The Healthcare Financial Management Association (HFMA) defines revenue cycle management (RCM) as “all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.” Many practices collaborate with an experienced outside medical billing service provider to manage these tasks. RCM comprises front-end and back-end financial processes.

The front-end operations relate to processes involving direct interaction with patients, whereas the back-end involves claims management and reimbursement. While these areas usually operate separately, efficient front-end processes are crucial for the back-end’s success. Medical billing success starts at the front desk. Synergy in front- and back-end operations is also necessary to drive revenue through the cycle.

Front-end Processes in RCM

The front-end RCM steps are patient appointment scheduling, patient registration, insurance eligibility and authorization, and upfront patient collections.

  • Appointment scheduling: Healthcare providers need to schedule patient appointments constructively. Too many unfilled slots will reduce provider productivity and revenue, while overbooking can lead to provider burnout and increase the potential for patient dissatisfaction. Patient appointments should be scheduled to avoid long wait times and improve care access. Best practices include:
    • Booking patient visits to minimize wait times
    • Ensuring patients come in at the right time for their needs
    • Ensuring patients can see the right physician at the right time
    • Minimizing patient no-show rates

One way to optimize appointment scheduling is to partner with a technologically advanced medical billing company that offers automated solutions. Automated appointment scheduling is much easier for patients and providers. The software’s easy interface allows patients to view availability and set a date and time for their visit online. Physicians and staff can access schedules at the same time and from anywhere. The software can help them identify vacant time slots and sends out reminders to minimize no-shows for scheduled appointments.

  • Insurance eligibility verification and authorization: The success or failure of each patient claim begins and ends at the front desk. Eligibility problems are reportedly one of the most common causes for claim denial. Insurance verification is crucial to ensure that patients can pay for the services they receive. The key questions that a reliable insurance verification service provider will ask are:
    • Does the patient have coverage
    • Does the patient have additional insurance
    • Are the registration details correct – this data includes patient personal and contact information, and other demographic details, patient referral or appointment scheduling, patient health history, and patient orientation
    • What is the number of maximum allowable visits?
    • What is the patient’s cost responsibility?

A ClaimRemedi survey reported that patients are not being asked these types of questions enough (www.patientengagementhit.com). While 79% of surveyed practices reported checking a patient’s eligibility, only about 25% said they checked this information on subsequent visits. Eligibility verification needs to be done at each and every visit. Most health plans demand prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices services. Therefore, to prevent denials, practices also need to complete prior authorization requirements.

  • Upfront collections: Collecting patients’ financial responsibility is the final front-end RCM process. With high-deductible health plans, patients are responsible for a significant portion of healthcare costs. Patients should be informed of their financial estimates prior to service so they can plan payment accordingly. Other strategies to improve patient upfront collections include:
    • Offering multiple options to pay such as credit cards, check-in kiosks, online payments, payments via phone, and e-checks
    • Creating and posting a clear-cut financial policy the practice website
    • Developing payment plans that enable patients to pay off balances over time
    • Offering discounts to those who pay in a timely manner

As the industry moves toward value-based care, efficient front-end RCM is crucial for a smooth patient access experience as well as proper reimbursement. Following patient visits and related processes, clinical documentation and coding, the revenue cycle progresses to the back-end with claims management and medical billing, including accounts receivable.

Outsourcing for End-to-end RCM Solutions

A seamless revenue cycle is one that successfully integrates front-end and back-end RCM operations. Experienced medical billing service providers can ensure end-to-end RCM solutions that leverage appointment scheduling, insurance verifications, and patient collections along with billing, coding, payment posting, accounts receivable follow-up. In addition to a team of insurance verification service specialists, certified medical coders, and billing experts, the ideal vendor would have the necessary technology to provide streamlined and integrated RCM solutions.