INTRODUCTION TO RCM

Learning Objectives

1 Define what is Revenue Cycle Management

2 Identify the steps in the RCM process in relation to Home Infusion

Home Infusion 3 Identify the departments cared for by OGS in the RCM process

Revenue Cycle
4 Define the activities we complete on all steps of the RCM Process

Management
5 Understand the expected outcomes in each step of the RCM Process

2
Introduction to Revenue Cycle Management

 Revenue cycle management (RCM) is the financial process, utilizing medical

billing software, that healthcare facilities use to track patient care episodes from
registration and appointment scheduling to the final payment of a balance.
 RCM unifies the business and clinical sides of healthcare by coupling
administrative data, such as a patient's name, insurance provider and other
personal information, with the treatment a patient receives and their healthcare
data.
Referral Process

 Referral is the process of sending a patient to another practitioner (ex. specialist)

for consultation or a health care service that the referring source believes is
necessary but is not prepared or qualified to provide.
 In this stage what happens normally is
* Doctors issue referrals patients on drugs/therapy that is needed
to cure their ailments/illnesses.
* Referrals are issued to Pharmacies for review and preparation.
 Expected Output: Referral Form
Initial Intake Process

 In this stage of the process, we set up the patient in the system by entering the patient
information. This is also we accomplish the following items:
Reviews patient eligibility from their registered insurance
Reviews authorization requirement for drugs

Expected Output:
CPR+ (Main System) Profile
Demographic Data
Insurance Information
Authorization Requirements
Diagnosis
Therapy Information.
Benefits Verification and Authorizations

 Benefits verification is the confirmation that the patient has an active coverage
during the date of service. This is also the stage where we capture the
authorization for medications that would require them. To summarize, the below
are the things accomplished during this stage:
Assures that patients have coverage and reviews insurance to ensure coverage of
prescribed drugs
Gets authorization from payers for drug treatments prescribed• Works to ensure that
service provided will be reimbursed post billing
 Expected Output:
Confirmation of Active Benefits and Authorization on File
Final Intake Process

 During this part of the process, we already confirmed that insurance is active
during the date of service, the authorization, if required, is already on file, and the
patient profile has been created in CPR+. This phase then accomplishes the
following:
Helps patients understand their cost share (copay, deductible, coins)
Performs necessary checks and coordination w/ Pharmacy
Collaborates any nursing or need for professionals to administer the drugs
Conduct the Welcome Call to the Patient and have them sign the PSA.
 Expected Output:
Patient Services Agreement (PSA)
Billing

 This is the process of sending an invoice to customers for goods or services. In RCM
however, we are sending these “bills” to the insurance so we can extract payment for
the services rendered to the patient.
In this stage, we are expected to accomplish the following:
Ensures that the necessary billing pre-checks are confirmed such as delivery
confirmation, authorization and benefits verification
Verifies drugs, supplies and nursing care provided to the patient by thorough research of
notes in the system
Prepares the bill and encodes the right services & drugs w/ the corresponding claim
forms necessary to get the services paid (HCFA 1500; UB04; etc)
 Expected Outcome:
Claim Form/Invoices
Clearing House

 Clearing House functions as intermediaries who forward the claim information to the
insurance payers from the providers. Clearing House checks the claim for errors
(diagnostic codes and procedural codes are correct), and verify that the form is compatible
with the payers’ software. In general, this is done by another set of employees but for
Home Infusion, this is done by transmitting the claim to
 In this stage, we are expected to accomplish the following:
Claim once released for billing will have a billing hold to finalize the add on services such as
nursing provided etc.
Enters clearing house to ensure demographics and pre-claim checks performed to ensure clean
claim.
Transmits to payer once successfully accepted and goes back to billing once rejected
 Expected Outcome:
Clean Claim Form (No rejects from Zirmed)
Payer Processing

 This is the step where the insurance received the claim sent by our billers; they review
the claims received and the results would either be the following:
Paid claim according to the allowed amounts
Partially Paid claims
Denials
 During this phase, it is expected that the below is accomplished:
Reviews the claim for accuracy based on requirements for each drug dispensed.
Pays based on the NDC guidelines for each drug administered/billed
Denies based on policies and returns claims to provider for edits
 Expected Output:
Receipt of Explanation of Benefits (EOB)
Collections

 Once the EOB or ERA is received from the insurance, it is important that these are posted
to the patient accounts so we can reconcile the claims. Collections then become necessary
when an insurer has not remitted the full amount due or refuses to pay a portion of the bill,
which may transfer to the patient for payment and/or a patient has not remitted their full
amount due.
 During this step, we should be able to:
Reviews claims based on recent payer response
Performs the necessary action from coordination w/ other departments to provide additional
information to appealing of cases to ensure that claims gets paid by the payers
Calls the payers to identify claim status, gets payment information or to push claims to be
reprocessed or paid.
Expected Outcome:
•Sending of Corrected Claim, Processing Adjustment or Credits.
Cash Posting

 Cash Posting is the last and crucial step in the Revenue Cycle Management process.
Cash posting involves:
Posting insurance data from EOBs
Posting payment data from ERAs to patient accounts
 In this stage we are expected to complete the following
Reviews the remittance advice received from the payers and enters the details in CPR+
Reviews cases for payment accuracy
Resolves underpayments and overpayments as well as credit balances
Closes the account once complete payment from payers are received.
 Expected Outputs:
Updating of Patient Claim in CPR+, Reprocessing of Claims
Any Questions?