RCMS
(Revenue Cycle Management System)
Flow chart model
-By Veeresh Bikkaneti C.M.R.S)
-Email: galaxyblackhole1@gmail.com
-Blog: http://medicalbillingandcoding.blog.com/
-http://medicalbillingandcoding.blog.com/
10/28/2009
info compiled by veeresh C.M.R.S
1
New Employee
•employee selects insurance payer
•employer collects premium
•employer pays premium to payer
Pre-Visit
•Patient makes
appointment
•Registration
completed in system
•Patient given office
policies
•insurance verified
with payer
•referrals &
authorizations
obtained.
Contract
•Finalize contract
•educate practice on contract
•Physician credentialing
Check -IN/Visit
•Patient pays co pays/
Bank
Deductible
•Insurance card copied
•physician sees patient
•payment posted to account
•physician documents medical record
•physician completes encounter form
•Actual Vs. target reports
•coding accuracy
•payer performance
Insurance & Patient Follow-Up
•Account Follow-Up
•Patient referred to collection agency
•Credit balances resolved.
Patient
Medical
Group
Analysis & Reporting
Employer
Payer
Charge Entry
•Encounter Forms Audited
•Charge entered into system
•Charges scrubbed
Payments
•payer pays claims
•Check and EOB received by Bank
•Money deposited
•Deposit reconciled at practice
Denials
•claim denied by payer
•EOB received and posted
•claim corrected
•claim reset to payer
Claims
•claim Created
•claim sent to payer
•acknowledgment received.
RCMS : Responsibility and
Functionality
Responsibility
Functionality
Administration
Practice
Registration
coding Charge
capture
Reimbursement,
Fees and
credentialing
Revenue cycle
10/28/2009
info compiled by veeresh C.M.R.S
3
RCMS : Responsibility and
Functionality
Responsibility
Functionality
Billing Office
Billing Office
Collection agency
Claims transmission
payment posting
Insurance Follow- Up
Patient Follow- UP
Patient Collections
Traditional “billing Office”
Revenue cycle
10/28/2009
info compiled by Bikkaneti Veeresh C.M.R.S
4
RCMS : Responsibility and
Functionality
Responsibility
Functionality
Accounting finance
reporting
Revenue cycle
10/28/2009
info compiled by veeresh C.M.R.S
5
The Revenue Cycle: Billing Tasks
Payer contracts
Pre visit or
Benefits
determination
Payer Rejections
Front Desk Visit
Edits
Post the Visits &
charge entry
Billing &
collections
Reports & analysis
10/28/2009
info compiled by veeresh C.M.R.S
6
• Practices Need to Attend to Compliance issues though out the
revenue cycle.
• Billing process is often described as having both front End and
back end.
• As more care became “managed”, however, the End-to- End
process evolved so that billing now starts, When the Patient
calls to make an appointment.
• All functions outlined below represent Reimbursement
functions for the medical practice. Now this is clear that billing
and collection is no longer only a back office responsibility.
10/28/2009
info compiled by veeresh C.M.R.S
7
Front end and back end billing
functions
Front End Functions
Back End Functions
Appointment scheduling
Billing edits
Registration(demographic and insurance)
Claims to payers
Check – in Process
Account receivable follow-Up
(by payer type)
Check – Out Process
Account receivable follow-Up
(by payer type)
Referrals and Pre-Authorizations
Statement s to patients
Coding
Payment posting
Charges Capture and entry
Payment Variance Analysis
Financial counseling
Denials posting and resolution
Cash at time of service
Reporting results and analysis
10/28/2009
info compiled by veeresh C.M.R.S
8
Step1. Pre Visit
Revenue cycle
Business Pre-visit
•Registration
•Insurance verification
•authorization
Step2. Check-In
Patient Check -in
•Time-of-service payments
•Real time system updates
Provide service
•Inpatient
•Outpatient
10/28/2009
Step3. Charge Capture and Charge entry
Service capture -Inpatient
•Inpatient charge report
•Hospital face sheet
•Provider documents services
•Provider identifies procedure
and Diagnosis codes
Service capture –outpatient
•Outpatient charge report
info compiled by veeresh C.M.R.S
Review
•Compare with provider
schedule/contract with
the payer
•Missing charge reports
•Hospital reports and
logs
•Audit coding to
documentation
9
Charge entry
•At site or central billing office
•Daily recap balance
Step4. claims process
Generate and submit
claim
•Electronic or manual
yes
no
review
•Review edit report
•Correct claim
10/28/2009
info compiled by veeresh C.M.R.S
10
Step 6&8 Follow –up and collections
Transmit/mail claim
•Electronic claim submission
•Paper claim mailing
Print confirmation
report
•Claims#, $ amount
•Accepted , Yes/ No
Account –
Up and collections
•Reviews outstanding
A/R
•Research /review
•Request additional
information
•Resubmit/update claim
No
Step7. Denial
Management
Yes
Open mail
•Prepare batch.
•Endorse checks
•Prepare deposit.
10/28/2009
info compiled by veeresh C.M.R.S
11
Step5. payment posting
Payment posting
•Post batch.
•Prepare secondary
claims
•Flag appeals, rejections,
refunds.
•Balance batch
Yes
Spend $$$$$$
No
Research /review
•Call provider relations
•Follow instructions for appeal
•Process refund
•Continue to follow account
10/28/2009
info compiled by veeresh C.M.R.S
12
Thank you
10/28/2009
info compiled by veeresh C.M.R.S
13