Billing Cycle in a Fully Integrated RCM: Order Creation to Reimbursement Process

Summary

• The billing cycle starts at order creation in a Fully Integrated RCM by capturing important patient and insurance information.
• Next, the healthcare provider verifies Insurance Coverage and eligibility before submitting the claim to the insurance company.
• Once the claim is submitted, the provider waits for the insurance company to process and pay the claim before sending the patient an invoice for any remaining balance.

Introduction

Revenue Cycle Management (RCM) is a critical process in healthcare that ensures the financial health of a healthcare organization. In a Fully Integrated RCM system, the billing cycle begins at order creation and involves several key steps to ensure accurate and timely Reimbursement for services provided to patients. In this article, we will explore how the billing cycle starts at order creation in a Fully Integrated RCM.

Capture Patient and Insurance Information

One of the first steps in the billing cycle is to capture important patient and insurance information at the time of order creation. This includes demographic information such as the patient's name, address, date of birth, and insurance details such as the insurance company's name, policy number, and group number. This information is crucial for accurately billing the patient and submitting claims to the insurance company.

Verify Insurance Coverage and Eligibility

After capturing the patient and insurance information, the healthcare provider must verify Insurance Coverage and eligibility. This involves checking with the patient's insurance company to ensure that the services being provided are covered under the patient's insurance plan and that the patient is eligible for benefits. This step is essential to avoid claim denials and ensure timely Reimbursement for services rendered.

Submit Insurance Claim

Once Insurance Coverage and eligibility have been verified, the next step in the billing cycle is to submit the insurance claim to the insurance company. This involves sending a detailed claim that includes information about the services provided, the patient's diagnosis, and any other relevant information. The claim is then processed by the insurance company, which determines the amount that will be paid for the services.

Wait for Insurance Company Response

After the claim has been submitted, the healthcare provider must wait for the insurance company to process and pay the claim. This process can take some time, depending on the insurance company's policies and procedures. Once the claim has been processed, the insurance company will send a payment to the healthcare provider for the services rendered.

Send Patient Invoice

After the insurance company has paid its portion of the claim, the healthcare provider will send the patient an invoice for any remaining balance. This invoice will detail the services provided, the amount paid by the insurance company, and the patient's responsibility for any outstanding balance. The patient is then responsible for paying the remaining balance according to the provider's payment policies.

Conclusion

In conclusion, the billing cycle in a Fully Integrated RCM system starts at order creation and involves capturing patient and insurance information, verifying Insurance Coverage and eligibility, submitting Insurance Claims, waiting for the insurance company's response, and sending the patient an invoice for any remaining balance. By following these steps carefully and accurately, Healthcare Providers can ensure timely and accurate Reimbursement for the services they provide to patients.

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