In general terms, Revenue Cycle Management or RCM refers to the entire medical billing processes which track record of the patient from beginning to end. The episodes take control of registration formalities and appointment scheduling to the final payment of a balance. It may further include Data Capturing, entering, and editing the information needed to create a medical billing claim (to an insurance company or payer) till the collection and deduction analysis of claims are done. The entire process of Hospital Claim Recovery facilitates managing the administrative and clinical functions associated with claims processing, payment, and revenue generation. This further includes "demographic" information about the patient including insurance coverage details and "charge" information: a combination of CPT and ICD-10 codes. This financial process is the key basis that forms a link between the hospitals and patients. Revenue Cycle Management is the strategy that healthcare organizations use in order to settle the claims & the bills.
Basically, the process begins when a patient visits a doctor to seek advice and medical services. It ends when all claims and patient payments have been collected and reconciled. The whole process of Revenue Cycle Management provides a groundwork which makes it easy for claims to be billed and collected in the most effective and efficient manner.
The objective is to ensure complete payment is received by the hospital on time. We analyze underpaid / short payment claims by comparing payments to package rates agreed with the panels and flag exceptions wherever necessary. It's difficult to follow-up on these deduction cases and achieve collection results for a hospital however we manage this well with our technically sound and experienced professional resources through our strong deduction analysis.
Reporting is frequently viewed as an integral part of the revenue cycle, since it reflects the results and statistics about practice health, both financial health and operational health (e.g. productivity). We support the hospital with accurate dashboards on CGHS / ECHS / TPA recovery status followed by Daily Query Status reports, Timely settlement data and deduction analysis of claims.
We provide solutions to hospitals on timely recovery of their claims from following panels across India;
1. Collections from Insurance Companies or Third Party Administrators (TPAs) - Third Party Administrators (known as TPAs) are firms that provide administrative services in the health insurance field. In most cases, TPAs provide various services like claims processing, premium collection, underwriting, etc. In certain cases, they may also provide customer service on behalf of an insurance company.
2. Collections from all Government Panels including CGHS, ECHS, ESIC, DGEHS, Other State Govt. Schemes, Municipal Corporation Schemes, Ayushman Bharat, Northern Railway, North Central Railway, etc.
3. Collections from Public Sector Undertakings (PSUs) & Private Corporate- Public Sector Undertaking (PSU) is a Government owned corporation or a company in which Central or State Government have more than 51% share. It is either wholly or partly owned by central or a state government. We work with the following PSUs;
--> Maharatnas - (National Thermal Power Corporation (NTPC), Oil and Natural Gas Corporation (ONGC), Steel Authority of India Limited (SAIL), Bharat Heavy Electricals Limited (BHEL), Indian Oil Corporation Limited (IOCL), Hindustan Petroleum Corporation Limited (HPCL), Coal India Limited (CIL), Gas Authority of India Limited (GAIL), Bharat Petroleum Corporation Limited (BPCL) and Power Grid Corporation of India (POWERGRID).
--> Navratnas - Bharat Electronics Limited (BEL), Engineers India Limited (EIL), Hindustan Aeronautics Limited (HAL), Mahanagar Telephone Nigam Limited (MTNL), National Buildings Construction Corporation (NBCC), National Mineral Development Corporation (NMDC), Oil India Limited (OIL), Power Finance Corporation (PFC) and Shipping Corporation of India (SCI).
--> Miniratnas - Airports Authority of India (AAI), Bharat Sanchar Nigam Limited (BSNL), Central Warehousing Corporation, India Tourism Development Corporation (ITDC), India Trade Promotion Organisation (ITPO), Indian Railway Catering and Tourism Corporation (IRCTC), MMTC Ltd., National Small Industries Corporation Limited, RITES and National Film Development Corporation of India (NFDC)
Presently, the RCM workflow consists of the following medical billing cycle steps:
Step 1: Demographic Verification - It ensures if patient has valid insurance coverage before it schedules the appointment. Our professional Front Desk Team supports the patient to get accurate information about the hospital services and explain the credit billing process of CGHS, ECHS, ESIC, PSUs and TPAs.
Step 2: Collection of Balance - This process undertakes the collection of previous dues from patient or if any investigation documents that was taken by the patient but required by any IPD credit billing panels.
Step 3: Creating Claim, Validation and Submission - Manually or electronically, the claims are created and then submitted to the insurance provider or other panels. This includes Pre-billing Claim auditing, Billing, Post-billing claim auditing, docket preparation, Claim Upload to UTI portal, Claim submission, etc. Our expert team shall ensure 100% documents are checked and validated as per the CGHS / ECHS guidelines before uploading the claims to UTI portal.
Step 4: Correcting Errors/Denials - In this process, the claims are corrected or resubmitted if required. Additional documentation is done if necessary. Need More Information (NMI) / Query cases are tracked and monitored daily through dashboards and reports to ensure timely closure of NMIs / Queries.
Step 5: Claim Follow-up - Follow up is done with the Credit Panels either offline or online (whatever means possible). We track claim status at every point to ensure there is no unnecessary delay in processing of claims by Credit Panels. In case the claims are not processed by panels or if there is no movement of claims for 5 days, our team shall take up such claims directly with the respective panels to ensure timely processing and payment of hospital credit bills.
Step 6: Payment collection and Settlement of claims - For patient collections, there are two easiest modes available - mobile and online payment. For credit panels, we follow up with credit panels and ensure payment of credit bills as per the agreed TAT between hospital and the credit panel. We prepare settlement sheet of claims by referring each NEFT payment mapped to the hospital bill details that help hospital finance to settle the NEFT against Debtor's Ageing of hospital.
Step 8: Analysis/Data Analysis - In order to improvise business operations, data is processed into meaningful insights in form of increased collections, reduced days in A/R, and stable financial performance. We provide Daily Status Report where we share the details of daily billing, claims uploaded, NMI / Query cases processing with TAT, etc. Our weekly dashboard is mapped with the weekly Debtor's Ageing provided by the hospital which helps the hospital to track the processing stage of each of their claims that helps recovery from TPAs, CGHS, ECHS, DGEHS, ESIC, PSUs and Corporates easier. Our state of the art Deduction Analysis provides insights on the reason of Rejections and Deductions in hospital Claims. With this report, we support the hospital to plug their Operations Gap and there by bringing down the percentage of deductions drastically.
