Posted: January 17th, 2024

Best practices for revenue cycle management and claims processing

Best practices for revenue cycle management and claims processing
Revenue cycle management (RCM) and claims processing are essential aspects of healthcare delivery. RCM is the process of managing the financial transactions between healthcare providers and patients, from registration to payment. Claims processing is the process of submitting, verifying, and reimbursing medical claims from insurance companies. Both processes require accuracy, efficiency, and compliance to ensure timely and adequate reimbursement for the services rendered.

Some of the best practices for RCM and claims processing are:

– Implementing electronic health records (EHRs) and billing systems that are integrated and interoperable. This can reduce errors, duplication, and delays in data entry and transmission, as well as facilitate coding, documentation, and reporting.
– Adopting standardized coding systems, such as ICD-10, CPT, and HCPCS, that are consistent with the latest regulations and guidelines. This can improve the quality and specificity of the claims, as well as reduce denials and rejections.
– Automating and streamlining the workflow of RCM and claims processing, such as using automated eligibility verification, prior authorization, claim submission, claim status inquiry, remittance advice, and denial management. This can enhance the speed and accuracy of the processes, as well as reduce labor costs and administrative burden.
– Training and educating the staff involved in RCM and claims processing, such as coders, billers, collectors, and auditors. This can ensure that they have the necessary skills and knowledge to perform their tasks effectively and efficiently, as well as comply with the relevant policies and regulations.
– Monitoring and analyzing the performance of RCM and claims processing, such as using key performance indicators (KPIs), benchmarks, dashboards, and reports. This can help identify the strengths and weaknesses of the processes, as well as the opportunities for improvement and optimization.

By following these best practices, healthcare providers can improve their RCM and claims processing outcomes, such as increasing their revenue, reducing their costs, enhancing their cash flow, and improving their patient satisfaction.

References:

[1] A. K. Jha et al., “Use of Electronic Health Records in U.S. Hospitals,” New England Journal of Medicine, vol. 360, no. 16, pp. 1628-1638, 2009.

[2] S. H. Zuckerman et al., “Clarifying ICD-10: A Primer for Coding Professionals,” Journal of AHIMA, vol. 86, no. 4, pp. 34-39, 2015.

[3] M. M. LaForge et al., “Best Practices for Revenue Cycle Management,” Journal of Medical Practice Management , vol. 31, no. 6, pp. 336-340, 2016.

[4] K. M. Sullivan et al., “Key Performance Indicators for Revenue Cycle Excellence,” Journal of AHIMA , vol. 88 , no. 9 , pp . 64 – 69 , 2017.

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