What cycle can either maximize revenue, or leave organizations barely functional? The answer is revenue cycle management (RCM), and when done properly, this allows health and human service organizations to identify best practices for getting paid for services, and identifying “issues” in this process early, instead of “down the road.” Here are the eight fundamentals of RCM:
Intake – No plan can work without data, and the input that organizations collect up-front can pay big dividends later down the road. Starting with initial contact, organizations should seek as much information as possible from the consumer, including demographic data and insurance information. And, intake staff should have certain basic information at hand – this includes a working knowledge of insurance plans, in-network therapists/physicians/CNS, and alternate agencies to where consumers can be referred.
Insurance eligibility & benefit verification – As might be expected, verifying insurance eligibility and benefits is a very important step and optimally should take place before the initial patient visit. For existing patients, eligibility and benefits should verified at least once every six months. While it sounds basic, out of date records (name, plan subscriber, insurance ID number, date of birth, address, etc…) can quickly lead to no payment, or late payment. How to obtain eligibility and benefits information? Web based tools like Availity and Emdeon are an option, while many Payers (commercial & Medicaid HMOs) have their own web portals that can be accessed with User IDs/passwords to obtain member eligibility, benefits, in some cases, clinical authorizations, and web based billing.
Communication to staff involved in client’s initial visit – It is important that all parties (intake and administrative) communicate and share information regarding insurance and authorization requirements. Identifying problems up front is always easier (and cheaper) than reacting to them later. The more hands that “touch” a client, the more opportunity there is to communicate important information, such as clinical authorization, co-pay responsibility.
Financial Counseling – For a client’s initial visit, organizations should have in place a financial counseling process for all clients receiving services, including reviewing client’s eligibility and benefits. Getting paid often comes down to setting clear expectations around client responsibilities (co-pays, deductibles, obtaining a PCP referral, coordination of benefit issues). Paperwork such as a financial responsibility form can help, and also gives staff a chance to troubleshoot any challenges regarding ability to pay for services.
Clinical authorization process – As mentioned earlier, in some cases, you are able to obtain initial and follow up visit authorization at the time of verification. Some payers authorize an initial assessment and several follow up visits (3-7 visits at a time), and have specific CPT codes for this. If authorization was not attempted, for whatever reason, most payers will deny these services and they must be “written off.” The client cannot be “balance billed.” Generally, treating clinicians will be responsible for obtaining any ongoing clinical authorizations (through phone, web portal, faxing outpatient authorization report).
Charge capture & billing – Getting paid starts with knowing what you should be paid for. Make sure that you have processes in place (electronic and/or paper) to capture the services rendered by your providers. Have an established process to review charge information and account for all services rendered before the services are billed, develop oversight systems to ensure billing is turned in a timely and accurate fashion, and then make sure the business/billing office has the insurance verification information that was obtained at the front end of this process.
Billing follow-up – All staff should be familiar with Payer’s claims adjudication process (State Prompt Pay laws, contractual requirements), and have a system in place to deal with “working denials.” This means that when a claim is not paid, it may not be a denial issue. The process outlined above should give staff ample information to pursue an effective follow-up
Management oversight – Many a great plan fails because there is no one to put (and keep) that plan into action. The solutions? Develop tools to assist staff by establishing a process to monitor denials, authorization & re-authorization of clinical services, establish a process of monitoring performance of the Payers (contracting is a two way street), and monitor denials on a monthly basis and have staff report back on actions taken and results achieved.
For an even deeper dive into revenue cycle management, check out my presentation – Getting Paid for What you Do: A Look into Developing A Revenue Cycle Management Process – delivered at the C3 CareLogic Community Conference, March 19 in Fort Lauderdale, Florida. Remember, having a good defense against non-payment often means have a good offensive – taking the steps to get paid can only increase the likelihood that an organization will collect on services rendered.
For another free resource, see: A Revenue Cycle Management Primer all members