RCM for Healthcare 101

Since 2020, staffing issues have plagued the revenue cycle management industry. This trend has forced RCM professionals to become more adaptable and willing to take on additional roles unexpectedly. It’s been brought to our attention by some of The Modern Healthcare Back Office listeners that our podcast is their main resource for educational RCM material.

We found the statements flattering at first, but upon further investigation, we discovered this was largely in part due to the lack of quality information available online about the subject for HME and infusion pharmacy providers. On this episode of The Modern Healthcare Back Office, we decided to act out an exchange between an inexperienced professional picking an RCM expert’s brain. 

Novice: What exactly is the revenue cycle?

Expert: The revenue cycle is the process a patient goes through. From a provider's perspective, the revenue cycle begins when they are first made aware they need to supply a patient with a product.

Novice: How do you start the process?

Expert: The first step of the revenue cycle is registration. Registration consists of identifying and documenting the patient's key basic demographics like name, date of birth, and address.

The second step is figuring out who’s paying for the order. Find out what kind of insurance the patient has and what percentage of the payment they’re responsible for.

The third step is identifying if there are any requirements that need to be met before it can be approved. The patient must possess all necessary documents before moving forward with the order. For example, a person receiving a CPAP machine has to provide documentation of their sleep study to acquire the device. 

The fourth step is checking if the patient’s insurance is valid, active, and covers the item that’s trying to be purchased.

Further Questions

What happens when everything is approved?

Once everything is together and approved, you get the claim transmitted to the insurance company. Transmitting a claim is the technical term for billing. Not only do you want to see the claim leave your system, but you also want to receive confirmation from the payer that they received the claim.

Once you receive confirmation, you’ll have to wait anywhere from one to three weeks to get the verdict on the claim. Their response will be one of these three possibilities:

1. A payment back
2. A denial 
3. No response (the worst of the three outcomes)
   
   

What happens when you get a denial?

The name can be a bit deceiving, but denials aren’t bad. A denial simply tells you why you’re not getting paid. There are multiple resources available to find out what’s causing it. Medicare has a website that allows you to plug in a denial code or remark code to find out what’s keeping the order from being processed. For non-Medicare patients, providers can resolve almost any denial scenario by simply Googling it.

What do you do if you don’t receive a response to a claim?

When a claim doesn’t get a response, the first thing to do is go to the payer’s website and try to log in to check the status of the claim. Thanks to online chat capabilities, you can also inquire about an issue with a representative on most websites. If you’re unable to access a payer’s website, unfortunately, you’re going to have to pick up the phone and call them.

The whole goal of the revenue cycle is to move from registration to the claim being closed and paid out with as few touches as possible. You can hear the full breakdown of the revenue cycle below: