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Inspecting the Basics of the Healthcare Revenue Cycle

Revenue Cycle Management in Health Care Organization is the process involved in getting the reimbursement for the physicians for the service provided. The fundamental purpose of Healthcare RCM is to create an efficient system to produce clean claims.

In this article, I wish to discuss how to “Inspect the basics of the healthcare Revenue cycle” through a case study.

Revenue cycle management is a billing process, utilizing medical billing software that hospitals and clinics use to track patient encounter from registration, appointments, patient documentation by providers which goes to in house staff for coding.

From there, the claims are prepared, submitted, and later adjudicated by Insurance or patient’s payer for the final payment. A claim being paid in a single cycle is called clean claim.

Let us now see how to Inspect the basics of Healthcare Revenue Cycle through a simple case -

A 36-year-old G2P1 woman is second trimester pregnant and being seen for gestational hypertension. At this time, she is not having any other problems.

O13.2 Hypertension, complicating, pregnancy, gestational (pregnancy induced) (transient) (without proteinuria), second trimester,

09.522 Supervision elderly multigravida, second trimester.

Z3A.27 Pregnancy (single) (uterine), weeks of gestation, 27 weeks.

This coding is as per clinical documentation and claim submitted.

Unfortunately, the claim is denied for 2 reasons-

• Wrong gender on claim form
• Incorrect weeks of gestation

Denial Reason 1 - When this claim is sent to denial management team for further investigation, it was found that the gender of patient was incorrectly selected as male in demographics by administrative staff. Many software today, have drop down list from which staffs select, instead of manual typing. By mistake the staff had selected the wrong gender and the claim had been submitted without a quality audit in place. Claims audit and error resolution is a very important step in any RCM process which would save time and money. Errors which are resolved before submission contribute to a major percentage in preventing rejections in Healthcare RCM.

Denial reason 2 - The coder assumed and coded weeks of gestation as 27 weeks, even though the other 2 codes indicate second trimester. This again is lack of quality check before submission. This denial shows lack of Clinical documentation by the physician on number of weeks and also coder’s carelessness in choosing 27 weeks which doesn’t fall in 2nd trimester.

• Audit team - While Inspecting this case, both these errors could have been resolved before claim submission if an audit team was in place or if both admin staff and coder would have done a self-audit before passing it to the next team.
• Refresher Training - There should always be periodic refresher training for all the staffs of RCM with reference to common errors in the team.
• Query Management – A coder should be aware when to query the physician and not assume.
• Clinical Documentation – This case also shows the importance of clinical documentation training for physicians to understand the impact of revenue loss.

Conclusion –

Successful healthcare revenue cycle management strategies focus on front-end tasks to help claims move along. Many errors occur in the first stages of a patient’s account and these issues can carry through the revenue cycle to disrupt claims reimbursement.

To prevent such errors, staffs can refresh their knowledge through courses like Patient access, Certified Healthcare Revenue Cycle Professional or Specialist or Executive and many more.