How Does Revenue Cycle Management RCM Healthcare Services Work?

Providers receive a bill from a healthcare provider. The patient is responsible for the copay, deductible, and coinsurance, but if they have insurance, claims are filed with their insurance company to help offset these costs. If the patient has Medicaid or Medicare benefits, providers file claims for reimbursement. Patients can also pay cash upfront and be reimbursed by an insurer later. Inpatient care bills patients daily until they are discharged from hospital care; outpatient services charge based on visits; medications and other supplies needed before receiving treatment may be billed as well.

Healthcare service revenue cycle management (RCM) includes:

  • Billing: collecting fees that were agreed upon in the contract between provider and payer for services rendered
  • Claims adjudication: verifying patient information, collecting and reviewing any necessary authorizations, determining if the claim is covered by insurance and the amount of allowable reimbursement
  • Claim payment: check sent to the provider to cover bill; payments are processed automatically when claims form a network with set rates or manually in situations in which payers give providers a denial letter with instructions on how to appeal.

The repayment process can be lengthy. For example, Medicare’s standard turnaround time for claims processing is 30 days. Medicaid has a shorter turnaround time at 21 days, but both programs have been known to take longer when backlogs occur. In addition, some private insurers fall short of providing timely reimbursement as well. For example, one study found that nearly half of all healthcare providers wait 60 days or longer to receive reimbursement from private insurers.

Inpatient care bills patients daily until they are discharged from hospital care; outpatient services charge based on visits, medications and other supplies needed before receiving treatment may be billed as well. Learn more about RCM healthcare services. Check out their website at AZZLY!

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