works to eliminate the objection and resubmit the claim for payment.

Payment:

If the claim application is accepted payment is made to the hospital.

Patient bill:

This is the very last stage where after getting the reimbursement from the insurance company, the hospital sends a medical bill to the patients that they have to pay by a certain deadline.

This was the process of RCM in simple steps. Now that you know what revenue cycle management in healthcare is, let’s look at some stats that will further elaborate on the importance of understanding this procedure for patients and hospitals alike.

• Hospitals organizations on average lose 10% of revenue due to a poor management system. This shows how much is important for them to learn this procedure and implement it correctly.
• The average number of days that the hospital gets its payment from the insurance company is 45 days which is a lengthy period spent on the bill but with the help of RCM, they can streamline their revenue cycle management process and get the payment within a week.
• The average rate of claim denial is 20% for the hospital, which is indeed a great loss for them but when they implement RCM with proper monitoring of claims approved and rejected they get to know their weak point which helps them enhance claim submission in the future and get more revenue.
• On average a patient faces medical bill errors once every 2 years which means they could lose their financial wealth but with the help of RCM, the chances of errors are reduced as the process is streamlined and monitoring is done at every stage. This fact is valuable for both patients and hospitals which shows that a patient is satisfied more if their medical bill is managed efficiently by the hospital.

To learn deep inside about RCM, have a look at our essential guide.

Billing may be the most crucial part of revenue generation for both healthcare facilities and patients.

When we talk about healthcare providers, billing is the means for them to receive the sum in return for their services. During treatment, all the medical procedures and supplies used are billed so that the expenses they spend get some return to balance financial resources.

For a patient, the medical bill might be a headache because they owe the charges. However, it is crucial for them to study the bill properly to identify any inaccuracies. Here are some terms that a patient is required to know before paying the bills:

Explanation of Benefits (EOB): An explanation of the charges for each medical billing procedure that are covered, rejected, or applied to your deductible.

Co-pay: A fixed amount you pay at the time of the visit for covered services (such as a doctor’s visit or prescription).

Deductible: The amount you must fork out yourself before your insurance begins to reimburse costs for covered procedures.

Coinsurance: The portion of the cost of covered treatments you pay for after reaching your deductible.

Out-of-Pocket Maximum/Limit: The most you’ll have to spend throughout a plan year for covered services.

In-Network Provider: A healthcare provider or institution that has a discounted rate arrangement with your insurance carrier

Out-of-Network Provider: A healthcare provider or facility with whom your insurance company does not have an agreement. Out-of-network care is generally more expensive.

Itemized Bill: Detailed costs for each service, treatment, or product you got.

Provider Network: Your insurance company has contracts with a group of doctors, hospitals, and other healthcare providers to provide treatment.

Pre-authorization/Pre-certification: Before getting some medical services, you must obtain approval from your insurance company to confirm that they are medically essential and under your coverage.

Allowed Amount: The most your insurance company will pay for a certain covered procedure.

Ancillary Services: Additional treatment-related services, such as lab testing, X-rays, or anesthesia.

Denial: When an insurance company refuses to pay for a medical service or treatment.

Appeal: If your claim is refused, you can request that your insurance company reconsider and perhaps amend their decision.

Balance Due: The amount you must pay after your insurance company has processed your claim.

Electronic Health Record (EHR): Your healthcare provider keeps digital records of your health information, including diagnosis, treatments, and prescriptions.

In today’s world of complexities, you must be prepared for some inaccuracies that come along with healthcare which include wrong charges, duplicate billing, rejected claims, and much more. But knowing some strategies and plans to deal with the situation is your weapon. Stay tuned to our posts and benefit from our guidelines on how to deal with specific billing situations the right way.

Also, if you belong to a healthcare facility, our resources will help you implement the latest billing techniques to ensure maximum and timely bill collection.

Explore our articles to be aware about entire medical billing.

Coding holds great importance in the process of the revenue cycle. In coding, all the patient treatments that have been listed are converted into specific codes. These codes then serve as a base of claim preparation which is then sent to the insurance payer. Insurers are the ones who decide whether you will be reimbursed or not and this decision totally depends on your claims. So eventually, medical coding is directly equal to revenue collection.

This procedure includes the entire coding system which is based on multiple code categories. Here is what type of codes a coding specialist deals with on a daily basis:

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)

Diagnoses and the reasons for medical treatments are coded by this system. Insurers, healthcare providers, and other parties use ICD for billing and statistical purposes.

CPT (Current Procedural Terminology)

CPT codes are used by healthcare providers to document their performance of medical, surgical, and diagnostic procedures.

