Revenue cycle management (RCM) encompasses all the administrative and clinical functions that contribute to the identification, capture and management of patient service revenue. A periodic review of RCM basics may uncover opportunities for process improvement within your organization. Points to consider:
- Do you have in-house support, or will you outsource RCM, billing and coding functions? If outsourced, do you receive consistent reports and feedback on your practice’s billing and coding?
- Do your providers and support staff receive ongoing education on Evaluation and Management (E/M) and billing considerations specific to house calls?
- Are your providers responsible for selecting their own billing codes or do you have an internal coding review?
- Do you monitor certain services (e.g., time-based) for accuracy and completeness prior to claim submission?
- Are progress notes locked and signed within 72 hours? Who monitors open encounter lags?
- How quickly are claims being paid and who follows up on outstanding unpaid claims/denials?
Also, be sure not to overlook the following:
- Credentialing – Documentation of each payer enrollment process and ensuring all providers are credentialed with each payer.
- Office of the Inspector General (OIG) Compliance – Section 6401 of the Affordable Care Act (ACA) requires providers to develop and implement a formal health care compliance program.
- Denial management process – Examine, resolve and/or appeal claims to recover lost revenues.
Finally, remember that, whether managed in-house or outsourced, successful RCM strategies depend on the accuracy and thoroughness of front-end tasks, such as verifying active insurance coverage prior to visits and the effective denial management process mentioned above.