This document discusses managing the revenue cycle in a healthcare practice. It explains that revenue cycle management involves determining patient insurance eligibility, coding claims properly, and streamlining billing and collections. The "old way" of managing the revenue cycle is described as inefficient, with no insurance verification, nothing collected upfront, and relying on insurance to cover payments. The "new way" outlines specific responsibilities for the front desk, insurance coordinator, coding and billing staff to improve the process through insurance verification, patient communication, accurate coding and claims submission, payment posting, and active accounts receivable follow-up and denial management. The document emphasizes that managing the revenue cycle effectively requires involvement and standard procedures from all areas of the practice.

1. Managing the Revenue Cycle
Tips & Tools
Rozmin Bapat, CCS-P, CPC, CPMA

2. Revenue Cycle Management (RCM)
• Revenue cycle management (RCM) is the process of managing claims,
payment and revenue generation. RCM encompasses everything from
determining patient insurance eligibility and collecting co-pays to
properly coding claims. A well-designed RCM system is able to
communicate with the EHR and accounting systems to streamline the
billing and collection cycles.

3. Managing the Revenue Cycle
• The Old Way
See
Patient
File
Insurance
Claim
Post
Payment
Bill
Patient
Collect
Payment

4. Managing the Revenue Cycle
• What’s wrong with the old way?
• No Insurance verification
• Nothing collected upfront
• Depending on insurance to cover the payment
• Hassle of billing and making collection efforts from patients
BOTTOM LINE
TIME AND MONEY LOST FOR THE PRACTICE!!!

5. Managing the Revenue Cycle
• The New Way
Obtain
complete
demographic
and insurance
information
from patient
Insurance
Verification
Patient
Demographic
Entry
Coding
Claims
Submission
Payment
Posting
A/R Follow-up
& Denial
Management

6. 1 of 7
Obtain
complete
demographic
and insurance
information
from patient
• Who is responsible?
• Front Desk
• Information must be collected
at the time of making the
appointment
• Before the patient arrives in
the office

7. 2 of 7
Insurance
Verification
• Who is responsible?
• Insurance Coordinator
• Determine eligibility
• Verify benefits
• Copay, coinsurance and deductibles met
• Referrals

8. 2 of 7
Insurance
Verification
• Who is responsible?
• Insurance Coordinator
• How much is the patient portion?
• Ask about authorizations for certain
procedures.
• Have a standardized verification form.

9. 3 of 7
Patient
Demographic
Entry
• Who is responsible?
• Front Desk
• Enter accurate demographics
• Current insurance
• Current address and phone number
• Scan in and update all changes

10. 3 of 7
Patient
Communication
• Who is responsible?
• Insurance Coordinator
• Communicate to the patient what they
owe upfront
• Have the allowables from patient’s
insurance available
• Collect, Collect, Collect

11. • Patient is the second largest payer in most offices
• 20% – 35% of revenue is patient’s responsibility
• Huge deal for practice’s bottom line
• Difference between a thriving and a sinking practice

12. 4 of 7
Coding
• Who is responsible?
• Coding Staff
• Know coding guidelines
• Know payer guidelines
• Accurate coding
• Sending clean claims

13. 4 of 7
ICD-10
Coding
• Who is responsible?
• Coding Staff
• Dual coding before implementation date
• Learn on the job
• Measure productivity
• Always train and educate staff

14. 5 of 7
Claims
Submission
• Who is responsible?
• Billing Staff
• Visual scanning
• Scrubbing
• Setting up system to prompt incorrect entries
• Explosion codes
• Modifiers

15. 6 of 7
Payment
Posting
• Who is responsible?
• Coding and/or billing staff
• Electronic Remittance (ERAs)
• Electronic Funds Transfer (EFT)
• Post from paper EOBs
• Send secondary & tertiary claims
• Automate

16. 7 of 7
A/R Follow-up &
Denial
Management
• Who is responsible?
• Billing Staff
• Working Denials
• Clearinghouse
• Catch errors before payer denials
• EOB denials
• Fix easy errors right away

17. 7 of 7
A/R Follow-up &
Denial
Management
• Choose one day a week to work denials
• Register on insurance websites for faster claim
status updates.
• Use your clearinghouse, Availity, Navinet for
multiple insurances
• Call insurance companies and document all
conversations in the claim window

18. 7 of 7
A/R Follow-up &
Denial
Management
• Look at unpaid claims every two weeks
• File appeal if needed
• Know Medicare and payer guidelines for
filing appeals

19. 7 of 7
A/R Follow-up &
Denial
Management
Patient Collections: Do’s and Don'ts
*** Collect Upfront***
• Payment Plan (Do’s)
• Down payment
• Schedule of payments
• Definitive end date
• Payment Plan (DON’Ts)
• Don’t offer unlimited time
• Don’t take just any amount
• Don’t let patients talk to physician about payment

20. 7 of 7
A/R Follow-up &
Denial
Management
Patient Collections
• Collect balance when making appointment
• Collect when patient comes in
• Online payment options
• Send statement
• Limit the amount of statements sent
• Have a plan for patients who cannot pay
• Send to collections
• Bad debt write-off
• Dismissal from practice (review the consequences)

21. Managing the Revenue Cycle
It takes a village!!
• Office policies and procedures manual
• Standardized forms and scripts
• Everyone needs to be on the same page!
• Cross Training
• Divides the burden
• Cost-effective
• Everyone in the office should have the same philosophy
• Empowers the employees

22. Thank you!