How does RCM differ from traditional billing?

Within traditional fee-for-service care delivery models, billing was characterized by the tasks and functions performed in the back office and was not often viewed as a shared responsibility between front office, back office and clinical staff. Today, billing strategies must evolve and mature within provider organizations to reflect clinically driven RCM models that proactively address payment even before a patient enters the office door.

For example, clinically driven RCM would involve conducting eligibility checking before a patient arrives in the office. But it’s not just about financial aspects. Clinically driven RCM takes an overall proactive approach to patient health, including reaching out to patients to remind them when it’s time for check-ups, services and procedures that may be required to maintain control over chronic conditions, such as diabetes and high blood pressure

As healthcare’s lean, quality-driven healthcare climate continues to unfold, revenue cycle depends on the complete and accurate documentation of patient information, beginning at the point of registration and extending through the clinical documentation process. One single gap in data can significantly impact revenue streams. For instance, if the front office staff is unable to get all the patient information required for payment or fails to check for eligibility, the downstream impact can be significant billing delays or irreversible claim denials. Lack of proactive outreach up front can also lead to workflow inefficiencies as back-office staff members are forced to spend valuable time correcting front office errors rather than engaging in timely follow up with payers. The reality is that only a fraction of problematic claims are ever resolved. Greenway Health research finds that only 62 percent of practices review delinquent claims and only 59 percent of secondary claims are filed due to back-office time constraints.

Often, RCM practices that hinder optimal billing performance can be traced back to four common mistakes in practices:

1) Not focusing on process: Billing glitches can originate in many areas of practice operations, especially during times of peak scheduling. When many patients are coming in and out of the doors of a provider organization, key patient information may be miscommunicated, overlooked or even lost. Billing processes must be standardized and optimized as a “cycle” that is clinically driven and embraced by all staff.

2) Neglecting critical information: There are a lot of documents that move through a practice. While managing all the critical information contained in these documents may seem overwhelming, it is a task that providers must embrace to optimize revenue opportunities. For instance, when organizations understand the nuances of payer contracts, they are in a better position to fully leverage payment and negotiations. Equally important is staying on top of edit reports, explanation of benefits forms and other claims issues, and making sure denied claims are reworked and resubmitted as needed.

3) Failing to follow up: Many strategies are employed by provider organizations to improve collections, including appeals, tracers, collections letters and payment plans. While these tactics are a good first step, many fall short of success due to lack of followup. Often, by the time a practice realizes a patient has not responded, it’s too late to collect the money owed.

4) Drowning in details: Details are important, but when billing practices become all about miniscule issues, organizations can neglect the bigger-picture revenue opportunities. For example, if practices look for trends, such as repeated claims denials for the same services or claims that are denied for registration errors, processes can be reworked to eliminate the potential for those errors to occur in the future.

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