HCPCS (Healthcare Common Procedure Coding System)

There are two levels in this system. The CPT serves as the foundation for Level I codes, which are mostly utilized by doctors and other medical professionals. Whereas, non-physician services like prosthetics, durable medical equipment, and ambulance services are mainly represented by Level II codes.

DRG (Diagnosis Related Group)

These codes are used for inpatient hospital stays. In order to facilitate billing and reimbursement, they group patients according to comparable clinical conditions and available treatments.

Medical Necessity Codes

The medical necessity of performing procedures or services is supported by these codes.

Modifiers

These are two-digit codes that are added to CPT or HCPCS codes to give more details about the procedure or service that was given.

Place of Service Codes

These codes designate the precise place where a service was rendered, such as an ambulatory surgical center, doctor’s office, or hospital outpatient department.

Revenue Codes

In healthcare facilities, these codes help identify particular accommodations, ancillary services, and billing schemes.

Anesthesia Codes

The administration of anesthesia during surgical or medical procedures is reported using these codes

Laboratory and Pathology Codes

Reports on laboratory procedures, tests, and services are made using these codes.

Durable Medical Equipment (DME) Codes

Equipment and supplies that are frequently used, suitable for use at home, and have a lifespan of more than three years are represented by these codes.

Home Health and Hospice Codes

Services rendered in a home health or hospice environment are reported using these codes.

Evaluation and Management (E/M) Codes

These codes indicate healthcare providers’ services for patient assessment, diagnosis, and management.

Medical coders need to know medical terminology, anatomy, and physiology as well as coding guidelines and regulations to conduct accurate coding. In this complicated changing landscape it is almost impossible to keep up with the industry updates. However, our website ensures you are well aware of any coding modifications, code updates, and trends. So follow our latest posts and enhance your knowledge in the field of medical coding.

As there are various medical treatment-related things mentioned in the bill there are certain codes as well that define a medical procedure in technical terms. As we said earlier, these are the crucial parts of a medical bill, let’s see in detail what are these cpt codes and how it makes up a medical bill.

CPT stands for current procedural terminology. This is a system under which certain codes (combination of numbers) are associated with some medical services and each time a medical treatment is written in the bill, the code is mentioned to help insurance companies understand the services a patient took. On the basis of these codes, insurance payers interpret the reimbursement that has to be paid and make the payment to the hospital.

So this was the easiest definition of CPT codes. Now let’s look at what exactly it looks like:

CPT code 99214: This code is used to report a new patient’s first office visit. This code’s sequence number is always 1.
CPT code 99215: This code is used to record a regular patient office visit. Depending on the complexity of the visit, the sequence number for this code might be 1, 2, or 3.
CPT code 99204: This code is used to indicate a follow-up office visit for a previously established patient. Depending on the intricacy of the visit, the sequence number for this code might be 4, 5, 6, or 7.
CPT code 99213: This code is used to document a follow-up office visit for a previously established patient. Depending on the intricacy of the visit, the sequence number for this code might be 8, 9, or 10.
CPT code 99285: This mark denotes a thorough evaluation and management service. This code’s sequence number is always 1.

These are only a handful of the codes that may be used to describe medical therapy. The particular codes used will vary according to the type of treatment offered, the intricacy of the treatment, and the patient’s condition.

In addition to CPT codes, other codes such as HCPCS codes and ICD-10 codes can be used to define a medical therapy. HCPCS numbers define particular medical items and services, whereas ICD-10 codes classify diseases and injuries.

The order in which codes are used in a bill is significant since it helps to guarantee that the bill is appropriately processed. The first code in a bill should always be the most significant code, with succeeding codes used to convey more detail about the service delivered.

For example, if a patient visits the doctor for a new disease, the bill may look like this:

CPT code 99214 (initial office visit for a new patient)
ICD-10 code G93.3 (migraine without aura)

If the patient then has a follow-up office visit for the same condition, the bill might look like this:

CPT code 99213 (follow-up office visit for an established patient)
ICD-10 code G93.3 (migraine without aura)

Medical coding involves many other coding aspects as well, have a look to learn more.

You now have pretty much knowledge about RCM, what steps are included in it, what a medical bill looks like, and more. One aspect we haven’t touched yet and that is denial management.

Whenever a healthcare facility sends a bill to the insurance organizations, they make sure it is accurate. They identify every code in detail and see if there is any mistake. If luck is on your side, your bill will be accepted and you will get your payment right away. But if it is your bad day, your bill won’t be accepted, the reason could be anything. So what’s next?

