Revenue Cycle Management is a process by which services are provided, charts coded, charges billed/submitted, and cash generated. Revenue cycle is the term used to cover a large spectrum of functions to procure cash flow for hospitals and health systems. Every medical practice is unique, and we consider that in refining the transformation of the cycle. Radical's client focused medical billing and coding services offer many advantages such as increased profit, quicker turnaround times, optimized collections, reduced office and administrative expenses, saving on capital investments, better management due to less employees, reduced operation cost, reduced audit risk, and savings of 30-40%.
Outsourcing maximizes billing revenue and reduce expenses. It also removes the burden of the billing departments turnover, training, continuing education, supervision and fluctuations in the volume of work. Frees up Administrative Staff time allowing the practice to run even more efficiently.
Revenue Cycle is initiated here. The physicians and offices get to know the patient in this phase. It is key to optimizing the healthcare revenue cycle management (RCM) process. During this step the patient account is created in detail of demographics, medical histories and insurance coverages. This provides the framework for creating and billing claims.
We have an ability to route the patients calls to our centralized call center and embed patients' account to the clinical management software. Our representatives are trained on life sciences; thus, accuracy is sustained.
This is the process, where an appointment/investigation/procedure is scheduled up to the point of admission (if required). As a patient advances through scheduling and pre-admission, the ability to collect both information and cash that greatly reduces barrier in the revenue generation process.
Our centralized call center can receive patients calls and book appointments upon availability of the physician. We fix appointments timely in an organized manner and reduce patient waiting time.
Referral plays a vital role in specialty billing. When a patient is referred to a specialist, the referral is to be verified during the appointment scheduling phase. It has the PCP’s consent for the specialty treatment. The verified & valid referral needs to be produced when required.
Our representatives are well trained on the Revenue Cycle Management and specialties. We can accommodate all specialties and can make the process smooth.
During Insurance Verification, the Front office staff should enter information gleaned from the insurance card, phone calls with the insurance company, electronic eligibility systems or verification of information in each patient's electronic medical record.
We can't sit in the front Office, as we work backend; however, we could verify eligibility of the patient insurance policies over phone/online. Prior to rendering services, we can give reliable insurance eligibility data.
Benefit verification is done in the patient eligibility verification phase, that confirms the agreement from the payer to cover specific services before the services are performed. The authorized services will carry a number to be documented in the claim. A recent study estimates that the mean cost per full-time provider for prior authorization compliance was between $2,100 and $3,400. An average primary care nurse spent 13.1 hours per week on patient prior authorizations and clerical staff spent 5.6 hours per week on prior authorization-related tasks.
Our representatives evaluate the insurance contracts to see which payers/procedures require the most prior authorizations. If it's a contract that isn't a major part of the revenue, and it's taking an inordinate amount of time in compliance. We suggest whether the provider really wants to participate & when it's time to renew. We can also use the payer's website whenever possible to get authorization; phone service takes much longer.
Batch preparation includes indexing of medical records and preparing batches for payment. The batches are prepared in different phases of RCM that makes reporting easier. Indexing of medical records makes the availability and transmission of the required record, in turn saves time.
Upon receiving the patient records and related documents securely, records can be reviewed and categorized by the indexing team. Members of the team then examine each document, index it into relevant digital records and store them in a client-defined central location. We adapt HIPAA guidelines and our client managers on-shore are experts in batch preparation.
The review of medical records to consolidate the patient information is vital for the provider to make decision in any instance. Not just the provider, the insurance companies and attorneys are few who look for the essence of the medical records.
We audit every detail in the medical records from appointment time to medicine prescription to ensure the information cascaded to our clients. We can provide a brief note of the patient or synopsis as required. Our medical records reviewers are life science graduates and the team is managed by the Medical Practitioner.
The correct coding of claims is vital for informing the insurance payer of what exactly the patient is being treated for as well as the method of treatment the patient is undergoing. The insurance payer can only make an accurate assessment if they have the correct codes and modifiers. Accurate coding allows a practice's bills to be paid in full and on-time, helping the practice to increase its revenue and eliminate costly time delays that can occur as the result of incorrect or improper coding.
Our CPC certified coders are highly skilled in all areas of coding, and that means we can help your practice/facility to improve its billing and collection practices. Certified medical coders also serve as a safeguard against audits that can be triggered when practices unintentionally apply the wrong codes and submit them for payment. Our certified coders (CPC, COC, CIC, CPC-P, CPM, CPMA, CPCO, CPC-H, etc.) take care of specific Specialties and ICD-10 coding. They assist in documenting with appropriate CPT and ICD codes and Modifiers. We also educate the practice about procedures that can be billed together along with a particular treatment or accompanying medical services. At the same time, we ensure sticking to the coding guidelines.
