A Deep-Dive Into Healthcare Revenue Cycle Systems and Processes

Where proper healthcare revenue cycle systems can make operations 10x efficient, the absence of it can lead to bankruptcy. Read for valuable tips.
healthcare revenue cycle systems

Healthcare revenue cycle systems and processes can be defined as the solutions used by healthcare providers to keep track of revenue generated from patients.

The healthcare revenue cycle starts with a hospital visit or the time an appointment is made. It ends when the healthcare provider is paid the entire amount for all the services provided. There are different steps in the healthcare revenue cycle.

These include:

  1. Pre-registration and registration.
  2. Charge capture.
  3. Claim submission.
  4. Remittance processing.
  5. Insurance follow-up.
  6. Patient collections.

Here is a deep-dive into the healthcare revenue cycle systems and processes steps;

1. Pre-registration and Registration

The first step in the healthcare revenue cycle systems and processes is pre-registration. This process allows healthcare providers to capture eligibility as well as insurance and demographic information in real-time.

However, for this to work effectively, healthcare providers need to make sure that they have implemented an effective system, as discussed in this guide for EHR implementation.

Registration, on the other hand, ensures that all the information captured during pre-registration is accurate.

The healthcare provider ensures that things such as insurance information, guarantors, date of birth, phone number, and address are accurate. In addition, this data is securely saved in the healthcare provider’s database.

2. Charge Capture

Different healthcare providers handle this step differently depending on their requirements. Some of them automate the process. This allows all the required information to automatically flow into their system’s billing modules.

Others handle this step manually. They use front desk personnel to manually enter information into their systems or send it to the finance department where it is added to the system manually.

Both approaches come with pros and cons. However, whichever approach a healthcare provider uses, it needs to make sure that it is not missing any charges. This is important for effective financial management. Ancillary services are among the most commonly forgotten charges among healthcare providers.

3. Claim Submission

This process requires healthcare providers to share patients’ information with their insurance provider after entering all the required charges. The billing team at the healthcare provider looks at things like diagnosis code, CPT code, and charges to initiate the process.

The process also involves a procedure referred to as claim scrubbing. It can be defined as the process through which healthcare providers ensure that all claims are correct. This way, they can be paid faster compared to those with issues.

To ensure that claims are correct, healthcare providers send the claims from their EHR systems to a clearinghouse. The clearinghouse then sends these claims out for payment.

4. Remittance Processing

After sending their claims, healthcare providers get remittances. This is a form of explanation that shows the healthcare providers the services that they were paid for. It is in this step that the determination of allowables takes place.

Allowables can be defined as the contract that exists between healthcare and insurance providers about a certain service. This contract is negotiated between the two providers. The insurance provider then determines the amount of money they are going to pay.

Healthcare providers need to be careful during remittance processing. Some of them post their remittances and forget about them. This might lead to problems, delaying payments.

5. Insurance Follow-Up

Insurance follow-up requires healthcare providers to look at the services that have been paid for and those that have not. This is because insurance providers might not pay for some services offered by healthcare providers.

They (healthcare providers) use A/R (accounts receivable) to see what could be sitting on the patients’ or insurance table. They can then generate a report to see any issues that might be affecting insurance follow-up.

After that, healthcare providers are then required to follow up with insurance providers and come to an agreement for payments to be made.

6. Patient Collections

This is the last but most challenging step in the healthcare revenue cycle systems and processes. The truth is that healthcare providers would face a few troubles if they obtained money from their patients when interacting with them.

For this to happen, they need to train their staff to ensure that they are capable of collecting payment when offering a service. To avoid any backlogs, healthcare providers should create a policy that dictates how payments are collected.

In addition, they need to clean their patient collections to avoid involving a bill collector. Those that have issues with this step can consult a professional.

Even though healthcare providers do an amazing job, especially when helping people with health complications, they need effective financial policies, systems, and procedures. This is what makes healthcare revenue cycle systems and processes important.

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