Understanding Revenue Cycle Management
Revenue cycle management in healthcare refers to the entire process of overseeing reimbursements and payment processing. The process takes into account the patient’s information, clinical data, health insurance information, medical codes, and billing information.
Steps Involved in Revenue Management
Let’s take a more detailed look at all the different steps involved in a typical revenue cycle.
- Claim Preparation: Before a healthcare provider can make a claim, they need to collect the patient’s personal data.
- Submission: Once all the fees are added up, the claim is then sent to the insurance company.
- Handling the Claim: The administrative staff gets in touch with the insurer to determine the scope of coverage.
- Payment Collection: Once the insurer reimburses the hospital, the patient also receives an invoice (if necessary) for any outstanding debt.
- Review: Hospitals and clinics assess the quality of treatments and the patient experience in order to find new ways of improving the care they provide.
Managing the revenue cycle in the medical field is an involved process composed of various time-draining tasks and processes.
Challenges Facing Healthcare Providers
There are several processes that become problematic for healthcare providers that don’t employ proper software solutions.
Disjointed Processes
The administrative staff of healthcare providers often have multiple responsibilities, which increases the risk of the occurrence of incomplete tasks. This can result in denied claims if not rectified on time.
Effective communication during the information gathering stage is critically important in determining coverage eligibility and helps with payment collections.
Eligibility Issues
Keeping constant contact with insurance providers is important because it helps avoid pending, denied, or rejected applications.
Manual Processes Dominate
Manual processes are the main culprits for why healthcare providers are plagued by inefficient revenue management.
How Can Healthcare Providers Improve Revenue Management?
Rules-powered compliance systems can spot mistakes in applications, which may reduce the rate of denied claims.
Efficient Processes
Revenue management software systems provide a straightforward and user-friendly tool to doctors, nurses, and administrative staff that can help manage revenue.
The ever-changing and complex healthcare regulations and reimbursement plans make it very difficult for healthcare providers to stay on top of the latest policies, preventing them from receiving timely payments.
Determine Coverage Scope and Eligibility
Many hospitals and clinics need authorization for tests, medications, and treatments because insurance providers constantly question the decisions of physicians.
In order to avoid errors, healthcare providers are deploying rules-based software systems that can carry out prior authorization and eligibility in mere seconds. As a result, hospitals and clinics spend less time on time-consuming administrative tasks and more time caring for their patients.
Rules-Powered Revenue Management Tools
A business rules engine is the secret behind robust revenue management software systems. A rules engine is a sophisticated piece of software that runs conditional “if-then” statements that automate business processes. These business rules help reduce the amount of time it takes to determine coverage, complete prior authorization, and keep an open line of communication with insurers.
As a result, rules-powered software solutions offer patients a seamless healthcare journey by streamlining repetitive and time-draining processes.
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