What are the Quality Checks in Revenue Cycle Management

What are the Quality Checks in Revenue Cycle Management?

The Healthcare industry is going through a period of metamorphosis. The evolution of volume-based healthcare services is an outcome of the changes that are occurring. If not the best, at least we can say that the concerns are being listened to and being worked upon for patient empowerment, patient experience, and better-quality healthcare standards. Unfortunately, we are still not where we all want to be. i.e., to reach a progressive and empowered healthcare system. Is there a checklist for RCM? How important are medical billing services?

The most concerning thing about today’s healthcare industry is the cost factor that is equally unsettling for patients and physicians. Patients talk about how high-quality and innovative healthcare programs are inaccessible to them merely because they can’t afford it or their insurance plan does not support it. When will medical billing companies start to look for efficient revenue cycle management?

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Medical Billing Services Responsibilities

Medical billing companies:

  • Process data gathered from the healthcare organizations
  • Code diagnostic procedures/services for each patient according to the CPT and ICD 10 codes
  • Bill each rendered service and create medical claims according to the insurance company’s guidelines
  • Submit claims to insurance companies and wait up for EOB (Explanation of Benefits statement)
  • Reimburse clinicians when Health Insurance Company accepts medical claims

As the process explains, many things can go wrong throughout the medical billing and coding and overall revenue cycle management process. The things we talk about are easy said than done. Managing everything while being compliant with HIPAA rules is indeed stressful. And, when you do not get desired results at the end after all the tiring work hours, it becomes even frustrating for medical billing services. Therefore, ensuring quality checks beforehand is good practice.

To make survival possible for healthcare organizations, medical billing outsourcing companies must ensure the following quality checks occur to work out in the best way possible for physicians.

Check Cost Collection Percentage

This step is particularly essential for those medical practices that do in-house medical billing and coding.

Make a total of all the expenses bore during the follow-up services and medical billing and coding (Preferably for a month). Ensure including other indirect expenses as the investment required for employees benefits (annual bonuses, paid vacations, sick leaves, health insurance, and more).

Divide the expenses by the total monthly earning. Now you have the cost collection. Find out its percentage, and analyze if it’s above 4%. If it’s the case, clinicians should instantly search on Google “Medical Billing Company near Me.”

Trust me, the best way to maintain bank balance in such cases is by outsourcing billing to any professional medical billing company.

Why outsource medical billing?

You are already spending way too much in the process and might not be so productive as a medical billing outsourcing company.

An expert medical billing service company offers specialty-specific billing services and has the best practices from which errors do not go unnoticed. Unlike in-house medical billings services, they implement strategies that reduced accounts receivable rates to a remarkable level while matching the volume of claims.

With proper documentation and appropriate coding techniques, you get to increase monthly collections by prominent difference.

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Accounts Receivable Management by Medical Billing Companies

This one is a special tip for medical billing services. Keep a check on your accounts receivable.

The days in which you get paid by payers have an important role in analyzing your revenue performance. If it is in between thirty to sixty days, that is ok. But, if it takes more than ninety days, you might want to settle this situation because after ninety days, take a hint that there is a good chance that your claim might go in vain.

Besides, we all are well aware of how things go with insurance companies. It is always like expect the unexpected. Not very clinicians receive reimbursements as expected.

Depending on the volume, specialty,  and payer mix (Jargon used for a percentage of revenue from private payers, patients, and government), each medical practice can write off expenses to some extent. If the charges you are waiving off are above a certain percentage, it is obvious you will not be able to meet your expenses comfortably.

Rate of Accepted Medical Claims

If the number of clean claims (medical claims accepted by the insurance companies in the first attempt) is high, it is a good sign for revenue cycle management.

The processing cost cuts down dramatically if there are fewer or nearly no errors in the medical claims, and fewer expenses mean high profit.

Review the Strategy for Payer Mix

You send different medical claims to different payers like Medicare, private payers, and more. It refers to Payers Mix. If your medical billing company is operating with this strategy, it’s good. Try to work on practices that help increase revenue percentage from each authority, for Instance, by developing claims as per specified rules of different payers.

If any medical billing company is not working with a payer mix strategy, it’s about time to try it out. Go for payer mix areas that target lesser CMS or self-pay and more commercial payers.

As a medical billing company, one has to be fully aware of revenue cycle duties and other performance categories, helping the cause of RCM.

A high percentage of revenue from governmental payers generally leads to lower overall income. Generally, commercial insurance payers pay a lot better than governmental insurances but account receivable days are slightly longer.

Compare Your Statistics with Competitors

Research if you and your competitors are checking the same number of patients on average. Based on this information, estimate if you are getting paid right at the end of the day? This is another benchmark that you need to check for efficient revenue cycle management.

Medical Billing Auditing

You might wonder if everything is going right and although your healthcare practice revenues are growing, do you worry about auditing the company and procedures?  It is, however, a great idea to review any common mistakes that cause lag in revenue generation. Auditing also sheds light on shady areas and identifies if modern standards create claims.

For this purpose, Comprehensive Error Rate Testing (CERT Audit) is a measure designed by CMS to analyze claims’ accuracy in relevance to governing bodies’ guidelines. The Centers for Medicare and Medicaid usually accept a 6% error rate. But our aim should be to compile claims with as few errors as possible to get high reimbursements.

The above-mentioned quality checks for revenue cycle management give insights into what things are going right for revenue cycle management and otherwise.  The things working well for you, keep on practicing those strategies. If not, adopt methods to generate productive, cost-effective, and automated outcomes. There is no place for obsolete systems and conventional orthodox strategies for revenue cycle management.

The only way forward is that medical billing companies strategically optimize their billing methods to generate and increase revenue.

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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. P3Care.com is a health IT consultancy & a MIPS Qualified Registry in 2018.

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