Healthcare Revenue Cycle Management Overview

This module focuses on healthcare revenue cycle management
Objectives include reviewing the importance of revenue in revenue cycle management, revenue enhancement, steps of a successful revenue cycle, analyzing current operations for areas of cost, financial policies and procedures, changes in Saudi healthcare reimbursement, RCM cycle under the new reimbursement system in KSA, potential risks of poor RCM function, challenges of the new RCM process, and the role of RCM as a profession.

RCM is the process used by healthcare systems to track revenue from patient registration to analysis.
The Healthcare Financial Management Association (HFMA) defines the healthcare revenue cycle as encompassing all administrative and clinical functions that contribute to capturing, managing, and collecting patient service revenue.
Generating revenue is vital for any business.
First key factors in financial success are to sustain and increase revenue opportunities, and the ability to capture and collect all revenue.

Revenue is crucial for businesses to remain open.
Healthcare, unlike other industries, is not paid immediately for services. Instead, invoices are sent to third-party payers and reimbursement is expected later.
Self-pay patients can pay via installments.
Revenue cycle management is critical for healthcare providers to effectively manage their financial processes.

Physicians are the primary source of revenue in a medical practice.
Providers should focus on tasks only a physician can perform.
Other tasks, such as those of nurses, medical assistants, receptionists, billers, and coders, should be assigned to appropriate support staff to maximize physician productivity.

Learning objectives are facilities in healthcare, types of healthcare providers and staff, patient journey/workflow, physician mindset, administration and accountability, and leadership, management, and communication.
Overview of facilities, providers, and typical workflow, especially changes with electronic medical records (EMRs).
Discussion on effective communication, administration, and accountability related to various healthcare facilities.

Healthcare sector includes various specialized facilities like hospitals, clinics, surgery centers, etc.
There are various services performed across different types of facilities, which include inpatient and outpatient settings.

Six types: hospital inpatient, day case, emergency patient, outpatient, home healthcare, and primary healthcare.
Types of admissions: immediate, emergency, elective waiting-list (government/self-pay/insurance).
Types of care include: acute care, rehabilitation, general maintenance, complex maintenance, boarder, and palliative care.

Independent facilities.
Separated tax identification number.
Services not part of the hospital cost report.
Physician services are not coded and billed by the facility unless the physician is employed by the ASC.

Billing for clinic services is based on the contract between the provider and the facility.
Reporting includes scheduled and unscheduled visits, consultations, and office procedures.
The clinic reports the resources used by the facility.

Admits patients without inpatient needs.
Business office handles claims processing, remittance documents, etc.
Health information management (HIM) manages medical records; may have paper or electronic records.

Patients admitted for overnight or multiple-day stays.
Inpatient services include bed, board, nursing care, medical social services, medications, and procedures.
Specific facilities, like acute care hospitals, specialized hospitals, private hospitals and military hospitals all function within different categories of care.

Key steps include appointment scheduling, registration, charge capture, billing, denial management, and accounts receivable follow-up.
Front desk staff are responsible for scheduling appointments and registrations
Includes insurance verification, copay collections, and patient record documentation
Effective denial management and accounts receivable follow-up are vital to minimize financial risks.

Various types, including physicians (MD or DO), physician assistants (PAs), nurse practitioners (NPs), and other non-physician practitioners (NPPs are also vital to healthcare.
Different specialties and roles within the healthcare sector.

Staff can include registered nurses, medical assistants, radiology technicians, physical therapists, speech therapists, and others.

Coding is the translation of medical information into standardized codes used in billing.
Codes are used for diagnoses (ICD-10-AM) and procedures (SBS).
Accurate coding is critical for reimbursement from payers.

Includes definitions, billing process, claims submission timelines, different types of medical billers.
Claims processed in different methods, both manually and electronically, follow a specific process to submit to the insurance company for payment.
Fraud is defined as intentional deceit to obtain benefits, while abuse is a lack of entitlement and misleading is defined differently.

Addressing and resolving denial issues for claim rejections is essential to collecting revenue.
The types of denial include technical (e.g. no coverage) and medical (e.g., incorrect diagnosis) issues.

Represents the total charges that have not yet been collected, and effective A/R management is vital for maintaining cash flow.
Aging report categorizes outstanding balances by time frame, and payers.

Office settings (outpatient) encompass various stages, including scheduling, verification of benefits, physician visit, checkout, including billing, and reconciliation.