Revenue Cycle Management

US HEALTHCARE
 RCM - Revenue Cycle Management
Revenue Cycle Management is the process used by healthcare industry in the
United States to track the revenue from Insurance company and / or patient.

• The Revenue Cycle Management process begins when a patient schedules

an appointment and it ends when the healthcare provider has accepted all
payments.

• Errors in Revenue Cycle Management can lead to the healthcare provider

receiving delayed payments or no payment at all.
Revenue Cycle Overview: Basic Steps in Processing an
Insurance Claim
• Patient’s appointment • Medical services
• Insurance info received and performed
copied • Medical records
• HIPAA & AOB signed by the generated
Patient • Patient checks out of the
facility

Phase 1 Phase 2
Provider’s
Front Office
Entity

Phase 4 Phase 3
Payment & Follow- • Patient’s data received
• Payment or denial received up Billing & Tracking
with EOB at Medical Billing
Company and Account
• Posted to Patient’s account
created
and unpaid claims followed
up • Claim generated &
submitted
• Balance due forwarded to • Tracking of claim
patient
• Full payment received or
forwarded to Collection
 RCM - Phase 1

Front Office:

• Patient’s appointment – Patient visits the Provider’s office

• Insurance info received and copied – Receptionist collects patient’s insurance

ID cards and keeps a copy

• HIPAA & AOB signed by the Patient – Patient signs all necessary documents
 RCM - Phase 2

Provider’s Entity:

• Medical services performed – Provider sees the patient and performs medical services

• Medical records generated – Reports related to the medical service by the provider
generated

• Patient checks out of the facility – Patient leaves the Provider’s office
 RCM - Phase 3

Billing & Tracking

• Patient’s data received and Account created – Provider sends Medical records to the
Medical Billing Company.

• Claim generated & submitted – Generate Claim through Software and submits to
Insurance company

• Tracking of claim – Claim is tracked through Websites and RM

 RCM - Phase 4
Payment & Follow-up

• Payment or denial received with EOB – Post

adjudication we receive payment/denial along with
EOB

• Posted to Patient’s account and unpaid claims followed up – Post payment/denial as

per EOB

• Balance due forwarded to patient – Statement sent to patient if there is a patient

liability

• Full payment received or forwarded to Collection –

Close the account if full payment received or
forwarded to Collection agency if full payment
is not received.
 Methods of submitting a claim:

Different methods exist for processing insurance claims. The most common are as
followed:

1. Paper Claims - After posting charges in Software and submitting to the insurance
payer on legacy paper CMS-1500 (Centers for Medicare & Medicaid Services) claim
form.

2. Electronic claims transmitted from Software. We partner with a Clearinghouse to

submit claims to the appropriate payer in the correct format.

3. Direct Data Entry (DDE) into the payer’s system. Specialist of billing industry would
log directly into the insurance company’s system and key in the information needed
to process the claim.
 Claim Adjudication:

Claims adjudication is a term used in the insurance

industry to refer to the process of paying claims
submitted or denying them after comparing claims to the
benefit or coverage requirements.
 Components of an EOB
• An explanation of benefits (commonly referred to as an EOB
form) is a statement sent by a health insurance company to
Providers explaining what medical services were paid or
denied.
• There is no standard format for EOBs from insurance
companies, but information contained in each one is usually
the same.
 Claim Inquires and Follow Up Procedures:

The following are some reasons for making inquiries:

1. There was no response to a submitted claim within 45 days or a time

frame indicated by the AR Analysis
2. Payment received but the amount is incorrect
3. EOB shows that a professional or diagnostic code was change
4. Additional information / records are required
 ?
Any question
Thank You
Santanu Patwari