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CLAIM SUBMISSION

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CLAIM SUBMISSION

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Revenue Cycle Management (RCM):

 

The process used by healthcare systems/providers to track the revenue from patients, from their initial appointment or encounter, to their final payment of balance. The cycle can be defined as, “all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.” It is a cycle that describes and explains the life cycle of a patient (and subsequent revenue and payments) through a typical healthcare encounter from admission (registration) to final payment (or adjustment off of accounts receivable) .

 

The RCM process begins when a patient schedules an appointment. It ends when the healthcare provider has accepted all payments. Errors in revenue cycle management can lead to the healthcare provider receiving delayed payments or no payment at all. Because the revenue cycle process is complex and subject to regulatory oversight, healthcare providers can turn over their revenue cycle management to companies that handle this complex process 24/7 with specialized agents and proprietary technologies to manage healthcare provider revenue cycles.

 

Registration:

 

The first function within the revenue cycle is the registration function, which allows Paragon to obtain all of the necessary data needed in order to properly bill an insurance company (per the ANSI 837 5010 standards and requirements). Clerical errors that are made within patient registration processes are some of the largest causes of non-clinical denials from insurance payers. This can include many errors such as inputting an incorrect date of birth, not validating current insurance coverage/benefits, misspelling a guarantor’s name, etc. Normally, these errors are identifiable with experience, and are amended prior to submission. If not caught prior to submission, a new bill will be generated to most payers after correcting the few mistakes made in the registration department. It is critically important to monitor denials on a daily basis in order to identify how much of denial ratio is generated from these clerical errors so that both training and education can take place with the appropriate staff.

 

Medical coding:

An important aspect of the revenue cycle is compliance with coding regulations. Optimal coding compliance results in higher revenues and decreases claim denials from insurance companies. By achieving optimal coding, we help prevent disruption of the medical flow and avoid regulatory penalties.

 

Billing/collections:

The billing/collections team are responsible for submitting a complete UB-04 claim (facility and ancillary billing) or a CMS1500 form (physician billing) to the insurance payers after a patient has received services for either an inpatient or outpatient type of visit. A claim scrubbing system is used to ensure that claims are as clean and complete as possible, including edits that may automatically update the raw claim data received from the host system. The intention of this scrubbing is to inevitably avoid generating a potential denial from the payer, which can prolong reimbursement to a provider. The claim is then sent out in an ANSI 837 5010 standard format.

Denials can be sent back as a response to the claim from the payer stating a specific reason of why the claim cannot be adjudicated. This is where our denial management processes help to ensure that there is an expeditious resolution to any denials. Denial management can also help to identify if there are trending issues within a provider’s workflow processes, whether it be clinical or clerical-related.

“There are so many positives – to be totally honest with you – the system is so simple to use and you can access it from anywhere. You can even be in the car wash which I’ve done before actually – and its still so simple.”

Heather Boorman, MSW, LCSW

Founder, Boorman Counseling

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