Revenue Cycle Management

Reimbursement for physician practices has been impacted by numerous trends and changes in the healthcare industry over the last decade. Medicaid and Medicare programs have started reducing doctor reimbursement. In addition, third-party payers have negotiated fee-for-service contracts with physicians, which has resulted in less reimbursement. Because of these issues, many medical practices are searching for ways to improve their revenue cycle processes.

 

The Foundation of a Revenue Cycle

 

Every physician office needs a good base on which to build a revenue cycle. The foundation includes basic tools for your medical practice, along with good common sense. Patient relations by providers and staff go a long way to maintaining a loyal patient base. Ongoing staff education regarding all processes in the revenue cycle will help reduce problems in your office.

 

Another important foundation process is a good practice management system. The system must suit the needs of your practice. In addition, office managers and billing professionals must be trained in revenue cycle management, which includes knowledge about the functionality of the system. The management professionals should support and provide training to others who need to enter data, retrieve data, or generate reports from the system.

 

One basic support for the revenue cycle is the medical practice’s financial policy. This policy should be reviewed by legal counsel. The financial policy must provide guidance to patients regarding collection of co-payments, unpaid balances, patient responsibilities, insurance information, insurance requirements, and payment expectations. Finally, building files into the practice management system is vital. This includes loading and maintaining accurate payer and patient information.

 

The Revenue Cycle Processes

 

Many processes makeup a healthy revenue cycle. These include:

 

  • Front office management – The revenue cycle begins with scheduling the patient. The medical practice should use a check sheet or script guide to assure all pertinent information is collected at time of scheduling. The patient’s insurance data must be keyed into the computer, along with information used to collect co-pays and other payments. In addition, it is necessary to have one staff member designated to pre-certification and prior authorization work.

 

  • Medical record documentation – The provider must electronically document the office visit and services provided into the electronic system. There should be a written policy that addresses key issues involved, such as timeliness of records, recording patient’s name, dating entries, recording procedures performed, and documenting diagnosis for each visit. The policy must also address what nursing/medical assistant is responsible for services provided. A template often is used to assist providers in the medical record documentation process.

 

  • Charge capture – This may be in the form of a charge ticket or encounter form. The charge capture is vital to a healthy revenue cycle. All services and procedures should be billed to capture maximum reimbursement. Most practice management systems can produce customized encounter forms with a tracking capability. This saves system support costs and permits a more timely edit to the encounter form. In addition, all diagnoses should be marked on the encounter form to support the procedures given in the medical record. Internal audits are done to evaluate the documentation.

 

  • Proper coding – The medical practice should establish a person in charge of verifying correct codes for procedures, services, and diagnoses. Those responsible for coding should receive proper education and training. Coding and billing falls under the Evaluate and Management (E&M) guidelines, and is often payer-influenced. When payers require certain coding measures, the person in charge should adjust these factors as necessary.

 

Resources

 

Centers for Medicare and Medicaid Services Internet-Only Manuals. Retrieved from: http://www.cms.hhs.gov/Manuals/.

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