Revenue Cycle Management

In todays environment with declining reimbursement and rising costs, its

critical to manage the revenue cycle process effectively from start to finish.
That means having the right software in place to facilitate critical pre-visit
tasks and efficient claims creation, along with a skilled back-office team to
submit claims, post payments, and follow up with payers. As administrative
hassles and other hurdles to getting paid continue to rise, Concierge can
help you reduce the burden on your practice and avoid leaving money on
the table.
Revenue Cycle Management Is More Than Billing Patients
Revenue cycle management (RCM) is the lifeblood of any practice private or
nonprofit. Effective patient registration, insurance and benefit verification, charge
capture, and claims processing are essential to maintaining practice viability.
Before you can improve any process, you need to assess where you are now. Here
are some questions you should think about:
Do you know if you are achieving best practice standards in accounts-receivable
management?
Does it take your practice too long to collect, and/or are your write-offs and
adjustments too high?
Do you know your claim-denial rate on first submission (4 percent of claims or
fewer is best practice)?
Have you determined that you are not leaving any money on the table with a
reimbursement analysis?
What are your days in A/R? What percentage of your accounts receivable is more
than 120 days old (10 percent or less is best practice)?

Patient registration
The revenue cycle starts with patient registration. Patient registration begins with a
phone call for an appointment request. Your front-desk staff should interview the
patient on the phone to collect billing and insurance information; invite the patient
to go online to your website to complete their registration information; and follow
up if registration isn't completed two days prior to the appointment so that the
patient's insurance coverage can be verified. You can use an in-office kiosk for
patient check in and to collect demographic information. Some kiosks will
automatically verify insurance eligibility too.

Charge capture
Transferring patient charges from the EHR to your practice management (PM)
system should be seamless electronically transmitting data is an example of
efficient workflow. But, if you are forcing your providers to first complete a paper
visit-encounter form, and then transfer that information to the EHR, it can lead to
inconsistencies, lost data, and redundant work processes. Furthermore, asking your
check-out station to compare electronic patient information against the paper
encounter form is burdensome and creates even more work when discrepancies
arise.

Automatic payment posting
Automatic payment posting can significantly reduce staff work, so why don't more
billing staff embrace and drive implementation of auto-post opportunities? Holding
tight to the status quo manual payment posting and reconciliation is an
inefficient use of our most costly resource: staff.
Routinely ask your payers, clearinghouses, and software vendors about new
services coming online, and roll out every new payer as electronic remittance and
auto-posting become available. Investigate a bank lockbox service that converts the
paper explanation of benefits (EOBs) to electronic transactions (837s) for
automatic posting to patient accounts.

Insurance eligibility verification
Investigate and incorporate automatic insurance eligibility verification into your
work flows. You can use your clearinghouse service to upload the appointment
schedule a couple of days in advance, in a batch process. For walk-in patients, use
real-time verification through your PM system. An integrated verification solution
creates a history within the patient's record that supports follow-up collection
efforts, if there are later discrepancies with the payer.
Consider using a clearinghouse. Yes, clearinghouses have a cost. But, in-house
personnel come with a cost as well. Do the math; it is unlikely that you can
complete the same tasks (claims submission or eligibility verification direct to a
variety of payer web sites, patient statement processing, automated appointment
reminder calls, etc.,) more cost efficiently in-house than by outsourcing services
and paying a monthly subscription cost or a per transaction fee.
Real-time billing
You can improve your collections by billing closer to the date the patient received
services. Do this by generating patient statements every week. Each patient will
fall into a 28-day cycle, and a statement will be created during the week that they
were seen, or the week that you received their insurance coverage. This way the
incoming patient payments and questions will be distributed across the entire
month, rather than overwhelming your billing department one week each month.
Studies have shown that you collect faster too when the patient is presented with
their bill closer to their care encounter.
Weekly statement generation is easy to accomplish when you outsource statement
production. Does this mean that you can reduce staff members if you outsource?
Maybe, maybe not. But it does mean that you will improve the results you get from
your current staff because they will be attending to tasks that require personal
follow up, instead of performing tasks that can be automated and/or outsourced
more economically.
Have your staff focus on labor-intensive tasks like appealing denied claims;
working claims that were underpaid; validating appropria payments from
payers; and uploading reimbursement schedules for your dominant payers



