Looking at GI Practice Management Differently: Fortify the Business of Healthcare in the GI Practice | November 2021-08-Revenue Cycle Management

08-Revenue Cycle Management_Chaudhry

Pdf Summary

Revenue Cycle Management (RCM) involves all administrative and clinical functions that contribute to capturing, managing, and collecting patient service revenue. The process includes appointment scheduling, insurance eligibility, patient registration, coding and claims submission, insurance adjustments, and managing denials. Insurance eligibility and cost estimation are critical components of RCM as they determine if the insurance is in force, premiums are paid, services are covered, and if they are medically necessary.<br /><br />It is essential to check insurance eligibility and cost estimation prior to the date of service to ensure payment. This responsibility lies with the front office, and online tools are available for verification. It is important to obtain and scan a copy of the insurance card and know where to submit claims. Checking eligibility should be done for every appointment, on the date of service, and for follow-up appointments.<br /><br />Staff should be trained to answer patient questions about insurance coverage and calculate patient responsibilities such as deductibles, co-payments, and co-insurance. Educating patients about their insurance coverage is necessary, and tools can be used to calculate patient responsibilities and determine remaining deductibles. Key performance indicators in financial management include Account Receivable over 120 days, reimbursement rates, gross collection rates, revenue realization rates, average reimbursement per encounter, and denial rates.<br /><br />Denial management requires attention to demographic data accuracy, medical necessity, coordination of benefits, and timely filing. Analyzing denial trends, educating staff, involving patients, and utilizing appeal processes can help mitigate denials.<br /><br />The COVID-19 pandemic has presented challenges to RCM, including decreased revenue and staff retention issues. However, it has also created opportunities for a lean revenue cycle and automation through the use of clinical decision support and robotic process automation.<br /><br />Future trends in RCM include consumer-driven approaches such as app-based and web-based appointments, price transparency, automated patient responsibility calculation, insurance coverage confirmation, and online payments. Automation in documentation, care gap analysis, claims submission, denial management, and AI/ML-based analysis are also expected.<br /><br />To avoid losing money, practices should have in-house policies and oversight, collect patient co-pays and deductibles, verify insurance and benefits, cater to patient consumerism, and measure key performance indicators. Policies for financial decisions, effective staff communication, patient education, and selecting appropriate financial KPIs are practice pearls for successful RCM.

Keywords

Revenue Cycle Management

insurance eligibility

patient registration

denials

cost estimation

front office

deductibles

denial management

COVID-19 pandemic

automation