Bigger than Billing… Exploring the Nuances of True Revenue Cycle Management

Categories: Billing, CHC, PMG Insights Blog

February 19, 2018

When we tell people that PMG offers Revenue Cycle Management services to Community Health Centers (CHCs), many people assume that we created a fancy new phrase that just means medical billing. Others tell us that they purchased a top of the line practice management (PM) system and it will solve all billing woes. True, Revenue Cycle Management involves billing processes as well as PM systems, but what exactly does it in entail?

Medical Billing is Not Revenue Cycle Management

The first big difference is that RCM extends beyond the billing department, encompassing every step in the lifecycle of a claim. At PMG, we call this the “circle of communication.” Unlike billing, which starts at claim inception, RCM begins at the front desk and includes patient verification, sliding scale adjustments and self-payment collections at the time of service. Any error at this point in the RCM process will no doubt cause denied claims down the road.

Provider coding is another vital component of the “circle of communications” and therefore of RCM as well. The move away from Fee for Service and toward Alternative Payment Models with risk adjustment factors and hierarchical condition categories (hcc) continue to increase the importance of provider coding in relation to revenue generation. Revenue Cycle Management includes keeping a close eye on coding accuracy and also ensuring providers receive ongoing education to minimalize coding errors and optimize cash flow down the road.

Although it goes beyond the traditional idea of billing, RCM does reside heavily in the billing department but again goes above and beyond the status quo. In traditional billing situations, claims go out, some are paid and posted, and others come back as rejected or denied. Your billing staff corrects what they can, and the rest is eventually written off. True RCM does not simply fix what claims can be easily fixed and call it a day. True RCM service providers collect claim data and look for trends in claim denials/ rejections. Once the cause has been pinpointed, you are then able to take that information, communicate the issue to the appropriate department (i.e., front desk, provider, etc.) and create an action plan to stop the problem at the source and eliminate future denials.

Medical Billing Software is Not Revenue Cycle Management

A core component of any billing department is the practice management (PM) system. You probably spent hours vetting systems, exploring options to ensure that you selected just the right product to simplify and improve your billing results. This product was going to take your billing department to a whole new level, automating the billing process, eliminating human error, and providing you insightful report to make your job much easier. You purchased just the right system, and your billing team paid close attention during the onboarding process, diligently taking notes so they could be system experts in no time! After the setup, you and your team found issues in the system; it wasn’t built for CHCs and configuring it on your own is a nightmare. Your team sits on endless calls with the PM system vendor trying to customize or even just easily access all those flashy reports and atomization features you were so excited about.

Software no matter how well built is just that, software. It is simply a tool to get the job done and is only as good as the instructions we give it. Most of us struggle just to remember our email passwords, expecting anyone, no matter how tech-savvy, to master a complicated system with little or no training is a lot to ask. Herein lies another key component of RCM, the electronic data interface (EDI) team. Talented EDI staff is the key to unlocking your PM system’s full potential. Extensive knowledge of CHC billing nuances, combined with technical expertise can change your PM system from a cumbersome, pain- in the-you-know-what to a powerhouse tool that allows you to track and improve billing processes throughout the circle of communications.

In short, billing is not revenue cycle management; a PM system is not revenue cycle management. True RCM extends its reach far beyond the billing office, to every corner of your CHC, with opportunities for improvements and/or errors throughout. It does not matter if you have a billing team of one, an entire billing department, or an outsourced vendor, in order to increase returns, we must look beyond the processing of claims and embrace the habits of true revenue cycle management.