Revenue Cycle Management (RCM) Is a Process

Revenue cycle management (RCM) is the backbone of the healthcare industry. It manages the finances of the providers and keeps them going on a daily basis. Several organizations involved in the process to make it a success. The role of medical billing services in the US and the front-desk staff is undeniable. We will look at how each of those departments improves payments for the physicians and other clinicians.

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What is RCM?

RCM is a process that takes care of the financial cycle management. RCM works at the functional core of a healthcare organization whether it is a small practice or a large hospital. Each institution by law has to follow certain procedures to remain profitable, so the process of care delivery steadily moves on. In the wake of this current argument, it is appropriate to mention the key stakeholders in this process; Physicians, patients, and the payers.

Physicians and patients are directly part of the care delivery process, but the payers participate in it as an engine and the driving force. The revenue motivates both the doctors and the patients. The skyscraper of the healthcare industry comprises several basic building blocks to execute an end-to-end revenue cycle management process.

If there are loopholes and/or outstanding accounts receivables, they directly affect the income of a practitioner. The aftershocks of a lazy revenue cycle can cause major backlogs in terms of pending claims for the physicians.

Medical Billing Services in the US Play an Anchor Role

An effective revenue cycle management process in medical billing is what most practices strive to achieve. Mostly it is the third-party medical billing and coding companies that are responsible, assuming they have the experience and the skillset.  It is interesting to compare medical billing services in the United States to an anchor. They connect the providers to the payers like an anchor connects a ship to the shore.

To run a productive RCM process, it is imperative to hire an experienced billing service. Whether you believe in outsourcing the medical or using an in-house solution, a slight deviation from a certain level of alertness could mean failing at the whole process. Filing claims at the right time leads to quicker reimbursements. It requires certain skills and a combination of both novice and veteran billers.

9 Steps in Revenue Cycle Management

RCM is a process not than a product. While there is no replacement for high-quality care, there is literally no denying the importance of following the 9 steps of revenue cycle management.

As explained in recent publications, AI or Artificial Intelligence is going to boost the efficacy of a revenue cycle management system by acting as the digital employee to the physicians.

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Let’s take a look at the revenue cycle from beginning to end to educate ourselves in the best interest of care and healing.

  1. RCM Software or A Medical Billing Outsourcing Company

The first step in claims management is to decide whether to install RCM software in-house. Or, do you handover the task to a revenue cycle management company. Don’t fret, because it gets easier when you outsource medical billing services with skilled IT personnel to file claims, work on denials, and appeals on your behalf.

To search for a billing company that fits your practice, physicians usually search for the phrase “medical billing companies near me” in Google. It gives you the list of companies close by.

It is only logical to look for revenue cycle consulting companies near you when you don’t have expert IT staff members in your organization. When you run a small practice with able IT crew support, it is ideal to run an RCM software set up on local servers. However, larger organizations or those which lack skilled staff, consider medical billing services in the USA as the best practice.

  1. Patient Pre-certification or Pre-authorization

What is it? When a patient comes in, they undergo pre-authorization. The physician’s office pre-approves the patient of certain treatments and prescription drugs by this process.

At this step, the payers or the insurance companies decide whether the prescription drugs, procedures, services or equipment is medically necessary or not. Based on the decision, they will reimburse for the services rendered. The pre-authorization phase faces exceptions in case of a medical emergency.

Pre-authorization doesn’t necessarily mean that the health insurer will cover its cost, which is why the process is repetitive and needs continuous verification. It is always a good idea to double-check any doubts related to coverage with the insurance company. This goes for both the providers and the patients.

  1. Insurance Eligibility and Verification

The process is downright demotivating over the phone because it demands a lot of patience. Therefore, a set function must be a part of the RCM software to cater to it.  Artificial Intelligence could play a pioneering role in this phase of recognition, as it will automate the function.

Once patients go through with the care delivery, the Explanation of Benefits (EOB) statement incorporates all the details of the services or treatments paid on their behalf by the insurance company.

  1. Charge and Code

When the patient checks in at the office, the visit transforms into a set of codes. There is a high probability of human error in these codes, which is why professional medical coders are the go-to people for it. The codes have to follow a certain set of rules and concur with the CPT guidelines and the latest ICD-10 coding system.

  1. Co-payments and Deductibles

Each health plan comes with a deductible and a co-payment. Some have high and some have low deductibles. Whatever the amount is to be, the patients pay up the copays at the doctor’s office before they go back home. The deductible is the amount fixed in a health plan that you have to pay before the insurance company starts paying for those health care services.

  1. File Claims

Submission of claims is the vital stage in the overall process because the reimbursement directly depends on it. If it is flawed, the chances for reduced payments or outright denials increase.  As soon as the biller prepares the claims, they are filed with the insurance companies via a clearinghouse. The clearinghouse makes sure they are clean and free from errors.