Efficient use of medical codes with appropriate modifiers is an essential part of the medical billing process for any practice. Each time a new or existing patient is seen by a physician or other healthcare provider, the medical coder must assign the correct codes to that visit in order for the practice to be reimbursed for services that have been performed. When codes are used improperly, billing can be delayed, or claims can be denied. In some cases improper use of codes can even trigger a practice audit which may result in fines being assessed.
The coding done by the coders are reviewed by the coding auditors that ensures the clean claims sent to the payer, because we have the medical records reviewed as well.
When codes are used improperly, billing can be delayed, or claims can be denied; in some cases, improper use of codes can even trigger a practice audit which may result in fines being assessed.
Accurate coding allows a practice’s bills to be paid in full and on-time, helping the practice to increase its revenue and eliminate costly time delays that can occur as the result of incorrect or improper coding. Certified medical coders also serve as a safeguard against audits that can be triggered when practices unintentionally apply the wrong codes and submit them for payment.
Every Radical coder is experienced in abstracting coding information from detailed medical charts and reports. By carefully reviewing and analyzing individual health records, including doctor's notes, lab tests, imaging studies and more, our coders can identify relevant diagnoses and procedures for every patient visit to ensure all eligible codes are accurately applied. Once the patient records have been reviewed, our coders assign specific CPT, HCPCS and ICD-10 codes to ensure payment is made for all relevant treatments and procedures as quickly as possible and without delays that can be caused by improper coding. Also, on the coding denials, we have an expert team of reviewers who analyze the trend and fix the issue.
This refers to entering the charges for services that the patient received. The charge entry also includes the appropriate linking of medical codes to services and procedures rendered during the patient's visit. Improper or negligence of these information will lead to severe consequences from the authorities.
At Radical, each team member is trained professionally and supervised. The capturing of charges are reviewed by the quality audit team. The team is updated on the charges of each service rendered by the provider.
Once the claim has been properly completed, it must be submitted to the insurance payer for payment. Medical billers need to have access to the information they need about the insurance payer since there are so many variables for each insurance payer in determining how and when to submit a claim.
Radical maintains a 99% clean claim standard. The trends and analysis are shared with the Coding and Claims entry teams along with the client as per the client’s convenience / during the Review meetings. We have capability of filing the claims electronically through the clearing house and by paper.
This last step involves posting and deposit functions. At this point, the amount billed to the patient will be zero if it has been paid in full or it will reflect the amount owed by the patient. The insurance payer's responsibility should have been met by this step in the process. When it comes to medical billing, most practice administrators tend to focus on coding and documentation as the main spokes in the billing wheel. Payment posting seems like an afterthought, something that happens after the "real" work of medical billing ends.
But that view gives payment posting short shrift-accurate posting is actually one of the most critical functions in revenue cycle management and overall profitability. And when things go badly, the effects downstream can be financially catastrophic. It should be self-evident that accurate payment posting is important.
The patient will naturally receive an inaccurate statement. While a patient receiving an inaccurate credit is less likely to be upset than one being billed for fees they do not owe, it still suggests to the patient that your billing department isn't very conscientious about financial matters. That's not a reputation you want your practice to have.
The payment posting is an integral part of the overall revenue cycle management, so Radical ensures-
Posting and reconciling data from both paper EOBs and ERAs and ensuring electronic deposits match payment totals.
Identifying line item denials for medical necessity, non-covered services, and prior authorization and reporting any trends to management to head off potential ongoing process errors in the billing cycle.
Spotting issues with window collections, such as failing to collect deductibles or copayments, when processing insurance remittances.
Accurately moving balances to patient responsibility and ensuring prompt patient billing. Processing write-offs and adjustments and investigating unusual contractual adjustments, moving them up the management chain if problematic trends are identified.
Identifying claims with secondary payers and processing claims for any remaining balances.
The Payments received through ERA / EOB are posted on the system within 24 – 48 hours and the reports are reconciled on a daily basis. Denials are captured & moved to the Denial Analysis team.
Two levels of quality audit to make sure the process is at par with international standards. Trained staff who understands the patient responsibility too, like the Secondary balance, etc.
Upon payment posting, the benefits to your practice are obvious-improved cash flow not least among them.
Claims denials are one annoying factor that brings the revenue down and increases maintenance cost for the provider. Posting of correct denials to the client system is also one of the most important step. The follow-up on denials is tedious.
