What Is Medical Revenue Service? How It Does Works?

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Appedology.com | Date: April 30, 2021 | Posted by: Admin | Category: Planning
What Is Medical Revenue Service? How It Does Works?


What Is Medical Revenue Service? How It Does Works?

Medical Revenue services raise the standard in Healthcare Revenue Cycle Management with a functional and integrated approach to achieving financial results. What Medical Revenue Service is doing for your organization can be defined as accumulating all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue. In the most simplistic and basic terms, this is the entire life of a patient account from creation to payment.

The healthcare industry and associated healthcare revenue cycle is changing and growing more complex every day. Traditional models for medical reimbursement and accounts receivable management are becoming ineffective, as medical reimbursement shrinks and healthcare industry regulations grow.

Recent government regulations have impacted the healthcare industry and healthcare practices in many ways. Third-party health insurance payers negotiated fee-for-service contracts with providers, which resulted in lower reimbursement. 

HIPAA, the Healthcare Insurance Portability and Accountability Act also had an impact, by tightening the requirements for claim data submission. As the healthcare system changes over from a fee-for-service to a value-based reimbursement model, healthcare practices and providers have had to adjust the way they bill for the care they provide.

Having a healthy revenue cycle is more important than ever, because of these changes in government procedures.


Table of Contents

What is a Revenue Cycle?

A revenue cycle is the entire documented account of billing for a patient from creation to payment.

Strong revenue cycles follow billing and collection best practices to ensure bills are submitted in accordance with payor requirements and all services provided are billed. No organization, especially healthcare should face providing services and not being paid.


Revenue Cycle Leakage Points

There are many different leakage points in the revenue cycle, but here are the most common:

No referral

  •         Registration, coding or billing errors
  •         Unverified insurance
  •         Underpaid claims
  •         Denied appeals

Medical Billing Apps – Billing and Coding

Healthcare jobs are increasing at a faster rate than average. Medical billing and medical coding are two interrelated jobs that help facilitate payment between health care providers, insurance companies, and patients. Medical coders transcribe a patient visit and physician’s treatment into a series of pre-determined, universally accepted codes. Each code has guidelines on how they can be used, so accuracy is essential. These codes are used by health care providers, hospitals, insurance companies to create a record of a patient’s visit and submit an insurance claim.

Next, medical billers take the codes prepared by the medical coder and submit claims to the insurance company. They follow up with both the insurance company and the patients to make sure the medical office is compensated properly, the patient is billed correctly, and timely payments are made.

Both medical billers and coders are needed to handle insurance and patient claims.

A medical coder is responsible for:

  • Reviewing and analyzing clinical statements & patient records
  • Translating diagnosis and medical information into codes using CPT, ICD-10-CM and HCPS Level II classification systems
  • Interacting with physicians and assistants to ensure codes are accurate and ready to be converted into a medical billing claim.
  • Maintaining patient confidentiality and information security

A medical biller may perform all or some of the below mentioned job responsibilities, though not on a daily basis:

  • Audit and submit claims to insurance companies for patient procedures and treatments.
  • Obtain insurance referrals and pre-authorizations for patient procedures.
  • Verify insurance eligibility and benefits.
  • Understand insurance guidelines, including those for HMO/PPO, Medicare and Medicaid.
  • Review patient bills for accuracy and fill in any missing information.
  • Check payments for accuracy.
  • Research and appeal denied claims.
  • Talk with insurance companies about payment discrepancies.
  • Set up payment plans for patients.
  • Collect delinquent accounts.
  • Answer phone inquiries from patients and insurance companies.
  • Use medical billing software to perform job duties.
  • Update software with rate changes.
  • Know Fair Debt Collection Practices.

Types of Medical Billing Apps

Medical billing is one large system part of the overarching healthcare network. The healthcare network includes everything from medical billing to best practices for patient care, health institutions, and private practices. There are three basic types of systems: closed, open, and isolated.

  •  A closed system is doesn’t allow transfers: an example of a closed system is using EMRs, or electronic medical records in your practice. EMRs are the digital versions of archaic paper charts. While still used in modern practices today, it is usually combined with other types of records. EMRs, are as the system implies, closed, you cannot use them to collaborate with other doctors and healthcare facilities (i.e. labs, urgent cares, etc.).
  •  Open systems allow for transfers across healthcare professionals, practices, facilities, etc. EHRs, or electronic health records are open systems. Sometimes people in the medical field confuse the terms EMR and EHR, but EHRs are a highly collaborative record-keeping style, which enables everyone to be privy to the patient’s healthcare. Using open systems means the medical billing software (AdvancedMD, AllMeds, GE Centricity, McKesson, etc.) must communicate and collaborate efficiently. Some practitioners and healthcare facilities argue are conscious of HIPAA and maintain the importance of protecting the patient’s privacy.
  • Isolated systems are completely removed from healthcare facilities, physicians, and practices. PHRs, or personal health records, and are used in isolated medical billings systems. Complete healthcare records of patients are maintained and managed by them. These records simply help patients manage their health information.

PHRs cannot legally replace official healthcare records, hence isolated medical billing systems aren’t commonly used. If patients use appropriate software, PHR can be used to fill out the medical practices’ official records, but this requires open communication within the software to ensure that details get transferred correctly.

Once you decide which system and record-keeping you want, you can pick between choosing software or keeping your current records. Medical billing systems will help you determine the extent of outsourcing medical billing and coding.


