Choosing the Right Healthcare Revenue Cycle Management Solution

Choosing the right revenue cycle management (RCM) solution for your practice is an important decision. In healthcare, RCM encompasses the entirety of the patient’s journey from scheduling the first appointment through patient billing. It also extends throughout the lifecycle of the patient’s relationship with your organization. 

In most consumer-related RCM practices, the process is simplified. In healthcare, RCM involves the coordination of all the administrative and clinical functions of the practice. There are several options.  

Some healthcare organizations hire in-house staff to manage the revenue cycle management process, while others outsource all or some parts of RCM. For organizations handling any of the RCM processes internally, finding the right software solution is integral to managing all of the moving parts effectively. 

What Is Revenue Cycle Management? 

Healthcare organizations have a lot of responsibilities to consider. The most obvious and highest priority is the quality care of patients. However, revenue cycle management is also essential. In the complex landscape of healthcare, a precise and efficient process helps organizations flourish and provide the best services and outcomes for their patients

The Typical Cycle in Healthcare Includes: 

• Registration and Pre-registration. This step of the process includes the collection of information that will be necessary to process claims, execute medical billing, and even counsel the patient to help budget medical costs. Some of the information collected at this stage includes insurance information, medical history, consent forms, personal information such as social security numbers, and consent forms.  
• Medical coding. Assigning appropriate medical codes to procedures and diagnoses is essential for the treatment of patients and for submitting accurate claims for insurance and billing.
• Claims submission and processing. Preparing and submitting claims to insurance companies or government payers involves ensuring accurate information, attaching supporting documents, and following guidelines. Once submitted, the insurance company or payer reviews and verifies the information. They and determine the reimbursement. 
• Denial management. Handling claims that are rejected or denied by payers and taking appropriate actions to appeal or correct the errors that led to the denial. This process involves identifying the reasons for denial, resubmitting corrected claims, and addressing any coding or documentation issues.
• Payment posting. Recording and reconciling the payments received from insurance companies, patients, or third-party payers. It involves updating patient accounts with the payment information, including adjustments, co-pays, deductibles, and write-offs. 
• Accounts receivable (AR) management. Monitoring and managing outstanding balances, tracking unpaid claims, and following up on unpaid or partially paid claims to ensure timely and complete reimbursement. 
• Patient billing and collections. Generating patient statements, sending invoices, and managing patient payments and collections for services not covered by insurance or for patient responsibility portions such as deductibles, co-pays, and co-insurance. 
• Patient payment counseling. Using a comprehensive RCM solution can help you get a full picture of the patient, to flag those who might need extra help. Staff can aid them by explaining their coverage, offering options of treatment, and even helping them to find resources, such as government plans that might apply for their budget. 

It’s a complex process that includes many moving parts. Combined, these tasks allow healthcare organizations to optimize their financial performance, reduce claim denials, improve cash flow, and maintain compliance with healthcare regulations and payer requirements.  

Investing in an RCM solution, or outsourcing RCM offer excellent options for healthcare organizations 

When Should You Look for an RCM Company? 

Is there a threshold? When do you know it’s time to outsource to an RCM company or upgrade your solution? 

Here are a few tell-tale signs that it’s time to invest in a solution: 

1. Too much burden on your administrative staff. If your staff is no longer able to keep up with the tasks related to the RCM cycle or if you’re noticing many denials or mistakes, it may be time to outsource or bring in a good solution to help staff manage the workflow. 

2. Budget constraints. Often, outsourcing is more cost-effective than hiring in-house staff with the same expertise. If you find that staff is struggling to accomplish tasks outside of their knowledge base, outsourcing could be a good option. 

3. Concern about compliance. A great RCM solution includes safeguards to maintain all of your regulatory compliance requirements and keep your practice up to date at all times. 

5 Things to Look for in New RCM Software 

In choosing a new RCM solution, the practice should consider what is working with their current solution, as well as aspects they’d like to improve. There are many good models, but the right model for your practice will streamline efficiency and offer your staff the best tools to meet their goals. 

Here are five important qualities to look for in RCM software: 

1. Reporting and analytics – Using reports and analytics you can gain a greater perspective of your practice’s financial health.  Reports such as denial rates, revenue trends, and KPIs (Key Performance Indicators) you can identify areas of improvement and make informed decisions.  

2. Compliance and security – All RCM software should comply with healthcare regulations such as HIPAA.  There should be security measures in place to protect (PHI) Protect Health Information from unauthorized access or breaches. 

3. Ease of Use – The system should be user-friendly. Ensure that adequate training is provided for a successful implementation.  

4. Scalability – An RCM software needs to have scalability to meet the on-growing needs of your organization.  

5. Customer Support – Make sure to work with only vendors that offer ongoing reliable customer support.  

Choosing the right RCM company for your practice is vital for improving financial efficiency and optimizing your revenue cycle process.  By considering these factors you can RCM solution that aligns with the needs of your practice.