Revenue cycle management is the process used by healthcare systems in the United States to

track the revenue from patients, from their initial appointment or encounter with the healthcare
system to their final payment of balance. The cycle can be defined as, "all administrative and clinical
functions that contribute to the capture, management, and collection of patient service revenue."[1] It
is a cycle that describes and explains the life cycle of a patient (and subsequent revenue and
payments) through a typical healthcare encounter from admission (registration) to final payment (or
adjustment off of accounts receivables).

Contents

 1Information
 2Registration
 3Medical coding
 4Billing/collections
 5References

Information[edit]
The revenue cycle management process begins when a patient schedules an appointment and it
ends when the healthcare provider has accepted all payments.[2] Errors in revenue cycle
management can lead to the healthcare provider receiving delayed payments or no payment at all.
Because the revenue cycle process is complex and subject to regulatory oversight, healthcare
providers can turn over their revenue cycle management to companies that handle this complex
process 24/7 with specialized agents and proprietary technologies to manage healthcare provider
revenue cycles.[3]
Medical billing is getting increasingly more complicated, especially as medical code guidelines are
making the switch from ICD-9 to ICD-10. Proper revenue cycle management ensures that billing
errors are reduced so that reimbursements from the insurance companies are maximized. Revenue
cycle management teams are responsible for maintaining compliance with coding regulations, such
as the ICD-10 code update. Using the right coding for services rendered by a practice ensures that
insurance claims can be processed and that the practitioner is compensated for all of their services
rendered.[4] A revenue cycle management team is able to handle this, rather than having the doctor
take care of patients and learn new medical coding protocols.
In 2014 the revenue cycle management market was valued at $18.3 billion and is expected to grow
to $32.2 billion by 2019.[5]
For remittance received in 2014, the average physician practice took 18 days to generate a claim
after the date of service and had an 11% denial rate.[6]
Revenue cycle management is often considered a segment of the greater healthcare IT industry
which includes HIS, RIS, EHR, PACS, CPOE, VNA, mHealth, healthcare
analytics, telehealth, supply chain management, CRM, fraud management, and claims
management.[7][8]

Registration[edit]
The first function within the revenue cycle is the registration function, which allows the service
provider to obtain all of the necessary data needed in order to properly bill an insurance company
(per the ANSI 837 5010 standards and requirements). The information that is usually obtained is the
patient's full name, date of birth, address, email, phone number, marital status, gender, social
security number, emergency contact, release of information, primary insurance provider information.
Clerical errors that are made within patient registration processes are one of the biggest culprits that
 cause non-clinical denials from insurance payers. This can include many errors such as inputting an
incorrect date of birth, not validating current insurance coverage/benefits, misspelling a guarantor's
name, etc. Normally, these errors are usually easy to identify and amend upon submitting a new bill
to most payers after correcting a mistake made in the registration department. It is critically important
to monitor denials on a daily basis in order to identify how much denial ratio is generated from these
clerical errors so that both training and education can take place with the appropriate staff within the
registration department.

Medical coding[edit]
An important aspect of the revenue cycle is compliance with medical coding regulations. Optimal
coding compliance results in higher revenues and decreases claim denials from insurance
companies. By achieving optimal coding, a medical practice can prevent disruption of the medical
flow and avoid regulatory penalties.[9]

Billing/collections[edit]
Otherwise known as the Business Office or Patient Financial Services department, the
billing/collections team are responsible for submitting a complete UB-04 claim (facility and ancillary
billing) or a CMS1500 form (physician billing) to the insurance payers after a patient has received
services for either an inpatient or outpatient type of visit. Usually, a third-party claim scrubbing
system is then used to ensure that claims are clean and complete as possible, including edits that
may automatically update the raw claim data received from the host system. The intention of this
scrubbing is to inevitably avoid generating a potential denial from the payer, which can prolong
reimbursement to a provider. The claim is then sent out from the provider to the payer in an ANSI
837 5010 standard format.
Denials can be sent back as a response to the claim from the payer stating a specific reason of why
the claim cannot be adjudicated. This is where denial management processes help to ensure that
there is an immediate resolution to these denials. Denial management can also help to identify if
there are trending issues within a provider's workflow processes, whether it be clinical or clerical-
related. Feedback should be provided to the responsible revenue cycle departments if any of them
were the cause of the denial, especially with denial types such as medical necessity,
registration/clerical entry errors, etc.

References[edit]
1. ^ "Healthcare Financial Management Association, Online Glossary".
2. ^ "Revenue Cycle | Patient Business Services | OHSU". Ohsu.edu. 2013-04-16. Retrieved 2015-08-
26.
3. ^ "Show Me the Money... A Look at the Revenue Cycle from the Billing Perspective".
Library.ahima.org. Retrieved 2015-08-26.
4. ^ [1]
5. ^ Murphy, Brooke. "25 things to know in revenue cycle
management". www.beckershospitalreview.com. Retrieved 2016-10-27.
6. ^ Bermender, Jeremy. "Revenue Cycle Management". Remit Data. Retrieved 6 December 2016.
7. ^ "Healthcare IT Market size worth over $230bn by 2023: Global Market Insights Inc. |". Medgadget.
2016-10-19. Retrieved 2016-10-27.
8. ^ "Common Revenue Cycle Management Pitfalls to Avoid".
9. ^ "Regulatory Impact on Revenue Cycle Management— Think You're Prepared? Think Again".
Retrieved 12 October 2016.
Categories:
 Healthcare in the United States