The entire RCM workflow consists of the following components. There are more details in frequently asked questions here.
- Patient Insurance eligibility
- Prior Authorizations
- Patient Demographics
- Patient signatures on Assignment of Benefits Form
- Charge posting
- Payment posting
- Balance collections
On this page
Create baseline report
- How many claims are pending to be submitted as of date + reasons (e.g. no visit notes)
- How many claims are in “no responses” status
- How many claims have been denied and the reasons
- How many claims that are still within timely filing deadlines where we could recover monies
- Average claims cycle – days between DOS and claim paid
- Maintain a list of all plans accepted
- Maintain a matrix of all plans accepted at each location
- Maintain a matrix of all plans that a provider is par with
- Maintain the delta of which plans our providers still need to be on par with
- Each day, receive update file from eligibility team to update provider credentialing
- Use credentialmydoc.com website / application to track statuses
- For each provider vs each plan to be credentialed for, complete required documentation and identify exceptions.
- Next, verify provider/ location information from providers or the payer roster. Even if a provider does not practice at a specific location, get them credentialed so we can bill under.
- Regularly, follow-up on submitted credentialing requests.
- After receiving credentialing notice, capture that data, label and link images to specific providers/ locations in the payer’s database.
- Once a month, update provider information, and CAQH profile.
- Validate and update the provider’s pay-to address or the billing address with the payers
- Validate and if possible, enroll us for Electronic Data Interchange (EDI), Electronic Remittance Advice (ERA), Electronic Fund Transfer (EFT) and CSI with all payers possible
- Verify insurance eligibility 3 days before patient visit
- For each eligibility check, ensure that you update as many details as possible e.g
- copayment, deductible, outstanding deductible, coinsurance
- Secondary, tertiary insurance
- Medicare / medicaid details if any
- Effective from / effective to dates
- Mark differences in patient PCP and patient address from verification website (payer) vs your EMR
- Each day, deliver a file to the call center team for failed eligibility verifications (in active or eligibility check failed). Call center has to call the patient and sort out the correct insurance details. If a patient does not answer, leave a note in your EMR that is triggered upon the patient / appt open event in your EMR.
- If eligibility fails due to credentialing errors or credentialing TODOs (e.g. provider is not at par with the particular payer), reassign the patient to a provider that is at par with the patient’s payer. Leave a note that triggers an open patient/appt event in your EMR to inform front desk and techs/scribes that the patient cannot be seen by provider X/Y because they are not par.
- Each day, deliver a file to the credentialing team of patients that had to be reassigned (appointments) because of the provider not being credentialed. This will allow the credentialing team to prioritize providers that need to be credentialed for specific plans (based on volume of patients that needed to be reassigned to another at-par provider).
- Each day, deliver a file to call center team that notes patients whose demographics have not been updated in more than 6 months
- Refer to the billing cheat sheet to determine which patients need to get prior authorization for the visit.
- In your EMR, enter the authorization number, referring provider NPI, authorized provider and if necessary the ICD10s
- In your EMR, upload the referring provider referral PDF as you get via fax or werq website
- Capture Patient’s legal name, gender, address, phone numbers (work/home/mobile) – check “face sheet” and validate info
- If possible, Patient’s social security numbers for identification
- Health insurance information (name of the insurance company, name of the insured person and his/her place of work, mailing address for claims, and group and policy numbers)
- Medicaid or Medicare card (if the patient receives federal or state assistance)
- Name, address and telephone number for person who will be responsible for payments
- Enable patient portal by using patient email address if available or manually mark it as enabled (within 4 days of patient DOS)
Charge Entry / Charge Capture Audit (CCA)
- Use / refer to the charge description master
- Receive superbills from FTP or some kind of a shared drive
- Validate clinical data information (CDI) and ensure completeness / accuracy. Validate visit note for level of care, and all treatments rendered
- Daily, create a file and push CDI issues back to providers
- Capture the date of service, billing provider, referring provider, CPT/procedure codes, ICD-10, number of units and modifiers.
- Prepare charges after coding (done by coders), validate via software like EncoderPro
- Daily, create a file and push coding errors to coding team
- Run them through claim scrubber / EncoderPro (perform Charge Capture Audit CCA)
- Append necessary modifiers, bill exact number of units
- Verifying charges against fee schedule / CDM
- Identifying undercharges / under-coding, duplicate posting, and overcharges/over-coding
- IMPORTANT for commercial payers – if the patient has a referral provider, bill it as a consult rather than a visit because the reimbursement rates are higher. This doesn’t matter for Medicare/Medicaid.
Payment Posting / Remittance processing
- Daily, first do Electronic Remittance Advisory (ERA) Posting – question, what do we do here? Run ERA batches and post to your EMR? Process any exceptions by making corrections in your EMR.
- Daily, perform Manual Payment Posting from EOB. First, create inventory of EOBs received, payment details then post accurate payments, adjustments, write-offs and balance transfers. Update the inventory daily and prepare report
- Create a daily denials file and hand off to the denials team. First, create inventory of daily denials, reasons for denials. Create a file if denial is related to billing the secondary payer as well.
- Create a daily no-responses file and hand off to the denials team. Maximum time to wait is 30 days, so you should create a file for all claims wherein we have not received responses in 2 weeks.
- Create a daily patient responsibility file and hand off to the collections team. Also, create a file if denial balance has to be transferred to the patient account as patient responsibility.
- Create a daily file preparing remaining data to get approvals for making adjustments/ write-offs as per defined policies.
- Route the denied claims to appropriate work queues (call center, practice management staff etc)
- Daily Patient Payment posting. First, get a file from your payment processor for daily payments received. Look up patient accounts and post payments to avoid inflated A/R. Next, get a file for all payments made at the counter. Ensure that those payments are reflected in patient account balance to reduce A/R. Ensure that these payments are credited to the collections team to be applied to their daily quotas.
Denials is a separate topic altogether and covered in its entirety here.
Collections is a separate topic and covered in its entirety here. This requires you to understand how to collect as first party vs third party. Plus, you also need to understand reading out Miranda rights (mini Miranda as well)
Create a billing cheat sheet
- List of payers
- including Medicare, Medicaid, Blue Cross Blue Shield by state, Cigna, Aetna, United HealthCare, Tricare etc)
- include all contact information such as claims address, website, and provider information phone numbers.
- List of insurance verification websites + credentials
- Timely filing deadlines for each payer (e.g)
- Medicare – within 1 yr
- UHC – depends on agreement
- Cigna – in-network (90 days), Out-of-network – 180 days
- Aetna – 90 days
- List of payers requiring verification and prior auth, list process of prior auth for each payer, list all services (codes) for each payer that needs prior authorization
- Billing limits per service per payer – maintain the frequency allowed for specific services or procedures by payer. Include the number of procedures allowed and the process for billing multiple procedures (there are some gotchas for each specialty)
- Billing methods – make sure all your payers accept electronic claims (otherwise it is a laborious and painful)
- Payment timings – most payers are required to pay within 30 days, but if there are any payers that do NOT pay within 30 days of filing, note it in this cheat sheet.
- Denials / no responses – Identify and notate the appeals process required for each payer. Keep the timely filing deadline for each payer.