The revenue cycle may not be the first thing that comes to mind when thinking about health care. But administrators know that an efficient revenue cycle is critical to the overall functioning of the health care delivery system. Keeping the process in top condition needs to be a priority.
Let’s take a look at some of the key areas in the system where efficiency and accuracy can make the operation run smoothly…or come off the rails.
- Scheduling and pre-registration start the ball rolling. Quite a bit of useful information can be gained during the scheduling and pre-registration dialogue. How thorough is the pre-registration staff? Can they obtain all necessary information while handling multiple inquiries?
- Point-of-service registration counseling and collections are the next significant opportunity to gather data, while obtaining initial reimbursement. This may be the first “face” of the facility for the patient. A detail-oriented approach combined with a customer service orientation is ideal for employees in this area.
- Utilization review, the “evaluation of the necessity, quality, effectiveness, or efficiency of medical services, procedures, and facilities,” is a process that provides material that can significantly impact the likelihood of maximized reimbursement. Done well, it provides information for current and future reimbursement scenarios. Up-to-date training for utilization review managers makes that more likely.
- It is difficult to overestimate the value of the next piece in the revenue cycle. Charge capture and coding move the theoretical to the concrete. Services provided are captured as billable fees. And medical diagnoses and procedures are translated into universal code. The recent adoption of ICD-10 has brought a new learning curve to this area. Errors here mean delays at best, and lost revenue at worst.
- The next move involves submitting the claim to the insurance company. Claim submission requires accuracy and timeliness. Languishing claims, or those incorrectly rendered, can slow the revenue cycle with alarming frequency. A systematic, organized approach to claims submission remedies this headache.
- Third party follow-up demonstrates where persistence pays. Pursuing payments may in theory be unnecessary if the claims were correctly submitted in a timely manner, but the reality is that the system requires follow-up. Dogged determination is an asset.
- The next step is kind of like magic – making the money appear. Payments and adjustments must be posted to the correct accounts. Rejects must be identified and recorded. If it’s not posted, it doesn’t exist in the eyes of the revenue cycle.
- And then there are the stragglers – slow payers have to be pursued, sometimes via collections, and appeals must be filed. This step is an attempt to gather the most reimbursement possible in a given cycle. See dogged determination, above.
If, at any point, the revenue cycle slows, whether through human error, staffing issues, technology malfunction, or lack of knowledge, the health care system as a whole slows. A comprehensive review of an organization’s revenue cycle identifies areas with potential for improvement, including training opportunities. It may be just what the doctor ordered!