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Medical Billing Vs. Revenue Cycle Management


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medical billing vs. revenue cycle management

Medical billing vs. revenue cycle management is no longer encapsulated in one entity. Healthcare is a driven and highly fueled industry. In addition, medical billing services are breaking free of revenue management duties, and practice managers understand the importance of keeping a close watch over the bottom line. The complexity of medical billing codes, insurance company regulations, and diversity in treatment options leave no time for managing the revenue cycle.

Medical billing services understand the revenue cycle’s importance to peak performance. However, while striving to maintain control of the revenue cycle in their day-to-day billing protocols, the scope of revenue management is beyond their capabilities. As a result, medical billing has become a complex professional service requiring certified personnel educated in current coding requirements and insurance regulations. Medical billing vs. revenue cycle management must work hand in hand but are two separate entities.

What Is Medical Billing?

When comparing medical billing vs. revenue cycle management, it is essential to realize the importance of medical billing personnel to understand the revenue cycle. The revenue cycle, in its entirety, is what fuels revenue for the practice. Therefore, each cycle step must be timely and fully facilitated without exception. Management of the revenue cycle ensures the wheel is fixed for ultimate performance.

Medical billing receives charge information from the providers and immediately sets to correctly transform charges into codes and diagnosis codes into claim forms. Certified coders check coding to reduce denials by submitting claims that the insurance companies will not reject. Medical billing protocols have evolved into a complex set of responsibilities that keep the revenue cycle moving. Medical billing vs. revenue cycle management deals with charge capture, claim submission, and posting of reimbursement from patients and insurance companies.

Unfortunately, there are stumbling blocks in the process. Insurance companies implement diverse and strict computerized regulations for their claim submissions. Fighting rejections and denials is a constant battle for medical billers. Insurance companies continually deny medical necessity and computer glitches cause false denials. This portion of the revenue cycle can benefit from the input of revenue cycle managers to relay pertinent information in resolving the percentages of these issues.

Protocols of Medical Billing

Medical billing is a complex series of protocols, but to describe the essential functions, here is a list of responsibilities.

  1. Separate from the medical billing department, registration or medical staff collect patient demographic information needed for the claim form, insurance cards, subscriber information, and patient medical history.
  2. If a charge involves required authorization for services by the insurance company, another department procures that authorization by submitting a request for authorization to the insurance company.
  3. The billing department then receives charges from the provider and correctly codes the claims to submit to insurance. Finally, there must be a scrubbing of claims that ensures patient insurance and demographic information is correct and there are no rejections from the medical clearinghouse or the insurance company.
  4. The claims are submitted for processing to the insurance companies.
  5. Claims are either paid or denied by the insurance company. This cycle usually takes place within twenty-five days. The medical billing department posts claims payments, bill patient responsibility to the patient, and work denials as needed.

Of course, there are so many more steps. This is a basic description, but it’s essential to understand that medical billing vs. revenue cycle management are two completely separate entities that work hand in hand for optimal team performance. Fast-changing challenges forced revenue management from the hands of the billing department. As a result, medical billing is far more complex today.

What is Revenue Cycle Management?

Medical billing vs. revenue cycle management is a more distinct difference in today’s healthcare organizations. Revenue cycle management (RCM) is more involved with ensuring the revenue cycle wheel keeps moving and that all the entities involved are doing their parts. RCM involves billing, collections, and payments. Furthermore, denials, authorizations and clearinghouse activities in enrollments are all hot spots of problems.

The revenue cycle manager monitors each portion of the cycle. Appointment setters, registration personnel, billing departments, collections agencies, healthcare clearinghouses are all within this controller. Medical billing vs. revenue cycle management are too vast in their own rights to be one entity any longer. It’s big business and insurance companies complicate claim payments daily.

Integration of the relationship between medical billing vs. revenue cycle management is a key component of successful operations. Revenue cycle management must be proactive with reimbursement to avoid rejections, delays, denials, and other disruptions that delay payments of claims. RCM can initiate transparency to the revenue cycle and optimize the financial health of the practice.

Other close relationships for revenue cycle management include insurance reps, the providers and software personnel. Keeping in touch with these important tools can avoid problems with changing insurance requirements, updating providers with coding issues, and updates that software or electronic health records (EHR) often experience. If your practice is thinking of incorporating a revenue cycle manager position into the team, a healthcare consultant can help outline the necessary qualifications for that post.

Find Help with Medical Billing vs. Revenue Cycle Management in Florida

If your practice is beginning to realize it’s time to separate these entities, contact Bloom Consulting in Florida. Our experienced healthcare advisors can assess your situation and help determine what’s needed to move forward. It won’t be long before you see an increase in your bottom line. Contact us to make that important move.