Every day, healthcare practices lose thousands of dollars to preventable revenue cycle failures. Coding errors trigger claim denials. Manual eligibility verification creates bottlenecks. Poor denial management lets recoverable revenue slip away permanently.

As a result, practices are working harder but earning less, with administrative burdens consuming resources that should be dedicated to patient care. 

The solution isn't working longer hours. It is adopting an optimized medical revenue cycle management.

Modern healthcare demands precision at every touchpoint of the revenue cycle. From the moment a patient schedules an appointment to the final payment posting, each step presents opportunities to either maximize revenue or create costly inefficiencies. 

Yet many providers remain hesitant to modernize their established processes, even when those processes are clearly hindering their financial performance.

This article explores proven strategies that healthcare practitioners can implement to transform their medical RCM workflow, minimize claim denials, and create seamless patient experiences. 

Key Stages and Components of Medical RCM in Healthcare

Let’s take a look at the key stages and components of medical RCM in healthcare. 

1. Pre-registration and Registration

Pre-registration is carried out before the patient visits the healthcare facility by collecting their demographic and insurance-related data. This process is completed when the submitted medical, personal, and insurance details are verified. 

2. Insurance Verification

The healthcare provider verifies the insurance details and requests authorization from the insurance company before operating or treating the patient, to ensure the insurance company will cover the treatment expenses.

3. Creating Bill Codes 

Healthcare providers must document all the steps of the procedures and other services provided and create bill codes, such as CPT and ICD codes, to ensure a seamless insurance claim. 

4. Submitting the Claim

Once all the codes are documented, the healthcare provider must submit them to the insurance company, which will then determine whether the claim adheres to their policies and if the claim is eligible for reimbursement.

5. Payment Posting and Billing

The healthcare provider must post the payments received from the insurance to the patient’s billing account. Payment posting is essential so that all the stakeholders have real-time insights into the amount paid by the insurance company and pending dues from the patient.

6. Analysis

Internal analysis is crucial for healthcare providers, as it gives them a clear view of their medical RCM strategy and identifies areas for improvement. 

5 Strategies to Optimize Different Stages of Medical RCM Workflows

Let’s examine how healthcare providers can optimize the different stages of their medical RCM workflows. 

1. Appointment Scheduling

A healthcare practitioner’s revenue cycle starts as soon as a patient schedules an appointment. However, around 61% of patients said that they skip regular healthcare visits since scheduling an appointment is inconvenient. 

Cancelled appointments not only take a toll on operations but also often signal early signs of future revenue losses. 

Fortunately, there are solutions to address this:

• Use specialized tools that automate appointment reminders via WhatsApp, email, and SMS to minimize the number of no-shows. 
• Create a seamless appointment scheduling system where patients can book, cancel, and reschedule appointments.

To address these challenges effectively, practices need robust solutions. HOM's Scheduling and Demographic Entry services achieve 95% accuracy while reducing demographic-related rejections by up to 60%. It automates booking, validates information with a 24-48 hour turnaround, and proactively identifies discrepancies before they become costly denials.

2. Patient Eligibility Verification

In today’s tech-driven landscape, healthcare providers can no longer rely on manual and error-prone patient verification techniques, which often result in delayed payments and claim denials. 

Here’s how healthcare practices can improve patient eligibility verification:

• Implement advanced tools that streamline pre-service processes, including eligibility verification by capturing and cross-checking patient information against insurance databases.
• Creating a tailored process to determine coverage limits and patient eligibility before the patient’s arrival and admission.
• Conducting training sessions for relevant staff members in the front desk and billing team to detect anomalies at pre-registration. 

As a case in point, HOM's Eligibility & Benefits Verification services deliver 96% accuracy with a 48-hour turnaround time, helping practices achieve up to 60% reduction in demographic-related rejections and denials. The advanced verification system cross-checks patient information against insurance databases, ensuring clean claims from the start.

3. Streamline Claim Submission and Processing

Apart from modernizing patient eligibility verification, it is equally important to ensure that claim submissions are accurate and error-free.  

One of the most effective ways to modernize claim processing and submission is by maintaining electronic health records (EHRs) that ensure accurate and up-to-date patient information across all platforms.

• Healthcare providers must consider investing in an advanced claim management solution that populates patient and treatment data with relevant compliant claims.
• Use tools that provide real-time status of claims to reduce errors and fast-track claim submissions. 

HOM's Medical Billing services deliver a 97% first-pass ratio with up to 60% reduction in denials. The multi-platform compatibility ensures seamless integration with existing systems while guaranteeing consistency between CPT codes and diagnoses.

4. Claims Denial Management

Claim denials are often preventable. Therefore, it is crucial to focus on effective claim denial management to stop revenue leakages and acknowledge the main reasons for claim denials.  

The top reasons for denials include:

• Denials due to incomplete or pending patient eligibility verification
• Denials due to policy lapse
• Lack of prior authorization from the insurance company
• Medical procedures and services not covered in the insurance plan
• Administrative errors or inaccuracies
• Insurance benefit limit reached

To tackle these issues, here’s how healthcare providers can strengthen their denial management:

• Using sophisticated analytics tools to uncover denial patterns and common categories.
• Implementing standardized pre-registration checks.
• Leveraging patient financial counseling to help them understand their policy’s terms, co-pays, advance amounts, etc. 

• Denials due to inaccurate or error-prone bill codes can be significantly reduced with frequent staff training on new denial prevention strategies, billing rules, etc. 
• Detailed verification systems play a key role in minimizing denials due to missing or incomplete details by verifying documents during pre-registration. 

5. Medical Revenue Cycle Management KPI Analysis

Data uncovers multiple insights, allowing healthcare companies to stay on top of their medical RCM’s key performance indicators (KPI). 

A medical practice’s financial health depends on several moving parts, including accounts receivable, claim approvals/denials/rejections, no-show rate, and collection rate.

Here are a few suggestions to improve KPI analysis:

• Replace manual KPI tracking with automated reporting tools that work based on a pre-defined logic. 
• Frequently update KPIs to prevent the tracking of outdated or irrelevant KPIs.

HOM's real-time dashboards provide transparent, easy-to-understand reports offering full revenue cycle visibility. The analytics uncover denial patterns, revenue leaks, and operational inefficiencies while tracking key metrics like:

• Clean claim ratios (up to 98%) 
• First-pass collection rates 
• Denial recovery percentages (up to 95%) 
• Legacy AR reduction (less than 12%)

Parting Notes

Medical RCM is a non-negotiable component of a healthcare provider’s sustainable growth strategy. 

With nearly 8 years of proven experience, HOM has helped healthcare providers achieve:

• Up to 90% reduction in revenue leakages
• 70% denial recovery rates
• 30% reduction in overall operational costs

Our end-to-end RCM solutions span the entire patient journey – from pre-service credentialing and scheduling to post-service payment posting and denial management. 

ISO 27001:2013 certified for information security and ISO 9001:2015 certified for quality standards, HOM also ensures your data remains secure while optimizing your revenue cycle.

Ready to transform your practice? Contact our experts at partnerships@homrcm.com for a free audit and discover how HOM can unlock your revenue potential.

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