The healthcare revenue cycle involves capturing, managing, and collecting money for patient services. This cycle includes all clinical and administrative operations that help in the process. The cycle, however, is generally composed of various sections that often perform their functions independently from one another.
The front-end and the back-end are the two parts that make up a standard revenue cycle in the healthcare industry. The claims administration and reimbursement are handled by the back-end, while the front-end is responsible for managing the components of the system that interact with patients. In addition, certain divisions, individuals, and protocols must be followed to transfer money through the cycle.
FRONT-END REVENUE CYCLE
The front office of a healthcare facility or medical practice is the front end of the healthcare revenue cycle. When a person seeks care from a healthcare institution, they will first interact with departments and staff members affiliated with the company’s front-end. Scheduling appointments, registering patients, determining eligibility and authorizing care, and collecting upfront patient payments are essential front-end responsibilities.
Scheduling
Scheduling is crucial in ensuring that doctors visit patients on time, which is essential for the continued operation of healthcare institutions. Front desk schedulers are responsible for arranging patient appointments to ensure patients get the necessary, timely care and reduce unnecessary waiting periods. The company might be in jeopardy if people had to wait a long time for treatment or have restricted access to it. Seeing the appropriate doctor at the right time is crucial to patient happiness.
To this end, schedulers work to keep the number of patients who cancel appointments to a minimum. A large portion of a scheduler’s job is to contact patients via phone, text message, and email to remind them of upcoming appointments.
Eligibility & Verification of Patients
Registration and insurance verifications are the next steps in the revenue cycle once patients have been scheduled. At the front lines of care, workers enter information about patients into an electronic health record (EHR) or practice management system, such as their names, addresses, and health insurance policies.
Personnel must collect correct information before a patient arrives to ensure a smooth revenue cycle. It lays the framework for invoicing claims and receiving them most effectively and efficiently. Back-end claim rejections may be avoided with the help of eligibility and permission verifications performed by front-office workers.
It guarantees that patients are appropriately enrolled and that their insurance will pay for the services rendered. Verifying facts and fulfilling prior permission criteria may help front-end workers avoid a claim rejection on their end of the revenue cycle. More and more insurance companies require doctors to call ahead and verify that a patient’s visit will be covered before they see them in person.
Patient Upfront Payments
Upfront patient collections are a vital part of the front-end revenue cycle. Patients are expected to pay a share of healthcare expenses as elevated health plans gain popularity. Back-end patient collecting issues may be resolved by allowing front-desk workers to accept copayments and deductibles.
Patients with high balances of more than $5,000 have collection rates that are four times lower than those of patients with low deductible health plans. The front desk may improve patient collections at the point of treatment in several important ways, including allowing patients to make interest-free payments over time, accepting credit cards, and giving patients cost estimates before they get care.
BACK-END REVENUE CYCLE
Following a provider’s patient visit and the completion of associated documentation and coding duties, the revenue cycle moves to the back end. Workers on the back end of the business deal with patient financial responsibility, claims to handle, and medical billing.
Claims Management
Staff members at the back end are responsible for charge capture after a patient visit. The term “charge capture” refers to the method used to tally up the financial value of medical services and the time spent on such services by medical professionals.
Healthcare companies use a system coder to translate clinical codes into monetary values. However, incorrect charge capture and lost revenue may result from inadequate clinical documentation. The back-end employees handle claims for many payers. Submitting a claim might be difficult because of the intricate web of regulations imposed by various payers.
Though spotless claims are preferable, employees must sometimes clean them up to avoid rejection. In addition, the staff must double-check all patient and health insurance information, as well as all codes and modifiers used in the billing process, to guarantee correctness.
Eventually, the back-end personnel will receive claims that were denied. Therefore, employees should go into their denied allegations and see if there is any way to have them paid. It’s estimated that around 90% of claim rejections are avoidable and may be rectified to make payment.
Workers in the receivables department should double-check that payers have paid the organization by the contract terms for all claims that are eligible for reimbursement. In the background, managing contracts with payers is an important task. Organizations may enhance medical billing compliance and negotiate for higher reimbursement rates by measuring payer performance and assessing the accuracy of payments.
Payment Collections
After claims adjudication, any outstanding debt on a patient’s account should be forwarded to collections. Employees in the medical billing department are responsible for generating and sending patient invoices and coordinating with patients to get payment in full.
Providers may increase patient revenue collection by facilitating electronic payment via patient portals. Many patients, mainly those comfortable with technology, prefer to pay their medical bills with a credit card immediately upon receipt rather than writing a check and mailing it.
Staff on the back end of the healthcare system receive payments from patients and insurers, apply those funds to the patient’s case file and finally close the patient’s account.
Conclusion
While the front and back end of a business deal with distinct revenue cycle aspects, better collaboration between the two may boost a company’s bottom line. They complement each other’s functions in this way. Revenue cycle management is a complex practice in the healthcare business. Payments from patients and insurance companies have an impact on many different departments. Therefore, front- and back-end workers in the revenue cycle should work together and keep in close contact.