Healthcare revenue cycle management is a complex and complicated process that can drain resources when not properly managed. It takes considerable time and expertise to create and manage a well-maintained system that runs efficiently. An effective healthcare revenue cycle process maximizes organizational profits and keeps revenues pouring in. Medical professionals currently spend more valuable time and resources on the revenue cycle than any other industry. A healthy medical revenue cycle process works in tandem with other software and automates revenue cycle management.
It also aids in the migration to value-based reimbursement and maximizes organizational performance and regulatory compliance while minimizing the cost per claim. The best way to examine the process is with a healthcare revenue cycle flowchart.
Healthcare Revenue Cycle Flowchart . . . put into words.
The revenue cycle starts when a patient makes an appointment for services, and it continues until full payment has been remitted. While the healthcare revenue cycle flowchart is unique to each organization, some fundamental characteristics remain unchanged.
For instance, every healthcare revenue cycle flowchart has five sections. Of course, the names will vary between organizations, but the general contents of each section remain the same. Some flowcharts are, however, more detailed than others. The five key sections of the healthcare revenue cycle flowchart include pre-claim, front-end, transactional, back-end, and efficiency. Let’s zoom in.
1. Pre-Claim
The pre-claim section of the healthcare revenue cycle is the smallest section. However, it is still inherently important to the rest of the process. This section includes things such as provider credentialing and contract negotiations. EDI and ERA enrollment fits into this section along with the pricing and fee schedule for the organization. EDI is an acronym for Electronic Data Interchange, and ERA stands for Electronic Remittance Advice. These are both critical for regulatory compliance and claims processing.
2. Front End
The front-end section of the healthcare revenue cycle flowchart begins with the patient appointment and continues until the end of the patient visit. It includes everything from patient registration to deductibles, coding and charge capture. This part of the process is crucial to the rest of the healthcare revenue cycle. This is where a patient’s contact information is documented, and current insurance coverage is verified. Co-pays and deductibles are also collected at this point. A best practices revenue cycle process also includes payment arrangements for any outstanding balance that may not be covered by insurance.
3. Transactional
The transactional section of the healthcare revenue cycle flowchart includes everything from charge entry to cash reconciliation. This also includes posting payments, claim scrubbing and EFT processing, among other things. This is where charges are entered into the system, claims are submitted, and payments are posted for services rendered. It is the largest and most crucial part of the healthcare revenue cycle flowchart. A mistake in this section of the revenue cycle can cost the organization dearly, resulting in slow payments or the denial of claims. Regulatory compliance is also crucial in the transactional section of the flowchart.
4. Back End
The back end of the healthcare revenue cycle flowchart includes things such as checking the status of claims, patient statements and analyzing claim denials. Claims may be resubmitted for payment and patients need to be contacted to make payments on an outstanding balance. This is where appeals are submitted when necessary, and patients who refuse to pay may be sent to collections. The back-end section of the healthcare revenue cycle flowchart is where additional revenue is captured beyond the transactional section.
5. Efficiency
A healthy revenue cycle is efficient. It helps streamline the revenue collection process while promoting regulatory compliance and minimizing costs. It also ensures an organization is collecting the maximum amount of revenue available for its services. Utilizing a healthcare revenue cycle flowchart helps organizations isolate inefficiencies in the process. It allows them to target specific elements of the revenue cycle that need improvement. The reference to key indicators and benchmarks of best practices are essential! As healthcare revenue cycles become more complex, they present core challenges that require an innovative approach. Your best next step may be a medical billing audit, to identify the gaps in completing the revenue cycle flowchart.