Looking for ways to streamline your administrative workflow? Your billing and collections process is a great place to start! Odds are there are dozens of tasks that can be automated or optimized, thus putting more time and resources back into your practice. Let’s dissect what the standard claim management process looks like and which steps can be fine-tuned with the help of innovative software.

What Is RCM?

Revenue cycle management, commonly referred to as RCM, is the series of activities involved in generating healthcare practice revenue. There are many different ways to slice the RCM process, but ultimately, all claims are going to go through these stages.

PATIENT INTAKE 

Data Capture: This step includes setting up an appointment and “capturing” the necessary information, such as the patient demographic or insurance details in order to create a clean claim after the provider has documented the patient visit.

Insurance Benefits and Eligibility: Once the insurance information is gathered from a patient, that information is used to determine eligibility and benefits for the service that will be rendered. This information will dictate the financial transparency for each visit based on the benefits and services received as well as inform the practice that authorization will be required. If the insurance does not cover the service or therapy provided, the patient must be made aware of their responsibility as well as set up a payment plan if applicable.  

CHARGE CAPTURE & BILLING

Manual Claims Filing: Once a patient has finished their appointment and completed check-out, the information they gave in addition to the details of the services provided will be reviewed by a medical coder to start creating the official claim. The drafted claim is then handed off to the biller, who will double-check for compliance before finally creating the claim that will be sent out to the payor.

The Raintree Difference: After the visit is completely documented, the claim is posted by the system and scrubbed for any edits. Once the claim has gone through this review process, it will either be held in the follow-up queue for any missing and incorrect information or the claim will continue automatically over to the clearinghouse. However, if the claim is rejected, it will remain in Raintree under the rejection code provided by the clearinghouse or payor in order for a biller to review, correct and resubmit it. When the claim is successfully processed, its status will remain monitored until a payment is received.

ACCOUNTS RECEIVABLES (AR) MANAGEMENT

Claims Submission Reconciliation: The claim format, whether it is electronic or not, will determine the claim submission process and where to send it. It’s more common now to use electronic methods, which can be sent to federal payors directly or to a clearinghouse for further quality review and secure transfer to the payor. 

Claims Adjudication: This is where a payor evaluates a claim and determines how much of the claim they will pay the biller directly. It’s at this stage that a claim may be accepted, denied or rejected. If there is a secondary insurance on file, a claim will then run through this step again with that additional insurance information. In the event a claim is rejected, it is sent back to the biller for review, restarting the claims filing process.

Claim Payment: When the claim is accepted, the payor reimburses the biller, who then generates a patient bill for the remaining balance.

The Raintree Difference: While there are many reasons why a payment may be delayed or remain unpaid, being able to accurately follow up with insurance and allocate any underpayments in one secure, robust platform is a huge win for providers. In fact, Raintree’s automated billing and follow-up note functionality helps assist your practice in tracking streams of revenue in terms of whether you are paid what is owed and within a reasonable timeframe. 

By assigning follow-up notes to a specific user and having a date for when they should be completed, your business will be better suited for dealing with ledger items as well as improving staff productivity.

REVENUE ENHANCEMENT

Patient Account Maintenance: The lifecycle of a claim isn’t completed until the patient has paid off the remaining balance and sometimes that involves repeated follow up or even sending the balance to a collection agency. This step seamlessly transitions back into the data capture process if another appointment is scheduled.

Reporting: A clearinghouse will provide a history report for any claims you send through them, which is important to keep on hand to review for error trends. Beyond those reports, most practices will gather their own data to better their financial operations and manage expectations.

What Is A Clearinghouse?

A clearinghouse is an intermediary that facilitates the exchange of money, information or other sensitive goods between buyers and sellers. In the healthcare industry, that exchange is primarily to secure electronic medical claims or financial information between billers and payors. Most often, they take a huge strain off of medical billers by reviewing the provided information and structuring them to fit the payor’s claim requirements, cutting down on the likelihood of a rejection.

Even with the incredible optimization that clearinghouses provide, it’s no shock that the lifecycle of a claim is a long, tedious process with endless potential for errors that can disrupt a busy practice and delay payment.

What Are Your Options?

There’s no question that automation makes RCM easier, but as a provider, what exactly should you be looking for? It can be daunting to review the massive claim lifecycle and try to overhaul it without knowing what tools are out there to help. That’s why we’ve compiled a list of services that are designed to facilitate the claim management process every step of the way!

The data capture or digital intake stage is something that can be streamlined into an effortless process with the right patient engagement software. Management tools that offer a self-scheduler for patients can eliminate resource strain right off the bat! Additionally, seeking software that uses automated insurance verification with eligibility checks can also increase productivity, significantly reducing the amount of time spent on phone calls and manually updating patient details.

The charge capture and AR management stages are both largely done outside of your own financial operations, but that doesn’t mean they can’t be optimized! Take your practice a step further by taking advantage of a software that imitates a virtual clearinghouse, guaranteeing your claims are verified before they are sent to payors and condensing a multi-step process into one. By utilizing a billing software with automated task alerts and user friendly dashboards, your staff can instantly be notified when additional actions are needed to receive payment – meaning you get paid even faster!

And finally, the revenue enhancement stage is a process that every business needs to keep at the forefront of their mind when reviewing productivity and making informed adjustments to their financial operations. Invest in an all-in-one platform with interactive reporting that can help you identify areas of improvement and patient engagement tools that can automatically keep patients in the loop on the status of their bills as well as help them adequately get set up for their next visit.

As a software that can provide all of these services, Raintree Systems is ready to discuss overhauling your practice’s revenue cycle management workflow! Visit our website to learn how our technology-enabled solutions can improve your account receivables processes and so much more.