End-to-End RCM services

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End-to-End Revenue Cycle Management (RCM) Services

End-to-End RCM services encompass the full spectrum of processes involved in managing a healthcare provider’s revenue cycle. This includes everything from patient registration and insurance verification to claim submission, payment posting, and accounts receivable management. These services are designed to optimize the revenue cycle, ensuring that healthcare providers are reimbursed correctly and promptly for their services while maintaining compliance with healthcare regulations.

Patient Scheduling & Registration

  • Appointment Scheduling: Ensuring accurate scheduling and capturing patient details.
  • Pre-Registration: Collecting basic demographic and insurance information ahead of time.
  • Eligibility Verification: Confirming insurance details and verifying patient eligibility for services prior to treatment.
  • Pre-Authorization & Pre-Certification: Obtaining necessary approvals from insurance carriers before certain procedures or treatments.

Insurance Verification & Authorization

  • Insurance Eligibility Check: Verifying the patient’s coverage status in real-time with insurance providers.
  • Benefits and Coverage Analysis: Determining the patient’s coverage details, copayments, coinsurance, and deductible amounts.
  • Authorization Management: Ensuring the proper authorizations are secured for procedures, testing, and specialist referrals.
  • Eligibility and Benefits Verification (EBV): Regular verification of eligibility and benefits to avoid claim rejections.

Medical Coding

  • ICD-10, CPT, and HCPCS Coding: Accurate coding of diagnoses, procedures, and services rendered.
  • Code Mapping & Compliance: Ensuring proper code mapping and compliance with federal regulations such as HIPAA and CMS.
  • ICD-10 and CPT Updates: Keeping up-to-date with the latest coding guidelines and changes.
  • Code Review: Ensuring that the correct codes are assigned to reduce the risk of claim denials or underpayments.

Charge Capture

  • Accurate Documentation: Ensuring that charges are captured correctly from patient encounters, treatments, and procedures.
  • Real-Time Charge Capture: Using electronic systems to capture charges immediately following services or encounters.
  • Charge Entry: Entering the charges into the system for claim generation.

Claims Submission

  • Claim Generation: Creating and submitting claims to insurance companies or government payers (Medicare/Medicaid).
  • Claim Scrubbing: Automated or manual checking of claims for errors before submission to prevent rejections or denials.
  • Electronic Claim Submission: Submitting claims electronically for quicker processing and reimbursement.

Payment Posting

  • Payment Posting: Recording payments received from insurance payers and patients.
  • Payment Reconciliation: Matching payments to patient accounts and reconciling discrepancies.
  • Adjustment Management: Recording any contractual adjustments, patient adjustments, or write-offs.
  • Credit Balance Resolution: Managing and resolving any overpayments or credit balances.

Denial Management

  • Denial Prevention: Identifying trends in denials and proactively addressing root causes.
  • Denial Analysis: Reviewing denied claims to determine the reason for denial (e.g., coding errors, eligibility issues, or lack of prior authorization).
  • Denial Appeals: Crafting and submitting appeal letters to insurance providers to reverse denials or underpayments.
  • Denial Reporting: Regular reports to track denials and identify recurring issues.

Patient Billing & Collections

  • Patient Statement Generation: Creating clear and accurate billing statements for patients.
  • Payment Plans: Offering payment plans or financing options for patients who are unable to pay the full balance upfront.
  • Patient Collections: Managing the collection process for outstanding balances, including follow-up calls and letters.
  • Customer Service: Providing support to patients regarding billing inquiries and concerns.
  • Out-of-Pocket Estimates: Offering estimates for out-of-pocket costs before treatment.

Accounts Receivable (A/R) Management

  • A/R Follow-up: Monitoring accounts receivable for overdue payments and following up with payers and patients.
  • A/R Aging Reports: Generating and analyzing aging reports to identify and prioritize overdue accounts.
  • Collections: Coordinating with payers, patients, and collection agencies to resolve outstanding accounts.
  • Cash Flow Optimization: Ensuring that outstanding claims are collected in a timely manner to optimize cash flow.

Financial Reporting & Analytics

  • Revenue Cycle Reporting: Generating reports to monitor key performance indicators (KPIs) such as collection rates, denial rates, and days in A/R.
  • Financial Dashboards: Real-time dashboards to provide insights into the financial health of the practice or healthcare organization.
  • Performance Analytics: Analyzing trends to identify areas for improvement, such as coding errors, denial trends, or inefficiencies in the billing process.
  • Compliance Audits: Ensuring that all revenue cycle operations adhere to regulations and industry standards (e.g., HIPAA, CMS).

Compliance & Regulatory Management

  • HIPAA Compliance: Ensuring all patient data and billing practices comply with HIPAA guidelines to protect patient privacy.
  • Insurance Payer Regulations: Staying up to date with the requirements and guidelines set forth by insurance providers and government payers.
  • Fraud Prevention & Risk Management: Implementing processes to prevent fraud, waste, and abuse in the revenue cycle.