RCM in Physician Practices: Key Steps Revealed by AMA

physician practice RCM

Physician RCM: This guide dives into key areas physician private practices can target to strengthen their revenue cycle management (RCM), as outlined by the American Medical Association (AMA) in recent News. By optimizing these eight steps, practices can ensure timely and accurate reimbursement for services provided.

1. Patient Registration: Accuracy First

The foundation of a smooth RCM process is accurate patient information. Before appointments, prioritize verification and updates for details like date of birth, insurance information (payer details, ID number), and even middle initials. Even minor inconsistencies can lead to errors, claim denials, and lost revenue. As physician emphasizes, “It’s crucial to ensure accuracy at this point.”

2. Insurance Verification: Don’t Miss Out on Revenue

Taking the time upfront to verify patient insurance benefits is essential.  Administrative staff should contact the insurance company to confirm active coverage, network status, visit/procedure coverage, prior authorizations (if required), and patient responsibility. Failure to verify can lead to claim denials and lost revenue.

3. Patient Check-In, Check-Out: Seamless Communication

Clear communication between front desk staff and those handling prior authorizations/referrals is vital. Physician highlights the importance of a defined workflow: “The practice needs a system for these departments to easily share information. When a patient checks in, the front desk staff should know where to find insurance verification details and any copay or deposit information required at the appointment.”

4. Medical Billing and Coding: Documentation Matters

For accurate billing, ensure all necessary elements are documented in the patient chart. Billing and coding teams should verify that each Current Procedural Terminology (CPT®) code has a corresponding diagnosis code. Physician emphasizes, “Coding errors are the most common reason claims are denied. It’s crucial to get this step right before creating claims.” Collaboration between the administrative team and physicians to ensure correct codes and address discrepancies is key. Physician approval is required for any coding changes.

5. Claim Preparation and Submission: Avoid Delays

The billing team needs to ensure complete and accurate claims are submitted to the practice’s clearinghouse – an institution that electronically transmits medical claims data to insurance carriers and receives reimbursement information back. Different insurance companies have specific claim format requirements.  As physician RCM explains, “Incomplete or incorrect claims will be rejected or denied, delaying reimbursement.” Understanding each insurer’s needs is crucial to avoid delays.

6. Monitoring Payer Decisions: Be Proactive

Once claims are submitted, actively monitor payer decisions. First, verify that claims have reached the clearinghouse and are not stuck in “unsubmitted” status. Address unsubmitted claims first, then look at denied or rejected claims. These require correction before resubmission.

7. Preparing Patient Bills and Statements: Transparency is Key

The practice will receive an explanation of benefits (EOB) from the insurance company outlining covered CPT codes, patient responsibility, and any denials/rejections with explanations. Patient statements are then generated and sent for payment.  Before sending statements, verify insurance payments and adjustments are accurately reflected in the patient’s account.  Establish a regular schedule for generating and sending statements to avoid payment delays.

8. Managing Payments and Collections: Stay on Top of Accounts Receivable

The practice should regularly monitor accounts receivable reports to identify any issues with payments and collections. This proactive approach ensures timely follow-up and minimizes outstanding balances.

Potential Role of Allzone MS in A/R for RCM:

  • Account Receivable Follow-Up: Allzone MS highlights expertise in medical billing and RCM. They might specifically offer services to address outstanding accounts receivable (A/R) within the revenue cycle. This could involve tasks like:
      • Identifying overdue payments
      • Contacting patients for payment reminders
      • Collecting payments and resolving discrepancies
      • Working with insurance companies to resolve denied claims
  • Medical Billing and Coding: Accurate medical billing and coding are crucial to minimizing A/R issues. Allzone MS offers medical billing and coding services, which could ensure claims are submitted correctly, reducing denials and delays in receiving payments.