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Category Archives: RCM/EPM/CBO

Technology & Methodology for Revenue Cycle Management (RCM)

Posted on March 16, 2016 | Categories: Program and Project Management, Program Manager, Project Manager, RCM/EPM/CBO | Posted by: admin

Technology & Methodology for Revenue Cycle Management (RCM)


Revenue Cycle Management goes beyond

  • Conventional Claims Clearinghouses
  • It uses smart technology and an intuitive interface to help receive payments faster while reducing the administrative burden on the office staff
  • Intelligent analytics pinpoint trends affecting revenue cycle, that dramatically reduce accounts receivable and improve cash flows


Revenue Cycle Management (RCM) can help standardize, streamline and automate tasks related to

  • Billing and collections
  • Claim tracking and rework
  • Patient access
  • Payment posting



Revenue Cycle (RCM) is widely used in

  • Billing Services companies
  • Health System – Inpatients, Outpatient & Emergency Rooms
  • IPAs
  • Medical Group
  • Medical Practice
  • Physician Center Medical Homes (PCMH)


Stage of Revenue Cycle

  • Claims Submission Management
  • Edit/Error Management
  • Status Management
  • Denial Management
  • Remittance Management
  • EOB to ERA Conversion


Claims Submission Management

  • Submit claims instantly in standard and non-HIPAA standard formats*, and reduce or eliminate paper claims.
  • Submit claims in a batch or one-at-a-time, 24/7, to send to the health plan multiple times throughout a day.
  • Get real-time notification of electronic receipts and line-item, detail-level tracking.


Edit/Error Management

  • Benefit from automatic eligibility and benefit checks on submitted claims, ensuring completeness and accuracy.
  • Identify errors in real time, including HIPAA compliance, NPI and provider- and payer-specific errors.
  • Quickly see the fields to be fixed, plain-language summaries of each error and recommended actions for correcting them.
  • Use one standardized correction process for every payer, increasing efficiency for your staff.
  • View error patterns and trends in on-demand reports.


Status Management

  • Determine the status of pended claims with a daily automatic refresh.
  • Use automated searches and sorts to pinpoint claims that need the most attention, including unpaid, delayed and pended claims.
  • Search claim histories for proof of timely filing.
  • Find highlighted patterns, problems or delays in full lifecycle displays of individual or batched claims.


Denial Management

  • Accelerate cash flow
  • Adapt to all unique provider- and payer-specific rules in any practice-management system environment.
  • Create and control custom edits, including payer- and provider-based rules.
  • Create custom edits that fit organization’s business rules
  • Cut down on vendor costs by using a single integrated, standardized workflow.
  • Navigate a series of step-by-step screens for a user-friendly interface that cuts down on the need for programming resources.
  • Reduce denials with customized, up-front, provider-specific error identification.
  • Run eligibility during claim processing and reduce errors—ultimately, lowering the number of denials and speeding your payments
  • View the claim status, correct clearinghouse and payer edits, and resubmit the claim from a work queue


Remittance Management

  • Automatically post ERAs in the format required by most practice management systems.
  • Consolidate machine- and human-readable remittances into one common file feed, reducing the number of files to auto-post.
  • Track remits easily with plain-language explanations.


Analytics Management

  • Analyze, compare and monitor key business performance metrics for reimbursement, staff productivity, payer performance and code utilization.
  • Customize the system per user level, so answers to questions are simple and intuitive.
  • Provide transparency into business operations for even more visibility and control over your revenue cycle.


EOB to ERA Conversion

  • Achieve consistency and accuracy in posting while reducing costs of data entry and paper remittance handling.
  • Automated remittance and posting to automatically post all of payments, regardless of format.
  • Eliminate errors — and rejections — to expedite payments and account reconciliation.
  • View all remittances in a standard format.


For Technologies or Business Support related to Revenue Cycles, call us.

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RCM, CBO and EPM Workflows / Technology Assessment

Posted on December 31, 2014 | Categories: RCM/EPM/CBO | Posted by: admin

RCM, CBO and EPM Workflows / Technology Assessment


Based on Client’s response to these questions/observations, in conjunction with an on-site assessment, Techcusp will be able to develop a customized solution to support RCM / CBO Implementation requirements, which we believe can help you achieve significantly better outcomes (increased collections, reduced AR, reduced denials, etc.) as well as reduced collection costs.


Assessment Topics / Workflows



·         CBO / RCM Overview
·         Billing
·         Payment Posting
·         AR
·         Systems
·         Organization & Staffing
·         Payroll & Other Expenses
·         Budget & Time-lines



CBO / RCM Overview


1 How many active providers are there in the system? Please provide the names and provider type?
2 How many locations are there in your practice? Please list the location names?
3 What is your automatic system back-up timing?
4 Provide a list of top 10 payers.
5 Provide list of payers that you utilize website logins for and include the types of information you use the website for (i.e. insurance verification, claims status, etc.).
6 How many remit addresses does the organization have in total?
7 Provide historical monthly net collections by practice for past 12 months.
8 Provide the average age of balances for payments received in the past 6 months (i.e. 30% of payments received were for balances 0-30 days, 30% for balances 31-60, 15% for balances 61-90, etc.).
9 What is your Gross Collection Ratio (Average Charges / Average Payments)?
10 Provide policies and procedures that are followed for RCM activities.
11 Do you utilize a lockbox?   If so, what vendor manages the lockbox?




