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The Changing Face of RCM (Revenue Cycle Management)

September 02, 2009 | Chip Means, Web Editor | Healthcare Finanace News.com

Under self-pay structures, a significant amount of payments for medical costs is shifted from the commercial insurance company to the patient. This increases the need for hybrid performance in revenue cycle management solutions, said Brad Lund, executive director of the Healthcare Billing and Management Association. “If you send a clean claim to the insurance company, they send back a check, whereas the self-pay side is much more challenging,” he said. HBMA represents companies that manage revenue cycle operations for physician groups – a membership that accounts for 30 percent of all claims in the industry. Lund said the association is educating providers on properly managing claims ahead of major transitions, including RAC and ICD-10 – both of which, like self-pay, will have a great impact on RCM technology.

Three Trends to Watch:

RECOVERY AUDITS: Medicare’s RAC audits are affecting nearly every financial process for healthcare providers. As RAC auditors aim to find irregular claims information, providers need to ensure their systems can appropriately manage and process all financial data.

ICD-10: RCM and practice management systems that aren’t ready for ICD-10 will leave users facing significant billing issues, Lund said. Solutions that will accommodate the major transition from ICD-9 will rise to the to.p

EMR PROJECTS: Providers implementing EMRs should be focused on integration with their RCM solution. “The whole EMR thing is on the clinical side. And that’s OK, but we can’t forget the financial relationship between the patient encounter and how you’re moving that information to the payer and how the adjudication is moving back to the provider,” said Lund.