Who Is A Revenue Cycle Specialist And What Do They Do?

A revenue cycle specialist is a financial guru who oversees crucial tasks such as payment and collections within the healthcare industry. These professionals often work at hospitals or clinics, where they face many unique challenges due to the complex nature of the business.

For instance, when billing for services rendered, it's not always clear whether patients can afford them. The same goes for collecting payments from those who don't have insurance coverage or are in-network but haven't paid their bills yet. Additionally, there are times when credit card companies refuse to pay claims because of disputes overpricing, or other issues that may arise during processing - leaving revenue cycle specialists with no choice but to keep trying until they get paid.

A revenue cycle specialist must be well versed in modern business practices and technology. Most companies operate on an entirely digital basis, so knowledge of all the latest software and apps used in this industry is important.

Because revenue cycle specialists work with numbers and finances more than most people, they must possess exceptional interpersonal skills that enable them to build rapport with others. They also need to know how to speak clearly and effectively to communicate detailed information.

This is not a job that can be done without the proper education and training, so revenue cycle specialists are typically required to have at least an associate's degree in finance or business administration. They may also receive additional certification through the American Healthcare Professional Specialists Association (AHPSA). This article will discuss the nature of this job and provide some insight into the best ways to become a revenue cycle specialist.

How to Become a Revenue Cycle Specialist?

When it comes to advanced healthcare careers, becoming a certified revenue cycle specialist can be one of the most rewarding options available. This is because while it's not an entry-level job, it does require little to no experience, but a bachelor's degree can definitely help.

To begin with, students who want to be a certified revenue cycle specialist must choose between two primary paths: working their way up in the existing industry or starting at the bottom and entering from outside.

There are pros and cons to each approach, so individuals should carefully consider the circumstances of their situation before making a decision about being a revenue cycle specialist. For example, those who have worked in healthcare positions such as coding or billing may find that their skills and experience give them an advantage over employees fresh out of college. That said, because these areas require different types of training, it's also possible that having the education typically received by revenue cycle specialists will be just as helpful in many cases.

On the other hand, coming into the healthcare administrative management industry without experience or with only a minimal amount can be very advantageous in certain ways. For example, when starting out fresh, there are no bad habits to break so individuals are free to do things however they see fit. The fact that there is little room for preconceived notions about how things should be done can lead to great creativity and innovation, which may not be possible with those who have spent years in the business.

Regardless of the path chosen, the education and training received will generally include coursework in certain key areas. These include billing, reimbursement, accounts receivable, and coding. As the name suggests, revenue cycle management is basically a combination of these four areas working together to process claims efficiently and accurately - so most employers will expect their employees to have mastery over each one.

Different Steps Of Healthcare Revenue Cycle Management

Revenue cycle management (RCM) is the process that ties together claims processing, collections, accounts receivable, and coding to produce automated financial statements.

Discussing the revenue cycle in healthcare administrative management view can be envisioned in steps, beginning with deploying RCM software or outsourcing the work to a third party.

Within this step, there are several key tasks that must be accomplished to make sure all of the components are tied together correctly. Some of these are a delegation of tasks for each department involved in managing healthcare billing, educating staff on how to use the new system or service being deployed, and finding ways to establish standardized processes before implementing automation.

After the deployment has been completed successfully, it's necessary to keep track of RCM through ongoing tracking of data, validating that the system is running correctly, and creating backups in case anything should fail.

Outsourcing revenue cycle management can take place at any point after the initial launch stage. This step doesn't have to happen immediately following the implementation of an automated billing system or service. Instead, it may be beneficial to wait until all of the processes have been standardized so there are no manual tasks being handled at any point.

After that initial setup or outsourcing, adjustments to job alerts may be necessary once it's possible to compare the actual revenue received against the projected amount. This can include adding new accounts receivable specialists if numbers are low, redesigning workflows for RCM to maximize efficiency, or simply re-evaluating the accuracy of coding.

At all times, it's necessary to monitor data and audit trails so that any errors can be caught before they cause problems down the line. This can include fixing minor mistakes once they've been found as well as maintaining accountability for major issues that need more time or attention.

●  RCM Software

The first step in the healthcare revenue cycle is deciding how to handle your processing. This can involve implementing RCM software or outsourcing the work to a third party. Once this decision has been made, the next step is to delegate tasks for each department involved in managing healthcare billing. It's important to educate staff on how to use the new system or service being deployed and find ways to establish standardized processes before implementing automation. After the deployment has been completed successfully, it's necessary to keep track of RCM through ongoing tracking of data. This will help you adjust your system as needed and ensure that everything is running smoothly. Outsourcing revenue cycle management can take place at any point after the initial launch stage. However, it may be beneficial to wait until all of the processes have been standardized so there are no manual tasks being handled at any point. After that initial setup or outsourcing, adjustments may be necessary once it's possible to compare actual revenue received against the projected amount. This can include adding new accounts receivable specialists if numbers are low or re-evaluating coding accuracy.