In denial management, your hospital staff is responsible to clear the doubts of the insurance payer. If there are coding issues, they will resolve them, if there are patient verification issues, they will re-check the information and when they have reviewed the bill, they will submit that to the insurance payer where it is re-checked and if it satisfies the payer, your payment is made. So what are the main causes of claim denials or in other words what mistakes led to claim denials? Let’s see

Inaccurate Information: Incorrect information about the patient, their medical history, or treatment may result in claim denial. To guarantee accuracy, double-check all of the information you enter.

Missing Documentation: If you fail to provide certain papers, such as medical records or invoices, your claim may be denied. Keep track of any necessary documentation and include it with your claim.

Out-of-Network Services: Your claim may be refused if you obtain medical treatment from a healthcare practitioner who is not in your insurance network. Before seeking treatment, always confirm that the practitioner is covered by your insurance.

Lack of Pre-Approval: Some treatments or procedures necessitate prior permission from your insurance provider. Failure to get this approval before receiving treatment may result in claim denial.

Filing Deadline: Insurance claims must often be filed within a defined deadline. If you miss this date, your claim may be refused. Make certain to submit your claim on time.

Coordination of Benefits: If you have numerous insurance plans, you must decide which one will be the principal payer. Incorrect benefit coordination can lead to misunderstanding and claim denial.

Non-Covered Services: Insurance does not cover all medical procedures. If you obtain therapy that is not covered by your insurance, your claim will most likely be refused.

Policy Lapses: Your claim will be denied if your insurance coverage has lapsed or expired at the time of your treatment. Before obtaining medical attention, be sure your coverage is active.

Incomplete Claims: Filling out your claim form incorrectly or missing out key information might result in denial. Take your time filling out the form correctly and providing all required information.

Duplicate Claims: Submitting the same claim by mistake many times might lead to misunderstanding and denial. To avoid repeated entries, keep track of your contributions.

Most of the time insurance payers determine what was the issue with the rejected claim application, and 90% of mistakes will be from the above-mentioned issues. Try to resolve these problems and not only resolve but make sure to avoid these issues in future claim applications.

So here ends the process of RCM and claims reimbursement collection. But from here starts the role of a patient as they have to pay the bill, which marks the completion of the revenue cycle. So what does the hospital do in this case?

They conduct a process of bill collection which is called AR recovery. In this process, hospital staff collaborate with the patient, know about their financial conditions, offer some help or installments if applicable, and make sure to send regular reminders to make the process more efficient.

From the patient’s point of view, if you can’t pay the bill due to some financial issues you are offered many options. One of them is that your bill is divided into small installments and given a certain deadline under which you have to pay the installments. You can also negotiate the bill amount but of course only in certain situations. Also, many financial aid programs are offered to you by using which you can get funds and pay your bill without spending a dime of your own, but certain conditions may apply.

But the last option we are sure you wouldn’t want to go for is debt collection. In this process, a collection agency is hired to collect bills on behalf of the hospital. The main problem is that this process might become a little aggressive if you don’t pay the bill. Collection agencies will contact you as they will have your essential information like contact number and even personal address.

Sometimes they threaten you too, but in that case, you must know your rights in this condition. We have a detailed guide on your rights if you are stuck in such a situation. So make sure to check out that post.

As you might also be thinking that this is better to not go for the last option, so make sure to pay your bills on time and contact the healthcare facility if there is any problem regarding the bills.

The last but essential aspect of RCM also includes credentialing. It is a process that only needs to be known for hospitals, as it involves the verification of the hospital staff and equipment used quality. Without this step, your hospital won’t be able to show its credibility to the patients as you won’t have any certificate to prove your quality standards.

Credentialing involves either contacting an agency or performing through internal staff. In both cases, the responsible staff first receives the request of the suppliers interested in dealing with you. Their request is accepted, they make a visit, where some information is collected and then they are given access to your supply department if they fulfill the criteria. Of course, the process also involves some crucial and complex minor steps, but we are keeping it simple to thoroughly explain what credentialing is.

In credentialing, not only supplies are verified but also monitored continuously if they provide quality supplies and always checked to make sure there isn’t any problem with that as hospital supplies have a direct impact on the patient’s health.

To know more about credentialing, have a look at our essential piece of information.

With all that being said, we hope our words are enough to make you understand the essentials of RCM and other related areas. You might also know how important it is to keep yourself updated with these terms as health should be your main concern in today’s world where new diseases keep appearing and threatening human lives. We hope with the help of your guide you can now make an informed decision about your health and hospital bills and live a contented life.

To keep learning about all these terms we mentioned above, follow our articles. We always come up with accurate and updated information so that you never have to waste your time researching wrong information on the internet. Explore our site and make yourself informed about medical billing and coding like never before.