Health Maintenance Organizations (HMOs)
If you are enrolled in a health maintenance organization (HMO) you will need to
receive most or all of your health care from a network provider. HMOs require that
you select a primary care physician (PCP) who is responsible for managing and
coordinating all of your health care.
Your PCP will serve as your personal doctor to provide all of your basic healthcare
services. PCPs include internal medicine physicians, family physicians, and in some
HMOs, gynecologists who provide basic healthcare for women. For your children,
you can select a pediatrician or a family physician to be their PCP.
If you need care from a physician specialist in the network or a diagnostic service
such as a lab test or x-ray, your primary care physician (PCP) will have to provide you
with a referral. If you do not have a referral or you choose to go to a doctor outside of
your HMO's network, you will most likely have to pay all or most of the cost for that
care.
Preferred Provider Organizations (PPOs)
A preferred provider organization (PPO) is a health plan that has contracts with a
network of "preferred" providers from which you can choose. You do not need to
select a PCP and you do not need referrals to see other providers in the network.
If you receive your care from a doctor in the preferred network you will only be
responsible for your annual deductable (a feature of some PPOs) and a copayment for
your visit. If you get health services from a doctor or hospital that is not in the
preferred network (known as going "out-of-network") you will pay a higher amount.
And, you will need to pay the doctor directly and file a claim with the PPO to get
reimbursed.
How HMOs and PPOs Differ
The following outline compares some of the features of HMOs and PPOs. These are
general rules and you should speak with your human resources office at work or
directly with your health plan. If you are in the process of deciding between enrolling
in a HMO or PPO, you often can compare the plans by going online to the plans'
websites to learn about the available benefits and costs.
Which health care providers must I choose?
HMO: You must choose doctors, hospitals, and other providers in the HMO
network.
PPO: You can choose doctors, hospitals, and other providers from the PPO
network or from out-of-network. If you choose an out-of-network provider,
you most likely will pay more

Hmo &ppo
The biggest difference between an HMO and a PPO is that an HMO
allows you to see doctors only within the HMO's network of hospitals. With a
PPO, you can see any doctor you choose but coverage is greater for
certain providers(doctors, hospitals and other healthcare service providers)
that the PPO has contracted with. Seeing doctors outside of the PPO network
results in higher out-of-pocket costs like copays and coinsurance. Insurance
premiums are generally higher for a PPO compared to HMO.
A health maintenance organization (HMO) is a type of managed care
organization (MCO) that provides a form of health insurance coverage in the
United States that is fulfilled through hospitals, doctors, and other providers
with which the HMO has a contract. Under this model, providers contract
with an HMO to receive more patients and in return usually agree to provide
services at a discount. This arrangement allows the HMO to charge a lower
monthly premium, which is an advantage over indemnity insurance, provided
that its members are willing to abide by the additional restrictions
PPO means Preferred Provider Organization, a health care plan that
provides covered services at a discounted cost for subscribers who use
network health care providers. PPOs also provide coverage for services
rendered by health care providers who are not part of the PPO network; the
subscriber generally pays a greater portion of the cost for such services.
Usually, a PPO will pay a greater percentage of the cost for a preferred
provider, and less for a non-preferred provider.



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Clientele
Large corporate clientele since companies
offer HMO insurance to most of their
employees
Large retail clientele
Organisations
offering such
services
Kaiser Permanente, Aetna Beech Street PPO, Blue Cross Blue
Shield PPO


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What does it
stand for?
Health Maintenance Organizations Preferred Provider Organization
Medical
problems
covered
Mostly Basic Medical care and Preventive
care such as office visits, immunizations,
well-baby checkups, and physicals.
Specialist treatment included as well
Emergency
treatment
HMOs are not well suited for this since
they have a defined procedure for
emergency treatment outside its coverage
area.
Emergency treatments are also covered.
Flexibility in
choosing Doctors
and Hospitals
Limited. The patient has to choose a
Primary physician (PCP) within a network
and that physician takes care of all medical
needs of the patient, including referrals to
specialists. See restrictions below.
High. Members have an option to choose
from a number of doctors/specialists that
are in the network of the insurer.
Benefits are either curtailed or
unavailable if the member sees a doctor
outside the network.
Restrictions
Restrictions are laid down by the HMOs
for range and scope of treatment.
Specialists can be seen only after a referral
from a PCP. PCP may choose to only refer
to his own network or preferred group of
doctors within the In-NetworkHMO
Less restrictive. Referrals are not required
to see specialists in the network.


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doctors.
Cost
Lower premiums Premiums are higher than HMOs since it
offers more flexibility.
Doctor / Medical
Practitioner
Incentive
Doctors work on a retainer fees
(capitation) per year hence no incentive to
prolong treatment of patients
Doctors typically have a work-pay relation
i.e. they get paid per visit
Network Doctors
Members can only go to the specified
network doctors after taking prescription
from the Primary physician. See
restrictions above.
Members can go to non-network doctors
as well without any prescription.
Payment mode
Patients pay the provider through a card
without having to fill forms
Patients have to bear a part of the cost if
they go to a non-network (non-preferred.



