Claims from Beginning to End in RCM

In this article, we’ll track how a claim comes into existence and how you might be leaving money on the table, scattering in tips to increase your revenue throughout the entire process. 

From all the preparation that proceeds a patient’s visit to your practice, the claim, or the invoice/bill submitted to a health insurance company, and interactions between provider and payer after a claim is submitted is all part of a normal revenue cycle. But that doesn’t mean you’re actually making the revenue you desire or deserve. 

#1: Prepare for Care 

When you prepare for a patient visit, you are essentially preparing to get paid. Though there are many viable ways to operate a practice, you should consider the following directives:

Check Eligibility. Even if a patient has been to your practice before, it’s important to check insurance eligibility. Patient coverage can turn on a dime (e.g., loss of job, change of job, etc.) but when you check eligibility, your practice can prepare for changes before a claim is created and avoid inevitable denials. 

Obtain Prior Authorization when needed. Some patients need prior consent from their insurance provider before your practice should provide services to them. This step is only mandatory if you wish to avoid denials.

As it turns out, practices complete 40 prior authorization requests per physician per week on average, according to a recent AMA survey. Processing these requests takes approximately 16 hours per week, so it comes as no surprise that 85% of physicians described prior authorization as a high or extremely high burden, but there are ways to help alleviate some of the headaches caused from phone calls and faxes to insurance companies through technology. 

Offer patient cost estimates. After you’ve established that a patient will be covered by insurance through an eligibility check and possibly prior authorization, you should consider providing cost estimates to your patients. 

You see, most patients (83%) want accurate information on out-of-pocket costs before having health care services and 25% avoided obtaining care due to lack of cost information, according to the 2021 Annual Consumer Sentiment Benchmark. 

With accurate cost estimates, you can provide transparency to patients and increase revenue by collecting patient payment before services are rendered. 

Rivet estimates allow you to estimate patient responsibility for patients with multiple levels of coverage. Moreover, you can create a single comprehensive estimate for patients who will see multiple providers; have multiple visits; or receive care comprising professional, technical and/or ASC services.

At check-in, you can verify information and finish collecting out-of-pocket costs from patients. And with Rivet, your patients can be confident that they won’t be surprised with a bill months after their appointment.

#2: Turn Doctors’ Orders into Code

After a patient visits a practice, they probably don’t know where all their signed forms or doctor’s notes end up, but medical coders and billers do. 

A medical coder reviews “clinical documentation to translate billable information into medical codes using CPT®, ICD-10-CM, and HCPCS Level II classification systems.” In short, they translate medical reports into codes used in the healthcare industry.

A medical biller translates coders’ work into medical billing claims that include all relevant medical codes and charges for a patient visit. They’ll also submit and follow up on claims to ensure the practice is properly reimbursed. 

Upon finishing billing claims, medical billers will send a billing claim to a clearinghouse to get “scrubbed” for any missing or incorrect information before being sent to the payer. This middleman is important and a virtual necessity. The toughest part of all of this work, however, is that at some point you’ll see a denial because of an error that was completely avoidable.

#3: Insurance Adjudicates the Claim

Once a claim is passed to an insurance provider, it will go through what is called the adjudication process; a process by which insurance providers judge whether claims should be paid in full, in part or not at all. 

When claims are paid in part, it could be due to a clause in your contract with the payer known as the lesser-of clause. This clause allows insurance companies to pay the billed amount and not the contracted amount if the billed amount is lower than the contracted amount. 

Adjudication can be done manually, by a medical examiner, or electronically. In either manual or electronic adjudication, claims are processed for errors such as misspellings, mis-numbered policy numbers, lack of medical necessity proof, diagnosis and treatment misalignment, etc. Any error can result in a denial that health care providers could appeal. 

#4: Rework Denials and Underpaid Claims

Reworking denials can be expensive and time consuming, but you’re leaving thousands of dollars on the table if you don’t get your claims paid. In fact, the AMA found that, “Denied, rejected, resubmitted and underpaid claims can cost your practice as much as $100,000 per month.” 

 Denied claims actually:

  • spend longer in accounts receivable
  • cost money and time to rework
  • damage cash flow
  • and often result in lost reimbursement and increased write-offs.

The good news? You don’t have to settle for denials and underpaid claims and lose hundreds of thousands of dollars every year. The good news is that there’s a modern solution waiting for you to try.

Rivet is a modern revenue cycle product suite that integrates with your EHR to allow you to see the big picture of what’s going on in your practice with payer contracts, fee schedules, denials and underpayments. You can also check eligibility and provide accurate up-front patient cost estimates before services are rendered. The Rivet team will help you aggregate your fee schedules and input your claims data to enable you to increase revenue and decrease A/R days. 

For more information about the Rivet's modern product suite, schedule a Rivet demo.

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