Internally when practice management software connects with the medical billing software, it will initialize the operational process of the revenue cycle management.  The billing company follows up with the insurance company in light of those claims. It ensures the payer reimburses in a timely manner.

  1. Reimbursement for the Services Rendered

It is time for the insurance company to pay up. The payers match the procedures with their charges under the coverage limit. If the bills are appropriate, the process of acceptance becomes smoother and returns maximum reimbursements.

In the case of erroneous claims, incomplete patient information, or any other issues, the denials are inevitable. Most low-dollar claims tend to pile up unless the RCM is playing to its full potential.

  1. Manage Denials

For the claims which suffer rejection, they are resubmitted soon after they are scrubbed for coding mistakes. The resubmissions or the process of appeals demands critical screening with a finger on the pulse of the latest coding guidelines. In addition, minute details are checked against the patient profile and it makes the billers work directly with the payers.

  1. Collections

When there is reduced reimbursement from the payers, it means the health plan does not cover for all the services. Thereupon, it is the duty of the billers to send those outstanding payments to the patient(s) and follow-up.

Medical billing services do rigorous follow-ups until the patients finally pay up.

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With all the above steps in place, it helps to streamline the complex process of revenue cycle management.  Physicians need a proper team of individuals to carry the process towards the finish line by the successful execution of these stages. On the contrary, the denial rates even for a team of veteran billers are about 10%. As long as they don’t back down and continue to work for acceptance & maximum reimbursement, the payers are going to pay for your services as a healthcare professional.

Steps for HIPAA Medical Billing Outsourcing

First, physicians must acquire the services of medical billing companies nearby. Second, they must see if they demonstrate HIPAA compliance.  OCR audits only spare those practices with a credible security system in place providing maximum safety to protected health information (PHI). Any covered entity or business associate choosing to violate HIPAA is subject to hefty fines and jail time.

Medical billing services charge 3 to 7 percent of the total collections as their fee.

The top attributes of a genuine medical billing service provider are as follows:

  1. Medical Claims Scrubbing – While the billers prepare those claims, the coders keep a close eye on any mistakes before they are ready for submissions. Certified coders from organizations like AHIMA can really kick it up a notch for providers.
  2. Follow-Up – A good medical billing company will always stay on its toes until a claim returns positive results. It continues to follow-up on pending claims and exhibit accounts receivable (AR) management on a regular basis.
  3. Denial Management – Not every claim passes through the strict criteria of the payers in the first go, which is why active billers workaround denied claims for the physician through accurate resubmissions. They do everything in their capacity to successfully reimburse your services.
  4. Weekly Reporting – When the physicians give you responsibility for their finances, it is necessary for you to email them a detailed report regarding the performance of their claims. You may do it on a weekly basis or bi-monthly basis. The frequency of those reports depends on the Business Associate Agreements (BAAs).
  5. Dedicated Accounts Manager – The reliable medical billing services appoint an accounts manager acting as a liaison to the physician because communication is an important part of the contract. It also includes an additional support team of individuals to address any issues that may arise in the claims.

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The Revenue Cycle Management Flow Chart

When the administrators remove any obstacles in way of the revenue cycle management process, it puts claims on the path of first-time acceptance.

The following diagram represents the revenue cycle management flow chart in its true magnificence.


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The Vendors

There is a long list of revenue cycle management vendors that provide a permanent solution to your financial cycle needs. However, selecting the right one may be difficult given the range of services and bonus features that come along. Some of those solutions integrate with the certified EHR systems to speed up the entire system.

Performance Calibration

How do we know if the billing service is performing well?

The question is simple and it needs a straightforward answer.

We know a billing company is performing well by an increase in collections and a consistent cash flow. In other words, there are no hiccups.

Simply put, the volume of interactions with the insurance companies makes medical billing services the right choice to be the manager of your finances. Once they are on the driving seat, you can function as a normal healthcare professional without having to worry about your revenue stream.

CMS thrives on constant changes to the US healthcare system under the value-based care models. It makes medical billing services more suitable as they are more aware of the ongoing trends and regulations.

Phase Infinity

To stay on the brighter side, the documentation activity must go alongside practical realizations. Much of the revenue enters the successful stages right at the beginning when a patient comes in to receive care. The person sitting at the reception is going to run patient eligibility checks and commence the pre-authorization phase.

Nobody said the medical billing process is an easy one, but with the right steps in place, it becomes highly manageable. A medical billing software, RCM tools, and third-party medical billing services, physicians are very much on their way towards financial freedom.

jacaod michael

Jacob Michael has been writing for various industries in the past. Currently, his focus is on the US healthcare industry, and it is his passion to share his opinion in the best interest of the company & the providers. is a health IT consultancy & a MIPS Qualified Registry in 2018.

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