In order to avoid, at Radical we-
Accounts receivable (AR) assets are a living, breathing organism that is constantly evolving. Every transaction throughout the day increases or decreases the distance to the imaginary finish line, that magic number your accountant establishes as an acceptable outstanding balance.
Radical understands the rules of engagement, i.e., Medicare reimburses within two weeks of claim receipt, providing you file clean claims.
Engage provider relations representatives, establishing relationships with each payer on our roster; resulting anticipate changes.
Proactively managing challenges is far superior to tackling problems once they hit the AR stream.
Shorten review cycles, Complete a comprehensive AR review at least quarterly.
Tightening the patient account policies, Due-at-time-of-service policies have given many providers more control over their account management efforts. However, strict collections policies for patient accounts that your practice carries are necessary for financial survival today. Implementing a no-excuses policy. Perhaps: three statements, followed by a 15-day demand letter, and then, the file goes directly to a collections agent.
Each claim denied by the payer has a reason. The denials are either because of an unclean claim or the payer adjudication system error. The denials could be obtained by the ERA/EOB or by calling the payer. The error needs to be cured and re-filed in order to receive the payment.
At Radical, Claim Denials are analyzed carefully, and the root cause is defined for each problem. It is then escalated to the concerned teams to make sure the Denials are fixed & also ensuring they don’t re-occur in future. Denial analysis is shared with the client once a week. Also, Deal with Denials within 72 hours of receipt & Detect the trend and track the percentage of Denials daily.
We have collected millions of untapped dollars when we took over new projects. We check with the insurance companies for outstanding claims over 30 days through AR calling. The trend and details of the Report are shared with the practice once in a week or a month.
When submitting medical billing claims, doctors have two choices of how to do it. They can either submit the insurance claims directly to the insurance company, or they can contract a company to do the work for them. Companies that manage the medical billing functions are known as a 'clearinghouse'.
In the medical billing world, the task they perform is known as claims 'scrubbing'. The term scrubbing refers to an in-depth ‘cleaning’ of a medical insurance claim prior to submission. Over the past 10 years, automated claims editing has been developed which helps to validate that a claim is appropriate and accurate for submission.
A Clearinghouse will check the medical insurance claim for errors and verifying that it is compatible with the insurances payer software. The clearinghouse then checks to make sure that the medical procedure (CPT) and diagnosis codes (ICD) being submitted are valid. Each procedure code must be appropriate for the diagnosis code submitted with it.
In an ideal situation, the insurance payer checks the claim for any errors. If everything is correct (this is called a clean claim), the insurer submits payment to the physician for the services. If this doesn't happen, then the claim is rejected or denied.
Medical claim scrubbing helps prevent time-consuming processing errors. A medical billing clearinghouse cuts down on the amount of time it takes for medical claims to be accepted and processed by insurance companies.
We use the trusted partners as clearing houses and manage to scrub the claims. Our self-motivated team will analyze on EDI rejections and clears the barriers and making the clearing house to accept.
There's no doubt that electronic data interchange has streamlined the health insurance claims process, especially in an environment of ever-increasing medical necessity documentation needs. For most practices, EDI results in faster reimbursement, fewer rejections, less staff time reworking claims, and an overall boost to ROI.
Radical follows,
Most claims errors are eliminated with editing or "claims scrubbing" software that detects keystroke errors, ensures current code sets, and permits error correction before claims submission, make sure there were no problems with transmission, correct payment indicator and provider number, verify no errors occurred between your PM system and the vendor or payer, verify if the error correction systems is up-to-date.
Ask the EDI vendor to obtain a copy of the payer's acknowledgement to verify the submission was received.
Contact the payer's EDI help desk to follow up.
Upon review of the denial, the claims needs to be refiled to the insurance company.
Radical team members are well aware of the processes and procedures to be followed. The corrected claims are reviewed by the supervisors before they are re-filed to the payers. We make sure that the re-filed claims are not going for a toss.
Once the claim has been properly completed, it must be submitted to the insurance payer for payment. Medical billers need to have access to the information they need about the insurance payer since there are so many variables for each insurance payer in determining how and when to submit a claim.
Radical maintains a 99% clean claim standard. The trends and analysis are shared with the Coding and Claims entry teams along with the client as per the client’s convenience / during the Review meetings. We have capability of filing the claims electronically through the clearing house and by paper.
Credentialing is the validation of a provider in a private health plan and the approval to join the network. Credentialing also refers to the process of verifying the proven skills, training and education of healthcare providers. Verification of the providers credentials are done by contacting the "Primary Source", which has provided the license, training and education. The credentialing process is used by healthcare facilities as part of their hiring process and by insurance companies to allow the provider to participate in their network.
