May 2024
Marilyn Burgos, MS CDMP - Marketing Manager
In this blog, we'll delve into several fundamental elements that underpin a robust revenue cycle framework. As a revenue cycle professional, you're aware of maintaining revenue cycle integrity within your organization. Collaboration across departments is essential for establishing an interconnected system that serves as the bedrock for revenue optimization. By understanding and utilizing the essential components of the revenue cycle, from patient registration to coding, healthcare organizations can unlock the potential for revenue integrity optimization.
Patient Registration and Eligibility Verification
The first pillar of the revenue cycle is patient registration and eligibility verification. Accurate and efficient registration processes can impact revenue capture and minimize claim denials. Processes include:
- Verifying patients' insurance coverage.
- Capturing correct demographic data.
- Leveraging technology-driven solutions to streamline this critical process.
Documentation
Following a patient encounter, providers undertake the task of concise documentation. However, physicians may need to dedicate more time to comprehensive documentation amidst busy schedules and complex cases. Stringent policies further compound this challenge, leading to potential claim denials due to incomplete or inaccurate information. Thus, documentation serves as a crucial safeguard against payment denials, emphasizing the need for accuracy and intentionality in the documentation process.
Coding
Once documentation is complete, the coding department takes over. Many organizations face a shortage of professional coders dedicated solely to coding tasks. Consequently, coders may juggle multiple responsibilities, including coding, medical appeals, and other tasks, leading to inefficiencies. While AI-driven coding programs offer potential solutions, they also pose risks, such as introducing biases and lacking transparency. Thus, careful utilization of these tools is essential to mitigate adverse outcomes.
Billing
Implementing AI-driven tools to improve claims submissions requires consideration of advancements in payer technology, which may lead to increased claims denials. Evaluating payer contractual agreements and conducting risk analyses before implementing new health information systems is crucial. Additionally, unnecessary administrative expenses and claims denials impact hospitals' bottom lines, necessitating proactive measures to address these challenges.
Reimbursement
Various factors, including changes in Medicare payments and regulations, affect reimbursement. The appeals process, in particular, is time-consuming and resource-intensive, potentially diminishing healthcare providers' efficiency and impacting patient care. It's imperative to regularly reassess the foundation of revenue cycle management to improve billing and collection cycles while mitigating complexities proactively.
Let's recap, once the patient's eligibility is properly verified and registered in your system, we recommend revisiting the following four basic tenets:
- Documentation: Maintain focus and intentionality in documentation.
- Coding: Conduct internal audits and provide continuing education for coding teams.
- Billing: Proactively track denials and understand insurer filing requirements.
- Reimbursement: Conduct quarterly audits, review contracts, and establish financial contingency plans.
While innovation is essential, it's equally important to align organizational goals with:
- Refocusing: Review revenue cycle objectives frequently to ensure increased operational efficiencies, including strong documentation practices.
- Entitled Revenue: Reevaluate payer contracts to optimize long-term revenue.
- Staff Development: Invest in team development to improve morale, increase contributions to process improvement, and enhance job competency and retention.
At CBIZ KA Consulting, we provide comprehensive revenue cycle solutions and enterprise risk management services to assist management in making well-informed decisions. For questions about our revenue cycle services or to discuss how we could assist you, please contact us at 609-908-0990 or email us at [email protected].
A bit about the author:
Before diving into the world of marketing, Marilyn spent over 15 years working in various roles within the healthcare community. Her extensive experience in the field has provided her with valuable insights and a deep understanding of the industry. In addition, Marilyn's passion for sharing knowledge led her to coauthor a medical billing and coding book. Follow her on LinkedIn.
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