Medical Billing Services is the common name that is associated with the generic phenomenon called Medical Revenue Management Cycle. The process of recovering the fees payable for the services rendered and/or the goods sold for the medical treatment of any patient, as prescribed by any practicing physician from the relevant insurance company is, in a nutshell, Revenue Cycle Management.

Revenue Cycle Management has multiple facets to it. It is all about adhering to the legalities of the revenue reimbursement and being abreast of the latest billing software which makes work easy and accurate. However, it is easier said than done. If the healthcare providing organizations entrust their in-house employees to comply with the enormous task of billing, coding, follow up, coordination, cash collection and posting including denial management, chances are high of errors and faulty practices that can lead to accumulation of accounts and loss of revenue. In order to ensure regular cash flow and effective adjudication, it is advisable to outsource the responsibility of revenue regeneration to medical billing services organizations that specialize in revenue cycle management. 

Let us take a look at the various practices which comprise the revenue management system of the medical industry. 

• Authentication

It mainly includes verifying that the service to be availed by the patient from the provider is covered under the insurance policy of the patient. It is also called prior authorization, which is an extremely important step to reduce claim refusal. It also includes checking copayment requirements, the magnitude of co-insurance if applicable etc.      

• Coding

Under this, first, the bills are accessed from the provider’s office and then processed for verification which is later conveyed to the client, followed by medical coding. It is then cross-checked by the coding manager and sent for charge entry.     

• Entry

The details of the coded bills are included in the respective patient’s account. In the absence of a particular account, it is created with the help of the details entered by the patient in his registration form. However, before submission of the claim to the payer’s office, the ‘Quality Assurance’ team checks the validity of the claim by conducting a special audit         

• Claim transfer

After the documentation and auditing formalities are over, the claim is submitted to the payer electronically. After the submission of the same, a report is sent back to the practice office by the clearinghouse after scrutiny with rectifications if needed. The practice management team re-submits the claim after inculcating the changes.

• Payment

With the receiving of ‘Explanation of Benefits’ and checks, the payment details are entered into the system. Appropriate denial management procedure is initiated in case the total claim is not met.       

• Accounts receivable

Perusing the unpaid amount of the claim is also a part of the medical billing services. It is called the accounts receivable management. Processing and settling the unpaid and underpaid claims are referred to as a part of the accounts receivable agenda.   

• Denial management

The claims that are refused by the payer are re-processed on a priority basis. The reasons for the denial are investigated out and the claim is re-filed accordingly. If the rejection is because of the patient, it is sent back to the patient party for reconsideration.     

• Patient coordination

After the claim is processed, the patient is contacted for any pending dues. Patient’s statement is generated regularly followed up by telecommunication.    

• Reporting

The detailed report is prepared on insurance claims, the status of a business cycle, key performance indicators etc to reflect the exact situation of the practice.      

• Credit profiles

In case of the overpayment, the credit balance profile of the patient or the payer is processed to affect timely refund.   

• Credentialing

It includes a comprehensive maintenance of all the essential paperwork, following payer contracts and fee schedules.