Medical Revenue Cycle 101

Revenue Cycle Management

No matter what industry you are in, collecting payments from customers is an essential process that should be as efficient as possible. However, for medical billing and coding, it can seem almost impossibly complex. Fortunately, when you understand the billing cycle, you can optimize your revenue cycle management and achieve bottom-line results. 


The Medical Billing Cycle 


The process from first receiving a patient through to collecting payment follows a predictable set of steps known as the revenue cycle. Like any other business process, this can be optimized. That means faster revenue realization and more profit. However, before you can begin to improve your RCM, you need to understand the steps of the medical billing cycle. 


  • Patient Registration: When the patient first sets up an appointment, his or her information is captured. For new patients, a new record is created. For existing patients, the appointment is added to the appropriate record. 
  • Confirm Insurance Coverage: During this process, the insurance information should be gathered or updated. It is essential to confirm coverage and, if necessary, to ensure that the patient knows what his or her financial responsibility may be, particularly if the patient is uninsured. This step should involve confirming who will be financially responsible for the expected services. 
  • Check-In, Service and Check-Out: When the patient arrives, he or she should check in before the appointment. At this stage, it is a good idea to collect copayments/coinsurance, check record details and get information from the patient’s insurance card. Then, the appointment can begin. When the patient checks out, a report is sent to the medical coder. It is then turned into an accurate bill that can be provided to the medical biller and insurance. 
  • Prepare Claim: The next major step of the medical billing and coding process is to prepare the claim that will be submitted to the insurance payor. In theory, this should be as simple as translating the coded bill into the appropriate claim format of the insurance provider. However, this often requires a check to ensure that the bill meets the standards of billing compliance. These claims are complex and governed by numerous laws and regulations. So, compliance checking is an important part of mitigating liability. 
  • Submit Claim: Once ready, the claim can be submitted to the insurance provider. This transmission must be done in accordance with the Health Insurance Portability and Accountability Act. 
  • Claim Monitoring: Unfortunately, claims can be rejected. Even those that will ultimately be accepted must be adjudicated by the payer. This can be a slow process. Plus, any errors may result in an unfavorable result. So, it is important to continue to monitor the claim as it continues through the process. 
  • Send Patient Statements: Once the claim has been resolved with the insurance, it is time to send statements to the patient. If your patient owes additional money, getting clear, itemized statements out quickly can help significantly with the collection process. 
  • Follow-Up on Payments/Collections: Finally, continue to follow up with the patient about payment. It can take several attempts to receive payment. However, most patients settle their balance after being reminded. In the worst cases, the bill may need to be sent to collections. 


The above process is more complex than in many other industries. Nonetheless, it can be optimized and streamlined through RCM, helping to achieve significant benefits for your business. 


The Benefits of Effective Revenue Cycle Management 


Optimizing the above process can help your healthcare business in a few ways. These are the most outstanding benefits: 


  • More Successful Claims: By improving your medical billing process, you can decrease the chance of claims being denied. Checking coverage and avoiding errors in the coding or claims can make a huge difference. 
  • Greater Revenue Realization: By increasing your successful claims and improving payment collection from patients, you can realize more revenue. 
  • Reduced Costs: Fixing errors can cost a significant amount of time and money. By reducing your errors and streamlining the process, you will have fewer revenue-related costs. 
  • Profit-Optimized Services: With data from your RCM efforts, you can find the services that are the most profitable. This may help you to make your business more profitable overall. 


Reasons To Work With an Outsourced RCM Specialist 


Many healthcare businesses turn to medical billing companies for help with revenue cycle management. While you will maintain some parts of the cycle internally, it can help to get assistance with medical billing and coding. As described above, there is a lot of complexity associated with the full revenue cycle. So, getting additional help can be worthwhile. 


Furthermore, if you choose the right provider, you can be confident that your revenue realization and profits will increase. Outsourced providers are able to operate more efficiently, meaning that they are often less expensive than having an in-house billing and coding team. This is especially true for smaller practices. This may be the solution you need to get the most from your RCM. 


Contact us today to learn more about the services we offer! HL7 Bridge to AdvancedMD offers a cloud-based automated bridge interface that provides real time patient billing data transfer from the hospital to your practice management system. 

Parul Garg, CEO and co-founder of PracticeForces, has significantly contributed to the growth of over 1,000 U.S. medical practices through her expertise in medical billing and coding since the company’s inception in 2003. With a background in Computer Science and an MBA in Human Resources, her leadership and AAPC-certified coding skills have been pivotal in managing the company’s operations effectively.

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