Enrollment refers to the process of requesting participation in a health insurance network as a provider. The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract. Enrollment is also the validation of a provider in a public health plan and the approval to bill the agency for services rendered.
Our credentialing experts have extensive experience with CAQH registration. Our team can enroll your practice with all the top payers in your area including government, commercial, and managed care plans.
We work closely with you and your payers to eliminate any delays and expedite your enrollment process.
Many practices are struggling with ensuring their staff is up-to-date on these complex and comprehensive ICD-10 Coding. Approximately 65% of today’s medical documentation is complete for ICD-10 coding. Insufficient documentation to support the specificity required for the new ICD-10 code sets will be one of the largest problems. If an office is fully prepared for ICD-10, but clinical documentation has not improved, accurate coding and proper payment will not be feasible. M-Scribe believes that for most providers, a behavioral change in documentation habits will be crucial - now is the time to start preparing.
With the transition to ICD-10, some documentation subjects will require physicians and providers to capture new information while others may be involved in updating, modifying and expanding documentation needs.
Radical coding professionals are available for consultations and are fully trained in the latest coding practices and guidelines. All of our coders receive ongoing training in ICD-10, CPT and HCPCS codes as well as evolving industry guidelines and regulations, which means your practice can continue to run smoothly no matter what changes come along. Having an accurate and reliable coding system in place is the first and most critical step in ensuring a medical practice is reimbursed for all the procedures, treatments and diagnostic services provided by the physician or other healthcare provider, and it also plays a crucial role in making sure the practice remains in compliance with coding guidelines. Our professional coders take the worry and confusion out of the coding process, providing the billing department with the coding information they need to ensure a smooth and error-free billing and collections process.
We perform Clinical Documentation Assessments. This can involve evaluating samples of various types of medical records to determine if the documentation supports the level of detail found in ICD-10.
Improvement strategies can be implemented to address areas where documentation is deficient.
Assign an ICD-10 specialist to guide your practice to implement clinical documentation strategies.
The term adjustments refers to the balance to be billed to any other payer / patient, write-off by the provider upon receiving the payment. Upon complete payment cycle, the claim is closed.
Radical has ability to consolidate the adjustments based on the contract between the provider and payer. Adjustments are also done on the requirements of the client.
Credit Balance, meaning the remainder of the payment to be collected from the secondary payer or the patient. In case of the over payment from the either party, the refunds need to be done legitimately.
At Radical, the credit balance is maintained for the client based on the payer and follow-ups are also done. The transfer of the credit balance is supervised timely to ensure payment. Refunds are done only by the supervisors as not to affect the clients.
The credit status of the patient is balance the patient owes to the provider and for which the statement is sent. Patient billing accounts for one-fourth of a provider’s revenue and is the hardest money for physician offices to collect. More than half of patients who don’t pay their medical bills say it is because of lack of financing options or delays in receiving their patient statements.
Radical offers to improve patient billing and better manage your revenue. We track securely, online patient and patient statements solutions are designed to yield faster collection of patient-owed amounts, improve cash flow and reduce billing costs with less effort and paperwork.
Small Balance adjustments refers to the balance to be zeroed, upon receiving the payment from the payer or patient.
Radical has ability to consolidate the adjustments-based requirements of the client including the write-off.
Bad Debt is the part of payment that is owed by the patient to the provider. This indicates the patient's financial situation. The collection of these payments is very sensitive and need to be handled appropriately.
We at Radical have trained the team with outmost soft-skills are aware of the federal laws like FDCPA and state specific collection laws. We deal the patients with patience, however proven track in collections.
Explanation of Benefits by paper / electronic covers the claim data of payment, denials, requirements to adjudicate the claim. It is necessary to store and retrieve when required.
Radical has ability to store these securely, onsite and cloud as per the client's requirements.
An appeal is a legal process where you are asking the insurance company to review its adverse benefit determination with the patient’s claim for benefits or you are appealing a provider contract issue.
Our team continues to do reconsiderations and appeals neatly. We investigate the claim to the depth and make success on the appeals by gritting in touch with the correct officials at the payer's office. We also focus to do appeals electronically and in bulk to save time.
This term is self-explanatory to manage the accounts receivable that did not happen on time. This will have clusters of information mining to ensure the payment is collected from the payer/patient.
Our supervisors at Radical are trained specially on the Old AR Management. We consider each portfolio unique and find the pattern to collect the payment. The strategy that we have planned has always been unique to the portfolio and successful.
