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Verification of Benefits and Authorization

Eligibility Verification: Ensure the patient is elgibile to otbain the services by confirming details such as insurance coverage status, effective dates, and any restrictions or limitations on the policy.
Benefits Verification: This step involves understanding the scope of coverage provided by the patient's insurance plan. It includes identifying covered services, co-pay amounts, deductibles, and any other relevant financial details.
Authorization: Ensure prior authorization requriements are verified and obtain and follow until approved.

Charge Entry and Verification

Charge entry - Ensure services provided accuratley and timely etnered in the system and submit to the insurances.
Charge verification: Charge verification is the process of confirming that the charges entered align accurately with the services actually provided.
Rejections – Work on rejections and implement preventive methods.
Claim submission – Ensure verified claims are submitted immediately.

Payment Posting

Recording Payments: Payment posting involves entering details of payments received, including the amount paid, payment method, and any relevant payment reference numbers.
Reconciliation: Payments are reconciled against the corresponding billed services.
Insurance and Patient Payments: Ensure the payments received from insurance companies and Patients are posted accurately.
Adjustments and Denials: Ensure claim denials are tracked and worked.
Identifying Underpayments: Reviewing payments received from insurance companies to identify instances where the reimbursement falls short of the expected amount.

Denial Management and Insurance AR Collections

Follow-Up on Unpaid Claims: Systematical follow-up on claims that have not been paid by insurance companies within the expected timeframe. This may include investigating the reasons for non-payment or delays.
Appeals and Resubmissions: Initiating the appeals process for denied or underpaid claims. This may involve submitting additional documentation, clarifications, or appealing unfavorable decisions to secure the rightful reimbursement.
Resolution of Claim Issues: Working to resolve any issues or discrepancies related to insurance claims that may be causing delays or denials. This includes addressing coding errors, missing information, or any other issues contributing to payment delays.
Optimizing Reimbursement Rates: Negotiating with insurance companies to optimize reimbursement rates and ensure that healthcare providers receive fair compensation for their services.
Minimizing AR Backlog: Actively managing and minimizing the accounts receivable backlog related to insurance claims. This involves staying on top of aging accounts and taking appropriate actions to accelerate the collection process.

Patient Services

Billing Inquiries: Addressing and resolving patients' questions and concerns related to medical bills, statements, and invoices. Patient services teams strive to provide clear explanations of charges and facilitate understanding of the billing process.
Insurance Guidance: Assisting patients in understanding their insurance coverage, including details about copayments, deductibles, and coverage limitations. Patient services teams aim to help patients navigate the complexities of insurance policies.
Payment Plans: Assisting patients in setting up payment plans for any outstanding balances. Patient services teams work to accommodate individual financial situations and facilitate arrangements that align with patients' ability to pay.
Resolution of Billing Disputes: Handling and resolving any billing disputes or discrepancies that may arise, working to address concerns and discrepancies to the satisfaction of the patient.
Patient Statement Submission: Review of Patient accounts and ensure patient statements are submitted based on established frequency.
Customer Service: Offering high-quality customer service to patients, fostering a positive experience, and building trust in the healthcare provider's financial processes.

Reporting and Business Analytics

Key Performance Indicators (KPIs): Define and track KPIs that provide measurable insights into the efficiency and effectiveness of different RCM processes
Financial Reporting: Generate regular financial reports to provide a snapshot of the organization's financial health. This includes revenue summaries, reimbursement analysis, and comparisons between expected and actual financial outcomes.
Trend Analysis: Identify trends and patterns in the data over time to understand the factors influencing revenue cycle performance. This can help predict future challenges and opportunities.
Comparative Analysis: Benchmark performance against industry standards or compare internal performance across different periods. This allows organizations to assess their standing and prioritize areas for improvement.
Decision Support: Provide decision-makers with actionable insights derived from the analysis, empowering them to make informed decisions that positively impact the revenue cycle.

Sign up for a Free Practice Assesment

A Practice Assessment involves evaluating the financial health of your organization through industry-recommended Key Performance Indicators (KPIs).

About

Fivefold Healthcare Solutions specializes in streamlining financial operations for healthcare providers, ensuring precise and efficient revenue cycle management, enabling practices to focus on delivering superior patient care without financial stress.

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Fivefold Healthcare Solutions 9688 Middle Ground Place Frisco, Texas 75035

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Join the Best,Be the Best.