Healthcare Patient Registration Services
VeeBill provides detailed patient registration services which involves collecting patient demographics.
Our teams process the demographic information of the patient and then register a patient, prior to an
appointment at the healthcare facility.
VeeBill Patient Registration Process
Our healthcare team receives the patient information from the clients.
The details are entered into the patient information sheet in order to process patient demographics.
The information sheet contains fields for personal details as well as insurance details.
We process, verify and validate the patient information.
Once this process is complete the patient is registered at the healthcare provider's facility.
VeeBill then handles the appointment scheduling after registration of the patient.
Read more on Medical Billing Advantage.
Vee will be happy to answer your questions and discuss over a call. Please contact us on 1-866-666-5442 or E-Mail

MedicalBillingStar provides excellent payment posting solutions to medical practices. The effective way to
increase productivity in your medical practice is to streamline and automate the payment posting
procedure. The increase in your productivity is achieved by us through two distinct methods.

Posting Insurance Payments automatically through ERA.

Posting Insurance checks through EOBs.

We help you unleash the complete potential of your medical practice through the Electronic
Remittance(ER) technology. Regardless of the EMR software your practice uses (Web based, server
based) MedicalBillingStar maintains the standards as required by the health industry. The standard is
known as Electronic Remittance technology.
The core components being

EFT (Electronic Funds transfer)

ERA (Electronic Remittance Advice)

EFT : This helps health care providers to receive electronic payments from Insurance companies.
ERA : This is an electronic report prepared in a standard format by Insurance companies. This is sent to
the health care provider explaining the payments made.
These standards speed up the payment process as well as help to ease the understanding of patient
accounts.
Electronic Insurance Payments- Automatic Posting :

Electronic remittance reports facilitate the automatic posting of Insurance payments. MedicalBillingStar
initiates automated posting of Insurance payments through its unique automatic posting engine. The
engine supports the following.

Denied claims

Underpaid claims

Overpaid claims

Multi-adjustments

Reversals

Automatic cross-over

Secondary remittance
The Benefits You Can :

Export ERA reports in formats of your choice.

View and print ERR.

Review the details of adjustments, precursors, codes, payments processed.

Save ERR in ANSI-835 format.

Easy posting of Insurance checks using EOB reports :
MedicalBillingStar has made the posting of Insurance checks easier for medical practices that use EOB
reports. Our streamlined keyboard driven procedure helps medical practices significantly increase their
production by 80%. Payment Posting uses the PCN (Patient Control Numbers) as the key since this being
the unique number that is identified by the payers. Based on this, EOB reports are returned.
MedicalBillingStar calculates and posts the respective payments based on

Patient responsibility

Allowed payments

Paid amounts
MedicalBillingStar provides you the postings with the complete history of the encounter. We also generate
batch reports for your reference.

MedicalBillingStar makes your patient payment posting easy through the details entered in your front
office. We quickly match up the patient demography entered in the front office with that in the back office
and calculate copays in the charge entry. With this, we facilitate easy printing of patient receipts. With the
details collected in the check in-check out process. The overpaid payments can be narrowed in and the
repayment of funds to the overpaid patients can be processed quickly.

HMO
When you are shopping for a medical insurance plan, you have different options to choose
from. One popular plan is an HMO (Health Maintenance Organization). An HMO is a form
of managed care. Managed-care plans aim to offer comprehensive health care to its
members through a network of health care providers.
An HMO is designed to provide affordable medical care. Costs are controlled by restricting
your care to the physicians, care providers, and hospitals that are part of the HMO network.
If you go outside the network for care, you pay the entire cost out-of-pocket. .
If you are an HMO member, your costs come in two main forms. You pay a monthly
premium. You are also required to pay a co-payment for most services. A co-payment is an
amount paid at the time of treatment to offset a portion of the medical costs. The amount of
the co-payment varies depending on the specific medical treatment. For instance, medical
office visits have a different co-payment rate than prescriptions and more involved medical
treatments.
A distinguishing feature of an HMO is that it requires you to select a primary care physician
(PCP). Your PCP acts as a gatekeeper. You cannot see a specialist or any other physician or
care provider, unless you are referred for treatment by your PCP.
Why Choose an HMO?
Health Maintenance Organizations are generally more affordable than other managed care
insurance systems. The monthly fees and co-payments are usually not high and are an
affordable alternative to paying a percentage of the bill like other managed care providers
require.
HMOs are profitable when the members are healthy. Therefore, HMOs focus on
preventative care and checkups to catch heath problems early, before they escalate into
expensive, difficult to cure diseases. HMOs provide you with a wealth of medical
information on how to prevent illness and disease. They distribute health guides and
informative handbooks on how to stay healthy and avoid getting sick.
HMOs also have a good reputation and service record, generally speaking, for pediatric
medicine.
HMOs require you to fill out very little paperwork, as opposed to a fee-for-services plan that
requires you to file claims. If you don't like filling out paperwork (who does?), this can be a
big plus.
Why Not to Choose an HMO?
HMOs are more restrictive than other managed care providers.
HMOs only cover you when you visit doctors within the HMO network. If you want to see a
specialist and the physician is not in the HMO network, you will have to pay out-of-pocket
expenses.
HMOs offer services only at designated facilities, so an HMO can be a bad choice, if it is not
geographically convenient for you to visit the treatment facility.
You may feel restricted by having all care managed by your PCP. When you have a skin rash,
it can be frustrating to have to see your PCP before going to the dermatologist that you know
you want to see. It adds another step and sometimes a separate visit to get to a specialist.
This can require additional time off work.
In addition to a referral from your PCP, your treatment may need approval from your HMO.
HMOs have an incentive to keep you healthy, but also an incentive to restrict care. The less
care, the lower the HMOs costs, the more profit they make.
PPO - Preferred Provider Organization Basics

