Revenue Cycle 101

Prior authorization (also known as pre-authorization or pre-certification) is the process by which a healthcare provider must obtain approval from a health insurance payer before delivering a specific service, procedure, or medication to ensure that it will be covered.

Deciding whether to manage the revenue cycle internally or outsource it to a revenue cycle management (RCM) company depends on several factors specific to your healthcare organization. Here’s a breakdown to help you evaluate: Benefits of Managing Revenue Cycle In-House Control & Transparency You have direct oversight and control over

An effective SOP will ensure consistency, compliance, & efficiency Creating a Standard Operating Procedure (SOP) for the healthcare revenue cycle involves detailing each phase of managing the financial and administrative aspects of patient care from registration through payment collection. The healthcare revenue cycle is complex, involving multiple departments and systems,

An Explanation of Benefits (EOB) statement is a critical document in the healthcare revenue cycle. It provides detailed information about how a healthcare claim was processed by the insurance company. Here’s how to read and understand an EOB, with key sections explained in the context of the revenue cycle. Patient

In the revenue cycle management of healthcare services, denial codes are used to indicate why a claim was denied or rejected by an insurance company or payer. Understanding these codes is crucial for managing and resolving denied claims efficiently.

Using software & algorithms to automatically generate medical codes can significantly improve the billing process.

Revenue cycle employees contribute to the capture, coding, and collection of patient service revenue. Here are key jobs descriptions.

Clean claims rate” refers to the % of claims submitted to a payer that are processed & paid without any errors or rejections first time.

Workforce automation refers to the integration of technology solutions to automate tasks & processes performed manually by employees.

Workforce analytics are systematic analysis of employee data & performance metrics to enhance the effectiveness of operations for revenue generation.