Definitive guide to Medical Billing and RCM Operations
And let me be clear about something: This is NOT your average Medical billing For Healthcare Organizations In the 2023 predictions post. I’ll cover the most important Medical billing trends this year.
Additionally, you will observe recently effective tactics that are yielding positive results. So if you’re looking to improve your Medical billing, you’ll love this updated guide.
- Chapter 1 – 24/7 Medical Billing Services
- Chapter 2 – Co-Managed Medical Billing Services
- Chapter 3 – Revenue Cycle Management Tools
- Chapter 4 – Medical Billing Automation
- Chapter 5 – Medical Billing Workflow Management
24/7 Medical Billing Services:
If you’re looking to optimize your medical billing process, one of the first things you should focus on is the number of hours your billing staff works. Whether you’re using an in-house team or outsourcing to a medical billing company, the hours they work can have a significant impact on your revenue cycle management (RCM).
Let me tell you why…
Your in-house or outsourced staff would work only during your office hours (i.e. 8-9 hours a day), Still, think this is the usual routine eh? Well, think again!
There are 24/7 medical billing companies that specialize in this particular operating methodology.
What is different about the 24/7 medical billing operations?
Here’s an example:
When your in-house or outsourced staff is working they might try to focus on the wide array of medical billing and revenue cycle management processes like eligibility verification, charge capture, coding, accounts receivable, denial management, etc.
This prevents your staff from accomplishing the daily claims billing. It results in piling up unbilled claims and eventually being unable to collect them due to expired timely filing limits.
You should check whether your in-house or outsourced medical billing staff are performing this checklist:
- Revenue Analysis and Audit
- Re-Structure your Medical Billing
- Implementing SOPs
- Flexible Medical Billing Staffing
- Round-the-clock billing support
- Specialty-specific Medical Billing
- EMR/ EHR Experience
With 24/7 medical billing operations, you can achieve both daily claims billing and the routine processes which I have mentioned above. You can split the revenue cycle process into two categories: during your practice hours and after hours.
Imagine your daily billing cycle is top on your priority list and you also have pending AR and denial management processes.
The after-hours staff will immediately access your EHR and identify today’s encounters and start the pre-billing processes such as charge capture, coding, and claim transmission/submission. This allows you to bill out claims on the same day.
When you visit the office the next day you can see the claims for all the patients seen the previous day are all submitted to payers with a 99% first pass rate.
We can anticipate your next question, which is what about the hours my office is open?
While you may have staff working during this time, there are still tasks that need to be completed outside of patient care, such as accounts receivable, denial management, documentation submission, and patient collections and support services.
By having a dedicated billing team working during these hours, you can ensure that all of these tasks are being taken care of, maximizing your revenue and minimizing any billing-related issues.
Analyzing the number of hours your billing staff works is crucial for optimizing your medical billing process. Whether you’re working with an in-house team or outsourcing to a medical billing company, make sure that your billing needs are being met during all hours of operation.
By doing so, you can prevent backlog, increase revenue, and improve your overall RCM.
Co-Managed Medical Billing Services:
Too many billing staff attritions are the current trend among healthcare leaders. They frequently experience that staff leave or quit without prior notice.
This is why you should look for a flexible Co-Managed RCM team that can work with your practice or revenue cycle managers.
What is Co-Managed Medical Billing?
Co-Managed medical billing operations is a hybrid model of your healthcare leaders directly managing the outsourcing resources.
Here is an example so that you can understand better.
In-house billing staff that are less experienced feel more burnt out in performing complex staff also, any medical billing outsourcing company has its own supervisor and account manager and acts as an independent contractor.
This creates gaps in the revenue cycle process which results in incomplete tasks even when using a workflow management system.
Some of the major challenges;
- Miscommunication between the billing company and your in-house billing staff
- Expensive to handle only with an in-house billing team
- Unable to Monitor and Validating reports
- Involving them in a streamlined process
- Lengthy Approval process
- Eliminating the gap between remote resources and your billing department
By partnering with a Co-Managed, you can maintain control over your medical billing while benefiting from their expertise and support.