●  Patient Pre-Authorization

The next step in Revenue Cycle Management is the pre-authorization of each patient. A pre-authorization is a request from a medical provider for authorization from the insurer to either provide a service or perform a procedure on a specific patient and, in most cases, will be denied if not obtained.

Pre-authorizations can also be used as an additional security precaution by some insurers to minimize the risk of fraud and abuse. So, if you're having trouble getting pre-authorizations or they're taking too long to come back it's most likely because your requests are denied for one of these two reasons.

●  Releasing Funds

To release funds from one part of the revenue cycle to another, there needs to be a balance in the account. The deposit may have been a check, ACH transfer, or a wire transfer and all of these types need to clear before funds can be released from one department to another.

●  Invoicing

In order for funds to be deposited into the bank account of a healthcare provider, they must receive an invoice that is paid by the patient or their insurer. These invoices can be submitted manually through fax, online upload, email attachment or mailed to the insurance company's billing department. After they are processed, payment will be sent to the healthcare provider's bank account.

●  Eligibility & Benefits Verification

Some of the drudgeries of your front office staff have to do with checking on eligibility and benefits for patients. This includes verifying that the patient is covered by the insurance company and that they are eligible to receive the services that they are requesting. It also includes determining which benefits the patient is eligible for and what the coverage amount is.

●  Claims Submission

One of the most important aspects of a healthcare provider's revenue cycle is submitting claims for the services they provide to their patients. This includes all of the work that is done in the office from checking on eligibility and benefits to verifying insurance coverage and submitting the claim. If these steps are not followed, then your office will not receive payment for the services that have been provided.

●  Payment Posting

After the claim is successfully submitted and reviewed, the payment is posted and is able to be paid by your patient. The payment will then be deposited into your bank account and you will be able to use it to reimburse your staff for the work that they have done.

●  Denial Management

This is a question that can be difficult to answer as it depends on a variety of factors, such as the type of service that is being provided and the insurance company that is covering the patient. However, it's important to keep track of how often claims are denied so that you can adjust your system as needed.

●  Reporting

Medical practices and hospitals without detailed reports can have hidden problems that may be growing worse. Detailed reports can help identify these problems so that they can be addressed before they become too large to manage. Without reports, it can be difficult to determine where the practice or hospital is making money and where they are losing money. This information is essential for making informed decisions about the future of the business.

The Revenue Cycle Of Healthcare Practice.

Revenue cycle management is the process used by healthcare systems in the United States to track revenue from patients from their initial appointment until they remit payment. This includes work that is done by office personnel and claims processing personnel.

The major components of this process include:

  • - A patient's appointment and the billing and collection of payments for those appointments
  • - Preauthorization requests for procedures or services
  • - Payment posting to accounts receivable
  • - Denial management, meaning handling instances where the patient's insurance company denies coverage for a service or procedure
  • - Reporting, which can provide information about how much revenue steady practices are making and what they need to do to improve their finances. 

Below we will give some details of these steps to help you understand how they work together.

●  Step 1: Preregistration And Appointment Management

The first step in the revenue cycle process is preregistration and appointment management. This includes checking eligibility and benefits, verifying insurance coverage, scheduling appointments, and entering orders or referrals. If these steps are not completed correctly then your practice will miss out on valuable payment opportunities.

●  Step 2: Registration And Posting Payments

At the time of your appointment, you will need to check-in at the front desk. This includes giving them all of your relevant contact information and any referral or authorization numbers that may be required for your visit. After this is completed, they should provide you with a list of insurance carriers so that you can choose which one you will be using for this appointment.

●  Step 3: Charge Capture

Once you have chosen your plan, the next step in the revenue cycle is charge capture. You should be given an explanation of benefits or an explanation of charges by your insurance company (if it was not provided in step two).

●  Step 4: Claim Submission

Your practice will then submit your claim to your patient's insurance company. If you are using an electronic system, the claim is usually filed when payment is received for the visit.

●  Step 5: Remittance Processing

A patient's account is updated with a balance after the claim has been paid. If a patient has a balance due on their account, you will begin to work on this phase of the revenue cycle process. First, you should send out statements that detail how much the patient owes and when their payment is due. You can then follow up on unpaid balances over a period of time and take additional steps to get paid. This may include financial assistance or other means to help your patient pay.

●  Step 6: Insurance Follow-up

You can follow up on denials of claims by your patient's insurance company. If the claim is denied, you will work with the financial department to make sure that documentation is correct and resubmit it or appeal the decision. The goal of this step in the revenue cycle process is to get paid for services rendered.