When shopping for health care insurance, one option you have is to choose a
Preferred Provider Organization (PPO). A PPO is a form of managed care.
Managed-care plans aim to offer comprehensive health care to its members
through a network of health care providers.
How a PPO works
The PPO has doctors, hospitals, and health care providers that are part of its network that
are available to provide your medical needs. PPOs encourage you to utilize the doctors and
hospitals within the PPO network, by making it cheaper to use in-network providers. In a
PPO, you are allowed to visit out-of-network medical services providers, but it will cost you
more. If you visit a doctor or medical facility that is not within the PPO network, you are not
covered at the level you are when visiting an in-network provider.
PPOs require a monthly premium, usually higher than what an HMO (Health Maintenance
Organization) requires. You also make co-payments in a PPO. A co-payment is an amount
paid at the time of treatment to offset a portion of the medical costs. The amount of the co-
pay varies depending on the specific medical treatment. Medical office visits have a different
co-payment rate than prescriptions and more involved medical treatments.
In addition to a co-payment, you may be required to meet a deductible as a PPO member. A
deductible is a dollar amount the PPO requires you to pay out-of-pocket before your benefits
kick in. The deductible amount is normally an annual sum. Once you meet your annual
deductible, the PPO pays for the rest of the care, though there can be an annual cap for the
care you receive. The deductible re-sets each calendar year. Some Preferred Provider
Organizations have exceptions and offer carry-over deductible features.
PPOs do not require you to choose a primary care physician, unlike an HMO. You can see
anyone in the network without approval from a gatekeeper. Also, your care in a PPO is not
restricted to providers within the network. You can go to outside care providers as a PPO
member. When you do, however, your insurance may cover only part of the service. In a
PPO, seeking outside-network care usually requires you to pay a larger percentage for your
care.
Why a Preferred Provider Organization?
The biggest benefit of a PPO, compared to an HMO, is that you have greater freedom of
choice. You are not restricted to only in-network care. The benefit of a PPO compared to an
indemnity/fee-for-services plan is that the PPO network offers lower costs, as long as you
stay with in-network care providers. The PPO brings medical customers in bulk to the care
providers, who then work with you at a reduced cost.
You have greater control over your healthcare decisions with a PPO, compared to an HMO.
With a PPO there is no need to work through a PCP. You have no gatekeeper. You can see
any doctor or care provider within the network without a referral. This means that you can
see a specialist when you want to.
Why Not a Preferred Provider Organization?
Preferred Provider Organizations can be more costly than HMOs. Since PPO care involves a
deductible, you often have greater out-of-pocket expenses for your care, depending on the
specific medical services you need throughout the year.
Also, even though a PPO offers you the freedom to visit an out-of-network provider, the cost
to do so will most likely be significant. PPOs strongly recommend members to use in-
network physicians and hospitals. To give you an incentive to remain within the network,
PPOs usually pay noticeably less for out-of-network care than they do for in-network
coverage.
A PPO can be a good choice for you, when shopping medical coverage. Before you decide on
a Preferred Provider Organization, read all the fine print. Significant details vary from plan
to plan, such as the monthly premium, the size of the network, the amount of the co-
payment, and the percentage of costs covered for out-of network care. Consider you and
your familys typical medical needs, so you can find the coverage that best fits your
situation, in terms of costs and care provided.
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