So, What is The Revenue Cycle?

We talk about the Revenue Cycle, but what is it? It could, simply, be defined as the administrative and clinical functions that factor into the capture, management, and collection of patient service revenue. There you have it! Speaking normal English, it’s a fancy way of saying that this is a full view of the life of a patient account from its creation to when payment is made. Understanding what the best practices in the management of your revenue cycle are critical to having the most functional income for the services that you render to your patients in their care. We’ll go over a few of the most common bleeding points in the average management process:

• Lack of referral.
  • All is not lost if the claim is denied or returned in the case of no, or lack of, referral. You may be able to contact the patient’s primary care physician to obtain this, the provider will usually know what form or information needs to be submitted with the claim to receive approval or reimbursement. If you’re too far along in the process, this could also fall on the person who is responsible for accounts receivable. If necessary, you may have the ability to submit an appeal with medical records that support the medical necessity for the treatment provided.
• Errors in registration, coding, and billing errors.
  • This is self-explanatory. However, an error that takes place when the patient is registering with your practice, as small as spelling their name incorrectly, or submitting themselves as male instead of female, will trigger a denial. If you’re found up-coding, or miscoding, you will fall into this leakage point. If you’re billing incorrectly and misrepresenting treatment, this is another issue that will make your revenue cycle more impossible.
• No insurance verification.
  • Insurance verification is critical to understanding what is due from your patients on the day of treatment. It will also let you know if the treatment that you are providing to your patient is covered by their insurer or their policy. The critical processes in verification are:
    • Insurance name.
    • Insurance phone number.
    • Claim address.
    • Insurance ID.
    • Group number.
    • Name of the insured.
      • This may not always be the patient.
      • Relationship to insured.
    • Policy effective date.
    • Policy end-date.
    • If coverage is currently active.
    • Whether the insurance covers the proposed procedure, diagnosis, and the services that will be provided.
    • If your practice participates with the plan.
    • The Limitations of the policy, inclusive of exclusions, and documentation requirements for billing.
    • If you require a referral, a pre-authorization certificate of medical necessity for payment.
    • The patient’s copay and deductible amounts.
  • Underpayment of a claim.
    • Simply, this is used to describe when the expected value of a claim is higher than the actual payment received.
  • Appeal denial.
    • This is simple to understand, in this case, you will need to re-process the claim and send it, with whatever their denial reason is resolved so that you can receive your payment for the services you rendered at the time of visit.

If you’d like to simplify your revenue cycle, Gables Medical Billing’s team of medical billing specialists is ready to help you through the process from claims submissions, to follow-ups, appeals, and payment posting.