Medical Revenue Service Payment

From the moment you make an appointment to see your physician, the healthcare provider starts tracking the financial features of your care. Medical billing software enables staff members to quickly accomplish a variety of key tasks. It verifies insurance coverage and determines copayments before you arrive for your appointment. It also sends claims with specific treatment codes to insurers once your care protocol is determined, and bill you for any remaining balance following the appointment.

Revenue cycle management (RCM) is the combined administration of these essential financial processes. Healthcare providers must implement accurate and efficient billing processes to operate a successful medical practice. In time, as healthcare payments shift away from fee-for-service payments toward value-based care, it is imperative to establishing core accounting protocols and check several Medical Revenue Service Reviews to make informed decisions.

 Using data to compare to these “standards”, is one of the have the best practices your healthcare organization can incorporate for a healthy revenue cycle  and this helps health care providers to understand leakage points and opportunities for improvement. 

 Common Revenue Cycle Best Practice Metrics

Some of the best practices include:

Carry Out Regular Financial Clearance – Patient information must be maintained and verified before the patient arrives for their appointment. Scrutinize insurance eligibility and track any any/all authorizations. Patients are informed of outstanding balances and prompt payment is encouraged.

Streamlined Check-In & Check-Out Process – Patient information is confirmed and verified, eligibility determined and all prior and new balances are collected.

Charge Capture – Use an electronic charge capture process. In such cases specific coding is applied and documentation audits are regularly performed.

Charge Entry – For this fee schedules are developed and managed and charges are entered into the system. These charges are then reviewed and audited and the person responsible for editing charges must be meticulous in all dealings, and must also be monitored diligently.

Proper Claims Management – Electronic claims are submitted and status updates are frequent; secondary claim process happens; attention is paid to maintain compliance with insurance carrier’s claim format requirements. These are multi-tiered claim editing checks, assistance with edit tracking and error resolution happens; a system for easy rebilling or corrected claim processing is implemented, and an overall analysis of billing process delay times is taking place.

Patient Statements – In the patient statements phase, cycled billing occurs; statements are clear and concise. Notes and automated holds are made on patient statements when applicable, and final notices go out.

Payment & Denial Posting – The next step is making data entries about payments, managing contractual write-offs, processing insurance reversal and credit balance resolution, and the review of denials and adjustments. The organization must carefully control and monitor who can edit payments.

Insurance Follow Up – Verification that insurance carriers are receiving claims and that the claims are being processed; accounts receivable are worked on by priority; staff’s collection actions are audited; your practice’s average days in accounts receivable and net collection rates are known.

Denial Management – During denial management, you’ll know if your claims denials rate is excessive, claims denials received are scrutinized and details clarified, common denial causes are analyzed to improve processes, and denied claims are resubmitted if payment can still be collected.

Patient Collections – During the patient collections phase, patient billing occurs; collection letters are sent and general collections take place. In certain cases payment plans are offered. Patient balances must be reviewed before appointments and the productivity of collectors evaluated.

Payor Management – In this phase, attention is paid to fee schedules, carrier provider numbers and NPI, assignment of benefits, carrier communications and contract dates, documentation to support claims, and carrier analysis take place.


Revenue Cycle Management Collection Agency

A successful business, a company or organization is one that ensures it is paid for all its products and services. Revenue cycle management, often associated with healthcare companies, is the process by which an organization manages the customer relationship, beginning when the agreement is made and ending when the account is paid. A Revenue Cycle Management Collection Agency plays an important part in collecting debts, whether they come from individuals or insurance companies.

 Small businesses with limited staff actually benefit more by hiring a professional debt collection agency, as it saves them time and makes money by collecting on past due accounts. Collection agencies get better results, because they have the time and experience collecting debts that a smaller organization will not necessarily have. But it is imperative to find a reputable agency to assist you.


Make Informed Decisions When Hiring a Debt Collection Agency

  • Get all required about an agency’s fee structure. Some collection agencies a standard fee that you pay monthly, other take a percentage of the amount they collect as their fee. They may also charge a higher percentage rate for older accounts, which are often difficult to collect. Flat monthly fees can be based on the number of delinquent accounts you hand over to the agency or on how often you give the agency past due accounts to collect, so it is important to get these details before settling on an agency.
  • Check if the agency offers skip-tracing services, as experienced debt collection companies often have access to multiple databases to locate debtors who have changed telephone numbers or addresses or moved to other states without leaving a forwarding address. Whereas there are both free and paid sites for this information, well-grounded collection agencies use pay sites for better results as these pay sites list cellphone numbers and can find people through their social security numbers.
  •  Ask if the agency reports to any of the three major credit-reporting bureaus. Not all collection agencies report debtors to credit bureaus. Some agencies may report to one or more of the credit bureaus, and an omission will affect the person’s credit score either negatively or positively. Unpaid debts negate a person’s credit score and remain on the credit report for seven years.
  • Hire an agency that has a credible reputation for complying with the Fair Debt Collections Practices Act. Contact the Better Business Bureau to determine if an agency is a BBB accredited business. Your organization can also confirm this with the Federal Trade Commission and your state attorney general office for any complaints of misconduct filed against a collection agency.

 Now, armed with enough Medical Revenue Cycle Management information for you to choose from, Appedology as a digital solutions provider can help you choose the best outcome for your billing and payment, medical history needs. Contact us for a free assessment to help you further draft your organization’s Best Practice.

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