At the heart of every hospital and doctor’s office is a process called revenue cycle management, and it can make or break the success of an office or organization. Revenue cycle management is, simply put, the general procedure of claims processing, payment and revenue generation. It is a cycle that begins with the patient and ends with the healthcare provider; when done correctly and efficiently, healthcare professionals profit and continue to provide their services. Even though the cycle begins with patients, it is still up to healthcare providers to guide the process along smoothly.
In the beginning, a patient makes an appointment to receive medical services, and this is when healthcare staff must step in and guide the patient through the proper steps toward full and successful payment. This typically involves patient scheduling, insurance verification and the creation of a patient account. By verifying insurance accurately, the front desk team at a physician’s office has an important role in the front end of the revenue cycle. The patient account ensures a full and accurate report of services rendered and payments received, so no lapses occur. With these preliminary steps taken care of, the groundwork for future successful treatments and transactions has been established. Proper training and management of the front desk team is an important function of a practice.
For the best and proper medical revenue cycle management, it is up to staff to maintain excellent service by processing patient claims as best as they can. The insurance verification and patient account creation has filled in the gaps in information, and now the patient is able to be scheduled at the practice. Once scheduled, the patient visits the office and provides a copy of their insurance card as well as their co-pay (if applicable) at check in.
The providers and staff need to select the diagnosis of the patient and the services received at the practice. Services include well visits, sick visits, vaccines, vaccine administration and procedures. After the proper services are included on the visit, the billing team needs to review the charges and appropriately submit to the insurance company.
When working with insurance companies, claims are inevitable–and so medical billers must understand each claim code and use the absolutely correct claim codes to optimize the revenue for the practice. The revenue cycle also requires follow-up by the account manager for the account to insure optimal payment from the payer/insurance company as well as from the patient. Managing this on a consistent basis usually achieves optimal results.
The biggest challenge facing healthcare professionals related to revenue cycle management is optimal payment for their services. Not all revenue cycle teams perform the same and this is why pediatric practices should benchmark their medical billing performance once per year to identify how their total revenue cycle management team performs versus benchmarks and understand where are the areas of opportunity. The benchmarking should be total potential revenue which includes both the insurance and patient payments. Ideally, a practice should have a business review one time per year to see summary level performance, review benchmarks and discuss areas to enhance practice revenue.