Understanding the Healthcare Practice Revenue Cycle

Medical providers cannot thrive unless they understand their healthcare practice revenue cycle and how they can improve it. This cycle is complex and requires cooperation from multiple parties, including the federal government, state governments, private insurance companies, and patients. 

The last several years have been extremely difficult on the healthcare system's finances, making efficient revenue collection imperative. Many providers are struggling to recoup their financial losses while still dealing with unprecedented strain on their resources. Fortunately, advanced software programs and automation implementation are benefiting the financial health of medical practices. Understanding and improving the revenue cycle provides long-lasting financial impacts. 

The Healthcare Practice Revenue Cycle

Providers need to understand all aspects of insurance claims, patient billing, and collections. This revenue cycle has seven main steps that must be completed to properly bill and collect physician, facility, testing, and lab fees. They are:

Charge Capture — The process that records physician information about the patient's medical appointment or treatment. This info is translated into a medical claims system so that providers can correctly bill patients. With many EHRs, physicians are typically able to automatically assign CPT & HCPCS codes along with ICD10 diagnosis codes for automatic coding, bypassing medical coding.

Coding — Coding specialists assign medical codes (CPT & HCPCS) to a patient's record based upon a physician's documentation. These codes are recognized by all insurance companies and the Centers for Medicare and Medicaid Services (CMS). They determine the reimbursement amounts a medical facility receives. 

Claims Submission — Medical providers submit claims to the insurers that charge set rates for each code. The information must be correct to receive reimbursement. This is typically done electronically to a clearinghouse who acts as the third party who submits to a payer.

Payment Posting - Once payment is received from payers or patients, the payments will need to be posted against the visits and reconciled with the bank account.

Communications — A provider's billing department continually communicates with these insurers about claim accuracy, patient coverage, and contract negotiations. They also need to continuously follow-up on outstanding accounts receivable due to them.

Patient Collections — Once providers receive insurer reimbursement, they bill patients for the balance due. Patients may need help understanding their claims and establishing a payment plan. This part of the cycle is perhaps the most sensitive, expensive, and difficult one.

Reporting - Quality reporting must be consistently run to track payers, measure productivity, and audit users. Every revenue cycle group must implement comprehensive reporting solutions to ensure financial stability.

Problems with any of these steps can impede revenue collection and compromise patient care. Medical providers rely on timely payments to meet their payroll and pay for other expenses. If a facility mishandles its revenue cycle, employees, patients, and providers may suffer. 

Problems in Healthcare Practice Revenue Cycles

All providers struggle with certain issues in their revenue cycle. First, accurate claim submission is a challenge for many facilities. Insurers will reject claims with a single coding issue, incorrect policy information, or other data error. Providers must correct and resubmit denied claims, which adds weeks or months to the collection process. 

After the insurers pay the claims, facilities may have problems collecting from patients, especially those with a high-deductible plan or those who are experiencing financial difficulty. Payment may be slow or non-existent from some patients, which compromises the facility's cash flow. 

Finally, facilities and their revenue practices must meet state and federal regulations. For instance, now that CMS has shifted towards basing payments on quality metrics, it can cost providers a significant amount of money if they are not carefully adhering to these regulations.

Solutions in Healthcare Practice Revenue Cycles

These financial challenges require timely answers. Experts in the field recommend using these strategies to optimize revenue cycles.

Medical providers have many options for improving their healthcare practice revenue cycles, something that many need now in the wake of the recent worldwide healthcare crisis. 

How TempDev Can Help

TempDev's experienced revenue cycle consultants can immediately help you improve your revenue cycle. They are experts in NextGen's revenue software, products that greatly improve your practice's claim processing and revenue collection. You will receive fewer denied claims and collect patient balances faster and with fewer complications. 

Your staff and your patients deserve the best service possible when it comes to revenue cycles, so contact TempDev today. Simply fill out our brief online contact form or call 1-888-TEMPDEV to schedule a consultation with TempDev!