Revenue Cycle Management (RCM) in healthcare describes the entire financial process involved in the handling of medical services provided to patients. Proper RCM includes all aspects of patient care, from the first point of contact through to the payment of claims and the collection of outstanding balances. This plays an important role in ensuring the financial stability of medical organizations, as well as the delivery of quality care to patients. What follows is a brief discussion regarding how business rules engines (BREs) help healthcare organizations improve their revenue cycle management.
The Importance of Revenue Cycle Management in Healthcare
Revenue cycle management in healthcare includes various processes, including patient registration, claims processing, charge capture, billing, payment plans processing, and collections. Obviously, these processes are complex and require a significant amount of time and resources to carry out effectively.
Faulty or incomplete data often leads to delayed claims processing, which in turn results in a decrease in revenue for healthcare providers. In addition, failing to comply with regulatory requirements may result in fines and penalties, further impacting the profit margins of these organizations.
Steps Involved in Revenue Cycle Management
The first step in revenue cycle management is patient registration. This includes collecting patient demographics, insurance information, and consent for treatment.
Then, once the patient is registered, the insurance verification process begins. This involves verifying the patient’s insurance coverage, including eligibility, benefits, and authorization requirements.
Once the patient has been treated, the healthcare provider documents the services provided and charges for those services. This is known as charge capture. It’s important to ensure that all services rendered are accurately documented and captured to prevent revenue loss.
After the charges have been documented, the claims are submitted to the insurance payer.
Then, the insurance payer processes the claim, the payment is posted to the patient’s account. This involves recording the payment received and reconciling it with the amount expected.
Finally, if applicable, the healthcare organization collects payments from patients and resolves any outstanding balances. It’s important to have a clear policy in place for patient collections and to follow all legal and regulatory requirements.
What is a Business Rules Engine?
A business rules engine is a pluggable software system that helps organizations automate decision-making processes based on predefined business rules. Rules engines enable companies to build, manage, and update business rules without the need for programming knowledge. This provides a streamlined and cost-effective approach to automating business tasks.
Rules engines run powerful conditional “if-then” statements called business rules that give instructions to business software systems.
What are Business Rules?
Business rules define the parameters within which decisions can be made and the actions that should be taken based on those decisions. Business rules can be simple or complex and can be applied to various aspects of an organization’s operations, including data management, compliance, and automation.
Business rules are typically created by non-technical subject matter experts and can be modified as needed to ensure that they remain up-to-date and relevant.
How Rules Engines Optimize Revenue Cycle Management
Many major healthcare organizations implement business rules engines to automate their billing and claims processing.
Rules engines enable these organizations to design and manage business rules that automate their claims processing, ensuring that all claims were submitted accurately and on time.
In addition, rules engines are configured to provide real-time feedback on claim status, allowing healthcare providers to identify and address issues promptly.
By automating their billing and claims processing, healthcare organizations are able to spot and address issues in their billing and claims processing, resulting in a decrease in denials and a significant improvement in their financial performance.
Another way that healthcare organizations benefit from rules engines is by automating their patient registration and insurance verification processes.
Rules engines validate data from various sources, including electronic medical records and insurance databases, to verify patient information and insurance coverage. As a result, healthcare providers cut down on errors and improve the accuracy of their patient records.
Summary
In conclusion, effective revenue cycle management is critical to the financial health of healthcare organizations. By automating decision-making processes using business rules engines, healthcare providers can improve the accuracy and efficiency of their revenue cycle management processes, resulting in a significant improvement in their financial performance.