1 What is the remit address included on claims?
2 Are you billing under a Group Name? If yes, please provide the following info.
  a. Group NPI #
  b. Group Tax ID #
  c. Medicaid Group PTAN or ID #
  d. BCBS Group PTAN or ID #
  e. Other Payer Group PTAN or ID #
3 Do any of your locations perform Lab services? If yes, provide location name and the CLIA #:
4 If a claim is not on file, what is process that you follow for resubmission?
5 Are encounter claims submissions and rejections tracked by location or by Physicians?
6 What is the turnaround time of receipt of the payer reports?
7 How are the rejections from the payer report processed?
8 Are these payer reports uploaded into software?
9 Explain the process for transmitting patient statements.



Payment Posting (PP)



1 Do you have a Payment Posting process documented / training manual available?
2 What is the process for posting the collection agency payments to the respective pt accounts (i.e. are collections fees posted in the system)?
3 Average daily volume of posting done over last 3 months
4 Productivity per person per day
5 Average time consumed per EOB/ Posting
6 Current audit % being followed
7 Provide audit checklist, if any is utilized
8 Insurance:ERA volume ($ and # of line items posted per day)

Manual volume ($ and # of line items posted per day)

9 Patient volume ($ and # of line items per day)
10 Number of refunds processed per month
11 Does your billing system allow for validation of payment against contracted or allowable rates per line item?
12 Turn- around time of payment receipt to posting
13 Is there a lockbox in use?
14 How are credit card payments processed?
15 What is the payment posting reconciliation process (manual and electronic payments)?
16 How are EOBs stored?   Are the scanned or stored on paper?



Account Receivables (AR) & Denials Mgt.



 1 What payers are you contracted with?
2 Are there any credentialing issues in your practice(s)? If yes, provide details.
3 Do you utilize the worklog in NextGen (or other RCM Platform) for assigning and prioritizing accounts to be worked?
4 How are coding denials handled?
5 Provide the list of top 10 CPT codes other than E & M codes – by location.
6 What collection agency do you use?
7 How do you identify underpayments?
8 What are your processes and protocols to do refunds?
9 AR trending reports:Please provide AR monthly trending reports showing AR for the last 12 months:

Total AR ($ and volume) – consolidated and by AR system if more than one system

Total patient AR ($ and volume)

Total credit balance AR ($ and volume)

DSO (days AR)

AR by payor ($ and volume)

AR by aging buckets (31-60 days, 61-90 days, etc.)

10 Collections ratio:total collections % (gross and/or net)
11 Denials reports:total denials ($ and volume) – consolidated and by AR system if more than one

denials by payor ($ and volume)

denials by denial type ($ and volume)

12 Do you have any claims/charges that are on hold for reasons such as credentialing, EDI, etc.?



RCM Systems /Billing Platforms



1 What version of NextGen / Platform are you on?
2 How long have you been on NextGen / Platform?
3 What modules of NextGen / Platform do you use (EPM, EHR, HIE, etc.)?
4 Do you have an AR being worked in a legacy system(s)? If so, what system(s)?
5 Have you been actively working on or completed system updates / upgrades? If yes, please explain setup changes and claims testing process and status.
6 Do you utilize claim edits in NextGen / Platform?
7 Do you utilize HIPAA X12 standard Reason Codes for payment posting?
8 How do you set up non-credentialed providers for specific payers in file maintenance?
9 Who is responsible to update the CPT and Diagnosis master file updates every year?
19 When did you last update your Fee Schedule (Charge Master)?
11 Do you have other systems that interface with NextGen?
12 What is the process followed by practices and CBO personnel to request new master file entries (i.e. new payers, new providers, etc.)?
13 Who is responsible to add new providers in NextGen?
14 Who is responsible to add other new master files in NextGen (i.e. Reason Codes, Dx Codes, SIM Codes, etc.)?
15 Please list all software that you use to manage the revenue cycle (system name and function)?
16 IT maintenance expenses:What is your annual IT maintenance expenses for RCM IT systems, including recurring license fees (exclude one-time license fees), training, implementation support, routine system upgrades, system administration, local hosting and server management (if any)
17 Please indicate the number of FTEs for IT support and system administration.
18 Is there a document imaging system and/or EHR system in place?



CBO Organization & Staffing



1 Number & Locations of centralized business office(s) (CBO) and/or other Operational Centers. List services performed at each of the above.
2 List the types of services/specialties provided and %s of total services for each:
3 Average number of procedures being done on a monthly/annual basis
4 Type of billing being done

  • Physician
  • Facility
  • Both
5 Who is responsible for authorizations and scheduling the patients?
6 Do you have any special contracts with the Hospital, Community Health Center/ Physician Groups/ Private Entities?
7 Do you have a policy and procedure manual related to the revenue cycle management process? If so, please provide a copy.
8 List the number and type of locations where services are performed
9 What is the total number of billable physicians?
What are the total annual gross charges billed?
10 What is the annual gross revenue?



Why Techcusp?


  • American Firm
  • Attractive Pricing
  • Cutting-edge Technology Consultants
  • Deep Domain knowledge
  • Onshore/Offshore Delivery for scale & quality




Mihir Desai

Partner – Technology Solutions

Cell: +1 646.479.9539 / 201.258.4704 / 201.604.3480

Insurance IT | HealthCare IT | Banking IT | Staffing

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