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Revenue Cycle Management (RCM)

RCM is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance. The revenue cycle includes all the administrative and clinical functions that contribute to the capture, management and collection of patient service revenue.

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Patient Scheduling and Eligibility Verification

This includes educating patients on the cost of the care they will receive, their insurance coverage and their individual responsibility. It also involves taking the time to understand an individual’s financial situation and determine the best way for the patient to manage their healthcare costs. HFMA has published best practices around:

  • When and where financial conversations may be conducted
  • Who would be best to participate in these discussions
  • What topics should be covered
  • Guidance for discussing issues such as financial assistance and prior balances

Patient Visit and Clinical Documentation

In healthcare revenue cycle, charge capture is essential. To process an insurance claim for healthcare services, every aspect of care must be accurately captured. Unless charge capture is performed correctly, the hospital or healthcare facility will not be paid for the care and services provided.

Superbill Completed by Provider

A Superbill is used by healthcare providers as a primary source of data for creating claims. These claims will eventually be submitted to payers for reimbursement. Essentially, a Superbill is an itemized list of all services provided to a client. The Superbill will also contain additional information about the patient visit including practice information, CPT codes, ICD-10 codes, referring doctor and more.

Patient Payment and Co-Pays Obtained

System with improved workflows for collecting co-pays and deductibles from patients, it reduces the stress of cash flow management and other financial concerns. At the same time, digital forms decrease the administrative burden on your staff members, helping the team focus on what matters most: the health of each patient.

Coding and Billing

Medical coding involves extracting billable information from the medical record and clinical documentation, while medical billing uses those codes to create insurance claims and bills for patients. Creating claims is where medical billing and coding intersect to form the backbone of the healthcare revenue cycle.

Claim Processing

Healthcare claim processing is complex work. From scheduling patient appointments to filing a claim with the patient’s insurance company, attention to detail and data integrity — the degree to which data are accurate and complete — are critical. Unless claims are filed in a timely manner, include all of the information necessary to process the claim, and sent to the correct place, the claim could easily be denied. When this happens, a healthcare provider will not receive payment unless it can successfully appeal the denial.

Patient Statement

Patient statement is the final step in the medical billing process. Once the payer has reviewed a medical claim and agreed to pay a certain amount, the payer bills the patient for any remaining costs.

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