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This session will give an understanding of
why messaging is used in healthcare and the
goals that are achieved
This session will cover:
What is Revenue Cycle Management (RCM)
Revenue Cycle Management Process Flow
Basic Questions Revenue cycle management (RCM) is the process that manages claims processing, payment and revenue
Revenue Cycle Management is the all-inclusive process of creating, submitting, analyzing, and paying for
In order to efficiently manage the revenue cycle, we need a medical billing software or practice management
software that allows you to effectively keep track of the claims process.
The entire healthcare revenue cycle process includes everything from determining patient eligibility, collecting
their co-pay, coding claims correctly, tracking claims, collecting payments and following up on denied claims.
Revenue Cycle Management
Basic Questions The revenue cycle starts when the patient calls your office for an appointment and your staff captures the
patient's name, phone number, and their insurance eligibility and coverage information
The cycle ends when the balance on their account is zero
Pre-visit eligibility verification is a best practice that every physician office should strive to accomplish
If eligibility verification is not done correctly it results in denial of a claim
Critical Steps in RCM process:
Accurate patient registration and billing information is a critical first step.
Getting the charge posted with the CPT service code and ICD-9 diagnosis code on a timely basis is the next step
in the revenue cycle process.
Scheduling: The revenue cycle starts with appointment scheduling of the patient with physician. The key objectives for scheduling
To verify/Enter the patient’s demographic information and source of payment
To accurately and efficiently schedule the requested service from a written order
To provide excellent physician and patient satisfaction with the process.
• Eligibility & Benefit Verification: Obtain insurance authorization
• Authorization & Referrals : Obtain referral information
Coding & Clinical Documentation:
Responsible for coding or verifying the correct codes for the diagnoses, services, and procedures
Better documentation give physicians a way to catch up on a particular patient's case history as quickly as possible, making them
ready for the appointment immediately
Charge Capture: In this portion of the revenue cycle, the charge capture can be viewed from the angles of ensuring that all encounters
are captured and all the services, procedures provided are captured and charges are entered for the procedures/services rendered.
• Encounter Forms: A document or record used to collect data about given elements of a patient visit that can become part of patient
record each time the patient visits.
• Claims form submission (837): The claim is submitted by the provider to payer in the form of EDI format
• Claim Scrubbing & Adjudication: The claim is checked for errors in codes (CPT, ICD) and verifying that it is compatible with the payer
• Clearing house or direct claim submission: Clearing house function as intermediaries who forward claims information from healthcare
providers to insurance payers.
• Payment Automation (835) : It gives the complete explanation of the claim
• Denial Management: It encompasses of any aspect of the revenue cycle that may result in no or low reimbursement. The reasons for
the denials can include incomplete or inaccurate insurance information, lack of pre-certification or prior authorization, not capturing all
of the tests or procedures etc.
• Remittance Management : AR follow up
• Medicare Claim Management : COB, AR follow up
Accounts Receivable follow up:
• Appeals: For denials
• Patient Statement (EOB) : Related to policy exclusions, Capping
• Real Time Reporting
• Historical Reporting
• Data Analysis
Nitor offers end to end RCM development capabilities to ISVs in North America.