What is Revenue Cycle Management?

01 Feb, 2018 / Health Care By: Aiswarya Somanath

Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance. In other words, it refers to the process of tracking the payments for the services rendered at a provider’s office, from the time of scheduling an appointment by the patient to the time of fulfillment of the payment by the payer or the patient themselves. RCM combines business and clinical sides of healthcare by collaborating patient health records, payer information, administrative and billing information.

The revenue cycle includes all the administrative and clinical functions that contribute to the capture, management and collection of patient service revenue, according to the Healthcare Financial Management Association (HFMA).

What are the steps involved in an RCM Cycle?

  • Charge capture: Rendering medical services into billable charges.
  • Claim submission: Submitting claims of billable fees to insurance companies.
  • Coding: Properly coding diagnoses and procedures.
  • Patient collections: Determining patient balances and collecting payments.
  • Preregistration: Collecting preregistration information, such as insurance coverage, before a patient arrives for inpatient or outpatient procedures.
  • Registration: Collecting subsequent patient information during registration to establish a medical record number and meet various regulatory, financial and clinical requirements.
  • Remittance processing: Applying or rejecting payments through remittance processing.
  • Third-party follow up: Collecting payments from third-party insurers.
  • Utilization review: Examining the necessity of medical services.

What is the need of an RCM System?

The primary aim of an RCM system is to reduce the duration between rendering of services to receipt of payment at the provider’s office by interacting with EHR and medical billing systems.
The RCM system also strives to reduce manual intervention by automating lot of the procedures that were previously performed by individuals leading to errors and delays. An RCM System should also be capable of alerting employees about potential denials and suggesting corrections for the same based on prior learning.

What is RCMBrain?
RCMBrain is one of the joint ventures partnered by IIA and aims to develop an intelligent self learning system which can provide valuable insights and help providers minimise their losses incurred through claim denials.

The system performs its actions via an intelligent bot called BETH, short for Bot Enabled Transaction Handler. BETH can be found as an app within Slack and does not have an interface of its own.

What all can BETH do?

  • BETH first gains access to all the relevant data with respect to patient claims from various legacy systems like Practice Management Systems, Clearinghouses, Payer Portals etc and brings them under one unbrella. This is done by showing BETH where to find the data in various systems ,just once, and BETH will do it next whenever you schedule it to happen. These scheduled jobs are called as workflows and BETH will gradually learn to predict workflows from familiar systems.
  • Once data from various systems has been downloaded, the next step is to extract and map it into a standardized form which is most relevant from an RCM perspective. BETH has the capability to extract data from various sources and formats like pdf, csv, xml etc using different methods like simple screen scraping to OCR and NLP. Extracted data then gets mapped into a standard schema defined for RCMBrain after applying many checks and algorithms.BETH will also constantly improve accuracy of the data extraction and mapping based on learning from previous encounters.
  • Once the data is available in the format understandable by RCMBrain, it needs to be processed to check for any potential denials or ARs. BETH needs to be provided with some rules that cause denials which are prevalent in today’s industry , which can be used to process the data and alert the user about claims which might lead to an AR. In the initial months, somebody will have to manually teach BETH the rules, however,over a period of time, BETH will learn to study the patterns found in the data and formulate rules within that. Many complex algorithms and tools are being used to process the data using the rules defined in natural language by the users to generate alerts based on specific conditions.
  • Processed data will then be used to trigger alerts to users about claims which need immediate attention – denied, rejected etc due to various reasons. Alerts may be of different types based on some conditions defined by industry standards. BETH will then study how users tackle these alerts – i.e, what is the action that is being taken by the user to correct/avoid the denial before resubmitting the claim. This learning will be used in future by BETH for correcting errors/recommending to user how to correct errors found in similar cases in future. BETH makes use of a continuous feedback loop that feeds the learning for predictions and recommendations.
  • BETH needs to consume and study large volumes of data from various clients to find patterns , generate reports, provide insights on ARs and potential denials so that they can be corrected before the initial submission of claims. Our AI and Big data analytics teams are utilising their expertise to the most to build these capabilities into BETH.

The vision of RCMBRain is to reach a point where the end-end process of Revenue Cycle Management can be handled by BETH through minimal training during the initial set up by any client.

Who built RCMBrain?
RCMBrain went on the floors 6 months back and is expected to have its first client onboarded by the month of February. An enthusiastic and immensely hard working team led by Ajith Kumar have put in countless hours and adopted a gamut of technologies for building BETH from scratch.. Under the able guidance of Anshad, our technology man and the constant support and appreciation from John Williamson, the CEO of RCMBrain, we hope BETH’s fame reaches far and wide.

If your revenue cycle isn’t working, your staff is frustrated – All you need is Beth!