Let’s talk Revenue Cycle Management

Insurance verification protects your revenue.  We call it Benefit Investigation because that’s what we do. Accessing a web portal to find out if a patient is eligible and has benefits for the service you render has its place.  And there are occasions when it’s beneficial to use them.  Being aware of patient eligibility and benefits prevents you from performing free service.The CBM team investigates and interrogates the insurance benefit representative to determine if the service you perform is a covered benefit  on the patients plan, if codes you intend to bill are covered on your contract and the patients plan and if the diagnosis you intend to bill with is covered by the patients plan.  All these efforts help prevent insurance denials.

Claims processing is how the insurance carriers handle your submitted claim.  Did you know that you and your biller have some control over this process?  You do! It all starts with the Medical Provider and the CPT and Diagnosis codes you put on your superbill. Then the control is passed down to your biller to ensure the data is entered correctly, timely, the codes you supplied to them have synergy and append the applicable modifier(s) when necessary. When all these steps are performed consistently and timely your claims are set up for success.  Once your claim reaches the insurance carrier database, it must pass all of their layers of edits before final adjudication.  This where you lose control and if you or your biller didn’t perform the steps we mentioned above the probability of receiving a denial instead of a payment increases…

It’s one of the most important tasks of the revenue cycle.   It gives a clear picture of practice revenue captured  throughout the month. Most importantly it reveals revenue leaks and peaks. The primary tool of payment posting is the EOB/ERA. The adjudication of a claim is explained to the clinic or provider on an EOB (explanation of benefits) or ERA (electronic remittance advice). EOB typically come via mail, by accessing a web portal or fax.  A ERA is automatically downloaded into the billing software.  ERA is preferred.  Depending on which clearinghouse, an ERA allows the practice to have an at-a-glance roster of payments.  This can help with forecasting revenue and allows transparency into unpaid claims.   However, a common mistake is if the ERA shows zero payment, then it’s assumed the claim was denied.  And that’s not always the case.