According to the Healthcare Financial Management Association (HFMA), revenue cycle management (RCM) is the process of “all administrative and clinical functions contributing to the capture, management, and collection of patient service revenue.”
Front-end vs back-end – what’s the difference?
Front-end relates to direct interaction with patients at or prior to services, as when checking in or booking an appointment. Back-end pertains to claims management and reimbursement for services. Although considered separate operating functions, the front-end processes are critical to the ultimate success of the back-end. Front-end tasks include:
- Patient appointment/scheduling
- Collecting insurance or other payer data from the patient during registration
- Verifying insurance eligibility and authorization
- Performing patient collections at the time of service
- Minimizing lost revenue through every step of the patient encounter by attention to the steps of the entire RCM process from appointment to receipt of payments
- Offering various payment methods such as credit card, online, phone payment, and check-in kiosks are proven ways to ease the financial burden on patients.
- Posting clear-cut financial policies on the provider’s website will help reduce misunderstandings at the outset, as will working with patients to create workable plans to pay off the balances within a reasonable time frame
Due to the level of administrative experience and skill required to successfully perform the above tasks, many practices have turned to collaborating with an outside medical billing service to help manage their front-end RCM. Below are steps Bikham takes to ensure excellence in RCM:
Invest in Administrative Staff
A good medical billing and management service stresses personnel experience and on-going training for clients who have entrusted their revenue cycle management tasks. This is one of the most critical and expensive facets of controlling the revenue cycle and one where mistakes are most often made, especially where front-end staff also do double duty performing other clinical or administrative tasks. Bikham’s experienced, highly-trained personnel help ensure a higher level of accuracy and timeliness in claim submission, tracking, and collection of revenues.
Step 1: RCM Software or Outsourcing Processing
- The initial cost of acquiring and setting up RCM software, including staff training, can be prohibitively expensive, especially for smaller practices and facilities.
- Software interfacing abilities are critical to connecting across varied platforms with insurance carriers, Medicare, and other payers.
- Updates to software are required periodically, requiring further expenditures for training and making up staff downtime.
- Bikham offers customizable RCM modules to stay on top of your revenue, including deploying and managing secure patient information storage solutions.
Step 2: Eligibility & Benefits Verification
The front-end staff needs to determine whether:
- The patient has insurance or other forms of insurance coverage
- There are additional payers, such as with a spouse’s policy
- The patient registration information is correct, including contact information and medical history
- There are maximum allowable amounts for visits or treatments
- The patient’s cost responsibility
Bikham makes sure that your patients have the coverage for procedures and other treatments to reduce eligibility-related denials, resulting in a 7-10% increase in revenue.
Step 3: Claims Submission
All outgoing claims need to be checked before being submitted to ensure that reimbursable charges are maximized without over-coding or other errors.
Bikham has increased client revenue by as much as 10% – 20%, with a goal of 100% claims reimbursement on first-attempt HCFA (Health Care Finance Administration). Bikham’s coders are kept up-to-date on the latest coding and regulatory changes to ensure first-time reimbursement.
As a result, our clients have a success rate of nearly 100% for first-attempt HCFA, as well as UB clearinghouse claims involving workers compensation and no-fault claims.
Step 4: Payment Posting
Although usually considered part of the back-end portion of the revenue cycle, accurate posting as a critical aspect in the RCM process is enhanced when administrative personnel know the estimated co-pays and other out-of-pocket costs up front to help prepare patients for payment at time of service or entering into a payment plan. Bikham posts and reconciles Explanation of Benefits (EOBs) and Electronic Remittance Advice (ERAs) daily for review by your own staff.
Step 5: Denial Management
Does your billing staff know the difference between Claims Denial and Rejected Claims?
- A denied claim is one which made it to the payer, however, reimbursement was denied due to failure to meet the carrier’s or payer’s criteria.
- A rejected claim never made it to the carrier/payer for processing.
Paying attention to the front-end functions is important to reducing denials further down the chain of processing, as many denials are often due to front-end errors and omissions, including:
- Inability to verify insurance due to job or carrier status changes
- Incorrect carrier or other payer information from patients
- Changes in a carrier’s coverage plan as well as changes in payouts for services
- Failure to obtain pre-authorization or pre-certification approval prior to beginning treatment or performing a procedure
Bikham’s experts have experience in overturning all kinds of denials, whether from benefits exhausted, medical necessity, coding errors, patient benefit changes, pre-auth and other issues.
Step 6: Reporting
Generating accurate and detailed reports of the revenue cycle in all stages, especially with missing, denied or resubmitted claims, is an essential function of good RCM transparency.
- Bikham’s billing teams share workflow logins with clients, with weekly reports.
- Monthly RCM sessions with clients are also held to explain all aging and other revenue reports, right up to any collections.
The Best Way to Maximize RCM Potential
The best way to optimize your RCM’s potential is to work with an experienced medical billing and practice management company which has the personnel, technology and dedication to properly client service and to oversee all aspects of the revenue cycle from checking and submitting the first claim to the final payment posting.
Bikham has the experience practices need, regardless of size or specialty, from their RCM provider, as well as the capability to complete every task successfully within its required time frame. Contact Bikham by email or phone (1-800-940-4943) to learn more about how they can help you take control over your RCM as you grow your practice.
