💱Revenue Cycle

A comprehensive process that involves the management of financial transactions and interactions between a care agency and its patients, and payers throughout the care journey.

Understanding the Revenue Cycle Management Process

The Revenue Cycle Management process is a workflow that care agencies usually follow to manage the financial aspects of patient care.

1. Patient Registration and Data Synch: The RCM process begins with patient registration (or agency assignment), where demographic and insurance information is collected. This step is crucial for establishing accurate patient records and determining insurance coverage.

2. Pre-Authorization: Pre-authorization may be necessary for certain procedures, ensuring that the payer approves the planned services before they are performed.

3. Coding and Charge Capture: Once the patient receives care, medical coders (or an intelligent system) assign alphanumeric codes to the diagnoses, procedures, and services provided. These codes are crucial for billing and reimbursement. Charge capture involves capturing all billable services and procedures to ensure accurate billing for the care delivered.

4. Claims Submission and Processing: In this stage, the coded information is used to create and submit claims to payers. This involves preparing and sending electronic claims with the relevant patient and service information. Payers then process these claims, determining the amount they will reimburse for the provided services.

5. Accounts Receivable Management: Accounts Receivable (AR) management involves tracking and managing payments from both patients and insurance companies. This includes monitoring outstanding balances, following up on unpaid claims, and ensuring that payments are collected in a timely manner. Efficient AR management is crucial for maintaining financial stability.

6. Denials Management and Appeals: Unfortunately, claims may be denied for various reasons, such as errors in coding or insufficient documentation. Denial management involves identifying and resolving these denials to ensure that healthcare providers receive the reimbursement they are entitled to. If a claim is denied, the agency may need to file an appeal, providing additional information to support the claim's validity.

Understanding and optimizing each stage of the Revenue Cycle Management process is essential for care organizations to maximize revenue, minimize financial risks, and provide quality care. It requires collaboration between various units, including front-end staff, coders, billing teams, and those responsible for accounts receivable management. By ensuring accuracy, efficiency, and compliance throughout the RCM process, agencies can navigate the complex financial landscape and sustain their operations.

Benefits of Care Revenue Cycle Management

The benefits of effective Revenue Cycle Management are far-reaching, impacting both the financial stability of social care organizations and the overall quality of patient care. Here are some of the specific benefits:

1. Timely and Accurate Reimbursement: A well-orchestrated RCM process ensures that claims are submitted accurately and promptly. This, in turn, accelerates the reimbursement process. Timely submission reduces the likelihood of claim denials and ensures that healthcare providers receive payments promptly, contributing to consistent cash flow.

2. Reduction in Bad Debt: Effective RCM practices help identify and address potential issues with patient payments early in the process. This includes verifying coverage, communicating clearly about patient financial responsibilities, and implementing efficient billing processes. As a result, the risk of bad debt—unpaid or unrecoverable patient balances—is significantly reduced.

3. Increase in Claims Paid After First Submission: A robust RCM process aims for a high rate of claims paid after the first submission. This reduces the need for time-consuming and resource-intensive appeals. When claims are submitted accurately the first time, care agencies can streamline their operations, minimize delays in reimbursement, and enhance overall efficiency.

Utilizing Technology for Improved Efficiency

Leveraging technology is integral to improving efficiency in Revenue Cycle Management, and one of the pivotal tools in this realm is Electronic Health Records (EHRs). Here's how The Fieldworker platform plays a crucial role in enhancing RCM efficiency:

1. Streamlined Documentation and Coding: The Fieldworker facilitates the digital capture of patient information, plans, goals, and objectives. This not only eliminates the need for paper-based records but also streamlines the documentation process. Accurate and detailed documentation in EHRs aids medical coders in assigning the right codes, reducing errors, and ensuring that claims are submitted with precision.

2. Real-Time Access to Patient Data: The Fieldworker platform provides real-time access to comprehensive patient data, allowing healthcare providers and administrative staff to retrieve information instantly. This real-time access enhances the speed and accuracy of decision-making, ensuring that billing processes are informed by the latest and most relevant patient information.

