Every healthcare organization should find the right medical software, including electronic medical records (EMR) systems and medical practice management software.
Fremont, CA: Any healthcare organization's central financial mechanism is revenue cycle management (RCM). If medical practices, hospitals, and laboratories are to thrive and make a profit, they must create an efficient and successful RCM process.
Unlike many other industries, healthcare providers seldom realize how much they will be paying when they offer their services. Furthermore, since there is a time period between delivery of care and payment, it is crucial to manage funds responsibly to keep accounts receivable going.
The "payers," who are entities such as insurance firms, are central to the RCM process. Payers are the entities that compensate providers for their services. Although patients may be required to pay a co-pay at the time of service, the vast majority of costs are billed to payers in the form of a "claim."
Here's how the process generally works from start to finish:
Eligibility verification: When a patient walks into a medical office,
their insurance eligibility is verified, and vital patient data is entered into the practice's electronic health record (EHR).
Charge capture and coding: The practice's services are provided to the patient. Using ICD-10 medical coding criteria, the visit is coded into a bill.
Patient collections: Before leaving the office, the patient pays any co-pays that are due.
Claims submission: The bill is coded and sent to the appropriate payer, usually through a clearinghouse. Billing departments will frequently need to follow up to ensure that a payer responds promptly.
Reimbursement: The payer can decide how much the provider receives based on the patient's coverage after reviewing the claims. Claims are often rejected due to coding errors, missing patient records, and other factors.
Denial management: When a claim is rejected, billing departments make the necessary adjustments and resubmit it. Scrubbing for coding errors, updating patient records, and working directly with the payer are all part of this process.
Patient collections: Providers must give patients an additional statement for care rendered if they accessed services for which they are not covered. Billing divisions will have to keep following up on patient statements until the balance is billed in full.