This innovative approach offers the perfect balance of control and assistance, allowing you to focus on providing the best possible care to your patients. With Co-Managed Medical Billing Services, you’ll have the tools and knowledge you need to maximize your revenue and minimize your workload.
Benefits of Co-Managed RCM:
- Minimized Denials
- Reduced AR
- Quick Workflow
- Stay in control of your revenue cycle processes
- Pay only for the revenue/expertise brought to the table
- Your billing staff to manage the billing team
- Put in place process improvement initiatives quickly
Revenue Cycle Management Tools:
Healthcare organizations are facing increasing pressure to manage their revenue cycle processes effectively to maintain financial stability and provide high-quality patient care.
RCM tools can help healthcare organizations streamline these processes and improve their financial performance.
Many healthcare leaders may raise a counter-argument as to why they have to spend for revenue cycle management tools.
The answer is simple, RCM tools cannot do what EHR software can. It is well-known that EMR and EHR software may have functions such as generating reports, indicating data, and more. But, there are certain challenges that EHR software cannot provide support for, including:
- Does not give you accurate patient benefit information using an inbuilt eligibility feature.
- Does not analyze days in AR, Net and gross collections, etc.
- No CARC and RARC code denial management features and actionable outcomes.
This is the main reason why a healthcare organization should have essential revenue cycle management tools.
Patient Eligibility And Benefits Verification Tool:
Imagine being able to select the perfect specialty from our download list and gain access to all the incredible benefits our specialists have to offer. Discover subscriber and insurance information like never before, including the effective date of coverage, out-of-pocket expenses, payer ID, and patient responsibility.
Verify the patient’s address, plan limitations, exclusions, and covered and non-covered services with ease. Using an eligibility verification tool allows you to find the Eligibility verification status in the Status column and view the detailed EV information with just a click. A customizable dashboard uses patient appointment data to calculate the number of eligibility checks needed in a day, week, or month.
You can even have the feature download the PDF file from the Action column and save it to educate the patient and upload it in the EHR under the patient’s encounter.
Claim Denial Management Tool:
Easily upload all of your pending denials from EHR/EMR into our revolutionary DMS portal using a convenient denial management template. Discover the power to view the overall pending denials for your healthcare organization, simply by selecting the “Pending Denials” option.
Take control of your workflow by assigning the pending denial claims to our expert denial management team or your in-house experts for completion. You can even handpick the respective claims and assign them to specific staff for completion. Watch as the denied claim gets automatically moved to completed denials once it’s addressed by the respective user. You won’t believe how easy it is to view all completed denials on our “Completed Denials” screen. Plus, the metrics screens can display the total denials in the system and the pending denials trend under different categories. You owe it to yourself and your healthcare organization to experience the ease and efficiency of the denial management tool.
Eliminate AR cycle inefficiencies, follow up better, and increase collections in simple clicks. Bring your team and data together on a single, innovative, and robust platform. AR Analyzer offers across-the-board receivables management solutions.
Some of the notable features are:
- Follows an automated receivables management workflow to systematically decrease days in AR.
- Prioritizes and organizes pending AR into buckets based on age, the value of the claim, and the insurer.
- Provides AR reports that allow multi-level drill down.
- Automatically tracks and updates the financial outcome of account receivables and follows up on it.
- Improves consistency, accuracy, and transparency in the AR management process through actionable insights.
Medical Billing Workflow Management:
Healthcare organizations face a variety of challenges when it comes to managing revenue cycles effectively. Workflow management systems can be an essential tool in overcoming these challenges and improving financial performance.
Here are some reasons why healthcare organizations should use workflow management systems for medical billing:
Streamlined Processes: Workflow management systems can help healthcare organizations streamline medical billing processes by automating repetitive tasks and providing real-time visibility into the status of claims and payments. This can reduce errors, improve efficiency, and save time and money.
Improved Communication: Workflow management systems can improve communication between different departments and stakeholders involved in medical billing, such as billing and coding departments, insurance companies, and patients. This can lead to more accurate and timely claims processing, better patient satisfaction, and improved financial performance.