3. Efficient Claims Submission and Processing: With the Fieldworker platform, the claims submission process becomes more efficient. Billing staff can generate claims directly from electronic records, reducing the chances of errors associated with manual data entry. The Fieldworker platform also enables electronic claims submission, accelerating the processing time with payers and minimizing delays in reimbursement.

4. Automated Reminders and Alerts: The Fieldworker platform can automate reminders and alerts related to billing and coding requirements. This helps healthcare providers stay compliant with regulations, reduce denials, and optimize the revenue cycle. For example, automated alerts can notify staff of missing information or coding discrepancies before claims are submitted.

5. Enhanced Communication and Collaboration: EHRs foster improved communication and collaboration among different departments involved in RCM. From front-end staff to billing teams, everyone has access to a centralized platform, reducing communication gaps and ensuring that relevant information is shared seamlessly.

6. Data Analytics for Performance Insights: EHRs come equipped with data analytics capabilities that provide valuable insights into the financial performance of healthcare organizations. By analyzing key metrics, organizations can identify areas for improvement, optimize workflows, and make informed decisions to enhance overall RCM efficiency.

RCM - For Support Coordination businesses in NJ

The Fieldworker team is working on building an account receiveable system where an agency could generate an estimate of expected revenue based on the client population, services rendered, and the cost structure to provide these services.

For a company that subscribes to ‘Financial Reporting’ and is a ‘Support Coordination’ company, on the first of every month, and when triggered

1. For every active customer, that has an active project with a start date before the first of the month, and the end date beyond the last day of the month, create a full month entry in the billable table.

2. If the record exists with a different plan version and/or name (This is determined when a new plan is added whose program type is different from the previous plan), two partial billable will be created. The first is for the Current plan which should be from the start date to the end of the month and the second billable should be from the 1st of the month to the day before the Current Plan Start date. This will generally happen in a middle-of-the-month run. If the plan_version of the entry in the database is different from the current plan version of the project.

3. For every active customer, that has an active project with a start date after the first of the month, and the end date beyond the last day of the month, create a partial month entry in the billable table, if the record does not already exist.

4. For every active customer, that has an active project with a start date before the first of the month, and the end date before the last day of the month, create a partial month entry in the billable table, if the record does not already exist.

5. For every active customer, create a partial month entry in the billable table, if the record does not already exist, with a start date later than (date assigned to the SC agency, the date the individual turns 21 if in the Supports program, or the creation date) to the end of the month and should post when the start date is updated for the initial plan - This will generally be for a new customer, but can happen on both scheduled or an unscheduled run. Most likely, it will be a case where a partial billable is created instead of monthly because the customer only became eligible to receive the service from a specific date, during the month.

What is the difference between Accounts Receivable, Prior Authorization, and Claims dashboards?

The Revenue Capital Management (RCM) for healthcare agencies generally requires three or more separate stakeholders. These may be your customers, payers and/or authorization agencies. Each of these three dashboards reflects a view from these perspectives.

1. The Accounts Receivable dashboard indicates a detailed view of the expected revenue for your client population and services offered to them based on payment rules.

2. In situations, where your payers require a prior authorization, the Prior Authorization dashboard allows you to upload, manage, and match the services provided to an authorization to reduce the claim denials. For your agency, this may also provide an automatic generation of claims.

3. The Claims dashboard lets you review claims, and have the Fieldworker platform review and validate the submission, check the payment status, and then finally manage the denials, if any.

All three dashboards work in tandem to provide an end-to-end view of the RCM process.

Can I submit a claim directly from Accounts Receivable dashboard?

The Accounts Receivable dashboard is your agency's sub-ledger indicating expected revenue from all possible payers. Different payers may have different rules or processes for accepting claims.

In the Fieldworker platform, all claims are submitted via the Claims dashboard, and may either be automatically generated via the Prior Auth dashboard, manually entered using the Claims dashboard, or may be bulk uploaded using a claims file.

For a new customer, we may not need any service to be provided for the first month's payment. How do I submit such claims?

Medicaid claims can only be submitted with an appropriate PA number. The first claim for a new customer will have to wait until the PA number is received. In cases, where any specific service is not needed before submission of the claim, the claim may be manually submitted as soon as the PA number is available.

Such cases will also be usually identified on the Changes dashboard for easy tracking.