RCM - Steps

At the front office

• Patient fills the registration form.
• Patient ID proof (SSN/DL)
• Submit insurance card copy
• AOB(Assignment of Benefits) Patient approves their benefits made directly to hospital or provider.
• ROI (Release of information)Releasing the patient health information to billing office/Insurance.
• Medical history (If any)
• For minor patient Guarantor info is must. Note: This activity has been done by doctor office.

Meeting Doctor

Check up/Treatment/procedure:

• Doctor checks the medical history report.
• Doctor diagnose the patient and provide necessary treatments.
• Doctor’s treatment details are simultaneously recorded.

Medical Transcription

• Once receive the voice file (treatment info) is converted into a text file.
• The conversion of "Voice to Text" is known as medical transcription.
Note: This process will be handled by medical transcription office.

Medical Coding

• Based on the transcribed sheet, the Medical coders assigns appropriate numerical value for both Diagnosis and procedures
• Medical coding done based on ICD and CPT manual

ICD-10- CM (Clinical modification)

ICD 10 Denotes disease.

• Based on the transcribed sheet, the Medical coders assigns appropriate numerical value for both Diagnosis and procedures
• Medical coding done based on ICD and CPT manual

Procedure Codes

Modifiers

Modifiers are two digit code which provide additional information about the service or procedure performed. They are used as an extension to alter a CPT code but not change the code or its definition. E.g. 50, LT, Q6 are modifiers. It will be given along with CPT like 73550-50

Demo-Entry

Once coding completed, super bills are sent to entry process along with demo sheets.
Below listed activities done at demo entry:

• Creation of account in billing software for each new patient
• Verification/ Updating for existing.

Demo creation

Patient found in provider S/W:
Verify the patient details as per demo sheet.Patient not found in S/W:
Need to create patient account in software based on the demo sheet such as

• Patient name
• DOB
• SS#
• Address
• Phone #

Insurance verification

Insurance details are updated in billing software based on the following:

• Insurance Name
• Policy #
• Group #
• Insured party
• Address
• Eligibility period

Charge entry

The process of entering details like provider, illness and treatment information in to a particular patient account in the billing software in order to get reimbursement for the service rendered by a physician from an insurance or patient is known as “Charge entry”.
Once patient registration is completed, charges can be entered as per super bill. Super bill contains:

• DOS
• Referring physician
• Rendering Dr
• POS
• CPT, DX , Modifiers and units
• Admit & Discharge date
• DOI

Claims Transmission

Once demo and charges are completed, claim will be transmitted to insurance for reimbursement.
Claims can be submitted in two ways:

• Electronic media claims submission (EMC) like Modem, floppy disk & etc
• Paper claims like CMS1500, CMS 1450 or UB 92

Clearing house

Healthcare clearing house is a bridge between the provider and the insurance.
It converts the electronic claims into insurance specific format and transmits the claim.

Why Electronic Claim?

• It's fast - eliminates mail and paper processing delay
• It's convenient - easy set-up and intuitive process, even for those new to computer
• It's secure - data security is higher than with paper-based claims
• It's efficient - electronic processing helps catch and reduce pre-submission errors, so more claims auto-adjudicate
• It's complete- you get feedback that your claim was received by the payer
• It's cost-efficient - you eliminate mailing costs, the solutions are free or low-

Payment / Denial posting

• After claim processed by insurance; EOB (Explanation of benefit)will be generated.
• Once EOB is received from the insurance company, the payment posting work begins.
• If the claim is paid, there will be a bank check for amount which is mentioned in the EOB.
• If a claim is not get paid by the insurance for any reason is known as “Denials” Sample denial codes:
CO 16 – Lack of information needed for claim processing
CO 18 – Duplicate claim/Service

Payment types & Nature

Insurance payment:-

• EFT (Electronic fund transfer)
• Check Patient payment:-
• Check & Cash
• Money order & Credit card Payment nature:-
• Low paid- Payment received less than the fee schedule.
• Fully paid- Payment received equal to fee schedule.
• Over paid- Payment received more than the fee schedule.

A/R follow up

• It is important for the billing service, as a third party involved in the billing and collection of our client’s accounts, to confirm our guidelines to the Act to the assure the protection of the billing service and it’s clients.
• AR is responsible for looking after denied claims and reopening them to receive maximum reimbursement from the insurance companies.
• Prioritize unpaid claims for calling according to the length of time it has been outstanding.

Collection agency

• It is an agency hired by the billing company or provider to collect long out standing balance from the patients. In US it comes into picture after 3 bills are sent to patient and no response.
• Once balances are moved to collections, collection agency follow-up with the patient and gets the amount. This is known as collection payment. Certain % of collected amount will be paid. to the agency as a fee for their work.

Hippa compliance

• Compliance is very important to us. Our company operates in full compliance and can assist you in developing
• The Health Insurance Portability and Accountability Act (HIPAA) sets the standard for sensitive patient data protection. Companies that deal with protected health information (PHI) must have physical, network, and process security measures in place and follow them to ensure HIPAA Compliance.