Implementing Revenue Cycle Management in Healthcare

Unlike other businesses in industries, healthcare has multiple responsibilities on its account; the one we know is saving lives and treating patients, and the other one is to develop successful processes and policies for financially staying healthy. However, it’s not simple; as said, the process involved in balancing the two sides is not complex but an arduous process that involves a dominant deal of knowledge extended through the various departments in healthcare.

That is where revenue cycle management plays. Healthcare revenue cycle management is the financial process of maintaining administrative and clinical functions associated with billing & coding, claim processing, and revenue generation. Unquestionably, revenue cycle management is invaluable for healthcare, even for small clinics, to maintain a healthcare function as well as steer clear of revenue leakage. But the problem is your healthcare facility is up to maintaining a seamless cycle? There are a lot of considerations about the in-house team yet. So, let’s discuss implementing revenue cycle management in healthcare and the superior way to maintain a revenue cycle.

Basic Workflow of Healthcare 

Each step involved in the revenue cycle is crucial for accurate healthcare facility function. Technically, there are many chances for errors to be placed. Revenue cycle management steps in healthcare begin with scheduling appointments when patients seek medical services from healthcare. And the process ends with organizations receiving all claims and patient payments. But the steps involved in the life of a patient’s account are not straightforward. Let’s look at the steps and pinfall areas to go over. 


The initial revenue cycle management process is key to optimizing the RCM cycle. In this step, the healthcare provider collects the information to create a patient account that contains medical history and insurance coverage to establish a patient account. This is the step the healthcare provider or in-house team is responsible for verifying insurance eligibility. RCM emphasizes accurately completing the step if a person already has an account. 

Incorrect information or ineligible insurance is the main reason the claim submissions lead to denial. This results in delays in reimbursement payments and additional work for the provider to comb through the patient’s information.

Charge Capture:

This is the step where provided treatments at healthcare facilities are transcribed into billable charges using universal medical codes. Further, these codes are converted into reimbursement payments by insurance payers. The patient’s claim could be denied if the codes are incorrect and also cost healthcare time and cost to look up the errors to investigate and appeal. Therefore, an effective revenue cycle is crucial to maintain accuracy in coding to avoid claim denials altogether.

Claim Submission:

Once the charges are properly coded, the healthcare centers submit the claims to corresponding insurance companies so that they proceed with the claims and provide reimbursed payment to healthcare as per the contract. Revenue cycle management ensures the claim submission as well as tracking and managing of the claims from the initial process. Error in claim submission results in payment delay.

Insurance Follow-Up:

Insurance follow-up is another significant process in the healthcare RCM. As per the estimation, 1 in 5 claim submissions are inaccurately processed, leaving the healthcare industry with an 80% accuracy rate in claim processing and paying. Some of the pinfall points in this step may be denial, underpayments, or non-payments. In this case, healthcare may not be satisfied with reimbursed percentage.

An ideal revenue cycle management encourages healthcare providers to analyze administrative and clinical treatment data. This analysis helps them pinpoint the errors that occur in the cycle to eliminate and lower the expense of reviewing the errors.

Best Practices and Walkthrough Step to Implement RCM in Healthcare 

RCM Software or Outsourcing

Deciding how to handle the RCM is the first step. First, determine this question to answer, how big your healthcare organization is? If you’re fairly limited with your facility and have a good IT team with hospital staff who are all well versed in handling medical billing software on board, then you can install RCM software.

On the other hand, outsourcing with an expert is best if you’re running a multi-spec healthcare organization with multiple physicians. Moreover, facilities with limited staff expertise will also find it beneficial to focus on patient care by outsourcing RCM with third-party experts.

Automate Insurance Validation

Verifying insurance eligibility and coverage during patient registration is essential while integrating revenue cycle management in medical practice. Many insurance companies uncompromised the requirements for pre-authorization and insurance verification. Suppose your in-house team isn’t able to conduct accurate data despite patient care. In that case, modern medical billing software includes automatic eligibility checking over secure channels on the internet to speed up the verification process with seamless data.

Know Patient’s Balance

While implementing RCM in healthcare, it’s crucial to be well aware of the patient’s payments. Any pending payments must be looked after with medical billing solutions. Pending payments will increase the AR duration and cause an impact on healthcare revenue. The best way to complete the payment cycle is by collecting payments or balances during check-in and check-out of hospital visits. RCM in medical billing enables your in-house team to track patients’ balances and help to receive payments promptly.

Cohere to Compliance Standards

Healthcare organizations must stick with HIPAA regulations, and healthcare providers must submit claims to insurance companies electronically in an approved format. Paper works for keeping patient’s claim records could lead to errors and miss the accuracy. Healthcare should adhere to HIPAA regulations to make the patient’s information more secure and accessible. RCM in healthcare enables to file accurate medical billing documents as well as more secure information.

Manage Claim Denials 

Claim denial is the major reason why some healthcare providers lack revenue cycle management in medical billing. Claim denials occur for several reasons, most importantly coding errors, duplicate claims, and lack of information on pre-authorization. This is the reason why it’s significant to look closely at the claim process. By implementing RCM, your staff can track and recognize the pattern of errors to prevent and help understand why the claim is denied. 

Bottom Line:

The above practices for implementing RCM in healthcare would streamline your healthcare facility’s administrative and clinical workflow. However, RCM is a long-term plan to invest money and time. The five best practices can increase cash flow and reduce account receivables and expenses if your healthcare and in-house team follow up to conventional standards. Are you concerned about your in-house team focused on your duty (caring for patients)? We can assist you in that part of maintaining a streamlined revenue cycle with end-to-end revenue cycle management solutions. MHRCM ensures each step of the revenue cycle with expert resources and high-centric capture to maintain a seamless cycle. Get your free quote today for medical, dental and therapy RCM solutions.

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