Increased Transparency: Workflow management systems can provide healthcare organizations with real-time data and insights into the medical billing process, allowing them to identify bottlenecks and areas for improvement. This can help organizations make data-driven decisions and optimize their medical billing processes for maximum efficiency and profitability.
Enhanced Compliance: Workflow management systems can help healthcare organizations ensure compliance with regulations such as HIPAA and the Affordable Care Act. By automating compliance tasks like claims processing and billing,
A Workflow management system can be easily navigable, with detailed revenue cycle reports, consolidating key financial metrics. Provide multi-level drill-downs without tiring, prompt, and meticulous performance reports. Set department-specific goals, view individual-level productivity data, and raise the bar.
Project management: Rise Tickets, Schedule prioritized work, and View assigned and completed tasks.
Staff monitoring: Productivity, Quality, Daily targets, Follow-ups, Actions taken, Training.
KPIs and Reports: Demo reports, Charge reports, Eligibility reports, Coding reports, Payment reports, AR and denial reports.
Healthcare IT and automation solutions companies like BillingParadise have this kind of revenue cycle workflow management called TeamBillingBridge.
Medical Billing Automation:
Manual medical billing for hospitals and medical groups can be complex. A medical billing staff can perform only so much within the 8-9 hours window. Healthcare organizations that function 24/7 or have a large patient volume can struggle to accomplish daily revenue cycle and medical billing tasks.
Major Problems faced during manual RCM and medical billing operations:
- Billing-related costs went from 2% to 5% for conventional Medicare and Medicaid to a surprising 17% for commercial payers.
- According to industry standard numbers by HFMA and MGMA a sizable healthcare facility with 189,000 unentered and failed to capture charges claims in one month can lose 50% in revenue.
- A hospital with a normal of 75 weekly inpatient encounters would require 325 hours of work, also the effects on RCM KPIs, for example, DNFB and AR days.
- Other dangers such as raising denials rates of which 15% is due to missing or invalid data from the EDI and payer side.
Automated RPA bots can perform tasks 200% faster than a human and with the same level of accuracy regardless of the revenue cycle or clinical operations process. The most RPA-used processes are:
Patient access, registration, and scheduling automation:
Enable stress-free and tackle large volumes of patient data using this type of automation RPA bot for your EHR/EMR.
Prior authorization automation:
Quick and accurate prior authorization paperwork, submission, and follow-up for healthcare organizations with a vast number of prior authorization requirements.
Charge capture and entry automation:
Enter and capture 1000s of charges within hours and increase timely submissions by 100% along with productivity, quality and fasten collections with charge capture and entry automation RPA bots
Medical coding automation:
ICD-10 keeps adding more and more codes and descriptions making it well-refined, as should your medical coding process. With medical coding RPA bots, we can easily code with utmost precision and accuracy avoiding external coding audits and coding denials.
Medical records management automation:
You no longer are afraid of improper CDI, PHI violations, and documentation errors. Medical records management automation RPA bot understands compliance and documents medical records precisely the way they should be.
Payment posting and reconciliation automation:
Keep track of every single dollar using payment posting and reconciliation automation RPA bots. Avoid repeated ERA downloads and manual EOB posting and let the bot handle this tedious task.
Claims denial and appeal management automation:
Claim denials are not going to be a problem when you implement denial and appeal management RPA bots. It is evident that these RPA bots predict denials and remove root causes preventing future denials.
There are only a handful of automation expert companies that only focus on healthcare revenue cycle management and medical billing automation. BillingParadise being a pioneer in healthcare IT and medical billing has the process and technology expertise to make this possible.
This guide provides valuable insights into Medical Billing for healthcare organizations in 2023. The guide is not a generic post but a comprehensive guide that covers the latest trends and effective tactics that yield positive results.
These topics provide actionable insights into optimizing medical billing processes, minimizing denials, reducing AR, implementing SOPs, and streamlining billing processes. By implementing the tactics provided in this guide, healthcare organizations can maximize their revenue, minimize their workload, and maintain financial stability.
The guide emphasizes the importance of analyzing the number of hours billing staff works, maintaining control over revenue cycle processes, and partnering with Co-Managed medical billing teams. In summary, this guide is a must-read for healthcare organizations looking to improve their Medical Billing Operations.