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

08-Revenue Cycle Management_Chaudhry

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Revenue Cycle Management (RCM) is the process of managing all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue. Key drivers and elements of RCM include appointment scheduling, insurance eligibility, patient registration and coding, claims submission, insurance adjustments, patient billing, and managing denials. Insurance eligibility and cost estimation prior to services are crucial components of RCM. It is essential to check insurance coverage and benefits to ensure payment for services.<br /><br />The problem with RCM lies in the lack of proper insurance verification and cost estimation processes. Checking insurance eligibility and patient responsibilities should be done not only when the appointment is made, but also on the date of service and for follow-up appointments. Verification is the responsibility of the front office, and various online tools and carrier websites can be utilized. Obtaining and scanning a copy of the insurance card is important for claims submission. Eligibility, coverage, benefits, deductible, co-payment, and co-insurance are key factors to check.<br /><br />Effective RCM also involves discussing and educating patients about their insurance coverage. Staff should be trained to answer patient questions, have access to fee schedules and tools for calculating patient responsibilities, and make calls to determine remaining deductibles. Financial key performance indicators for RCM include accounts receivable over 120 days, reimbursement rates, gross collection rates, revenue realization rates, average reimbursement per encounter, and first pass denial rate and resolution rate.<br /><br />Denial management is crucial in RCM, involving addressing demographic data errors, medical necessity, coordination of benefits, missing or invalid codes, and timely filing. Mitigation strategies include re-educating staff, timely submissions, involving the patient, and utilizing appeal processes.<br /><br />The COVID-19 pandemic has presented challenges in RCM, such as decreased revenue due to reduced volume, staff retention, and regulatory changes. However, it also presents opportunities for lean revenue cycles and automation, such as using clinical decision support and robotic process automation.<br /><br />Future trends in RCM include consumer-driven app and web-based appointments, price transparency, automated patient responsibility calculations, online payments, automation in various aspects of RCM, documentation at the point of care, pre-submission scrubbing, payor trend analysis, and AI/ML-based analysis and automated claim resubmission.<br /><br />Practices can lose money due to failure to have in-house policies and oversight, failure to collect patient co-pays and manage denials, failure to verify insurance and benefits, failure to cater to patient consumerism, and failure to measure key performance indicators. It is essential to have policies in place, effectively communicate with patients, educate them, and choose financial key performance indicators for measuring the success of RCM.

Keywords

Revenue Cycle Management

administrative functions

clinical functions

patient service revenue

appointment scheduling

insurance eligibility

patient registration

claims submission

patient billing

denial management