Those of us who are not employed by a hospital or other entity remain small business men/women, and therefore need to be as attentive to the business aspect of our practices as we are to the clinical care we offer our patients.
Eligibility determination. The process of revenue cycle management begins with information gathering at registration before services are performed. This includes obtaining demographic and insurance information. Many patients switch insurance plans, have guarantors that switch employment, or let their plan lapse without a clear understanding of the implications; it is critical to be certain that insurance is verified before service is provided. That includes verifying insurance eligibility, identifying the guarantor of payment, and obtaining medical necessity to forestall payment denial. It may include an assessment of ability to self-pay for whatever services are provided. Using real time adjudication online or by phone, you can easily check the patient's eligibility at the time of service.
Coding. Many practices employ coding experts to stay current with updates and nuances of the complex and arcane world of medical coding. Nevertheless, the Centers for Medicare & Medicaid Services and other payers still hold the provider responsible for compliant coding, which begins with the patient visit and documentation of the encounter. Physicians need to be knowledgeable about the coding process, especially documenting medical decision making, and should attend courses regularly.
Bill submission. Bills need to be submitted not only within 48 hours of the service provided, but also accurately. Sophisticated billing systems include "scrubbers" that ensure that each claim submitted is "clean" and free of errors, bundling edits, and mistakes that will result in delays in receiving your payments. Delay in payment equals added costs.
Bill tracking and posting. Your practice management system will track which claims are paid and which ones are denied. The first step in analyzing your collections is to identify why claims are being denied. You are wasting precious time and increasing your overhead costs with each claim denial. Effective revenue cycle management identifies the problems and then fixes them so they are not repeated. This means loading major payers' fee schedules into the practice management system to ensure that you are being paid the proper amount by each of your insurance carriers.