●  Step 7: Patient Collections

This is the final step in the revenue cycle process. If a patient has an unpaid balance, you can work with them to establish a payment plan or waive fees. This is also the time when you will turn to more serious collections measures or legal action if needed.

Outstanding accounts and overseeing collections is a constant job for healthcare revenue cycle management professionals. 

In general, this is how medical practices receive payment for services from patients and insurers. Each step is important and has the potential to affect the amount of payment you receive for your work. In order to provide optimal services, it is necessary that each area be managed with integrity. 

That is why a white glove RCM solution offers the latest in best practices to protect you from claims denials, expensive lawsuits, and lost revenue. 

Click here to learn more about white glove revenue cycle management process and how we can help you today!

What is a Certified Revenue Cycle Specialist?

A CRCS is a health care finance professional who has experience in all areas of the revenue cycle process. They can help your practice by providing guidance with preregistration and appointment management, charge capture, insurance follow-up, and patient collections. Their goal is to help you get paid for the services you provide.

There are a few important things to keep in mind when working with a CRCS. First, they should have experience in all areas of the revenue cycle process. This means they can help you with everything from preregistration to patient collections. Second, they should be up-to-date on changes in the industry and how they may impact your practice. Finally, it is important to find a CRCS who is willing to work with you as an educational resource. They should provide expertise without taking over control of your medical practice.

How can a CRCS Benefit Your Practice?

A CRCS can help your practice in three key ways that impact revenue generation.

First, they can improve registration processes by making them more accurate and efficient.

Second, they can help your practice find ways to increase patient collections.

Third, they can guide you through the appeals process if denied claims are an issue for your practice.

●  AAHAM Certifications

The AAHAM is a national organization that provides certification exams, membership services, and networking opportunities for healthcare administrative professions. The goal of the AAHAM is to provide support and resources for healthcare professionals in order to improve the quality of patient care. Their certification program is designed to test the knowledge and skills of healthcare administrators. The certification exams are offered at various locations throughout the United States.

If you are seeking a career in healthcare administration, the AAHAM offers many resources that can help you succeed. Their website provides information on upcoming events, certification requirements, and networking opportunities. They also have a job board where you can find employment opportunities in the healthcare industry. In addition, the AAHAM offers memberships that provide many benefits, such as discounted rates on certification exams.

●  Overview Of CRCS Exam

The CRCS exam is meant for any health care staff who are involved with the revenue cycle. This includes staff in pre-registration, insurance verification, charge capture, billing, and collections. The exam tests your knowledge and skills in all areas of the revenue cycle process. It is important to be familiar with the process in order to ensure that your practice receives payment for the services you provide.

●  CRCS Exam Content

The CRCS exam is for anyone who needs to be involved in the revenue cycle process at their practice or institution. Professional settings will take the CRCS-P exam, while institutional settings will take the CRCS-I exam. The content of both exams is very similar, but they have different types of questions.

The certification process is open to all health care professionals in order to promote high-quality patient care in an increasingly varied healthcare system. If you are already employed in a healthcare setting, you can complete the qualifications through your current work experience.

Something that we found very interesting in the field is about addressing revenue cycle labor shortages. Click the link above to learn more about it! 

Benefits Of Working With The Right Revenue Cycle Management Company

▪ RCM companies can help you determine which procedure codes are most commonly associated with the procedures that you perform. They also offer consultation on billing-for-services, pre registration services, insurance clearance, and patient billing. Some companies even offer software programs that will streamline your business activities. Medical billing services handle the technical side of billing for medical providers by submitting claims to carriers and collecting payments.

▪ RCM is essential for any clinic or organization seeking reimbursement for their services. It is critical to find a company that offers comprehensive services and understands what it takes to get patients paid on time. Choosing the right RCM company can dramatically improve your finances by helping you make sure you don't miss out on any opportunities for reimbursement from insurance companies.

▪ Decrease Your Risk For Bad Debt. Getting paid by insurance companies has become increasingly complicated, which is why you need to hire an RCM company that understands the complex billing requirements of medical practices. The best revenue cycle management companies understand how to navigate through the rules and regulations of insurance companies in order to help you get paid for the services you provide.

▪ Improve Cash Flow. The best RCM companies will take care of your accounts receivable so that you don't have to worry about missing out on potential income from late payments. This is especially important when it comes to low-reimbursement services like implants and cosmetic surgery.

▪ Decrease Patient Accounts Receivable Time. The time that you spend dealing with patient accounts receivables can be minimized through the use of an RCM company. Allowing an outside agency to handle these tasks will save you both time and money so that you can focus on providing excellent care for your patients.

▪ Manage Your Accounts Receivable Processes. The best RCM companies will handle all of the functions related to patient accounts receivable so that you don't have to worry about ever losing out on money that is owed to your practice. Most revenue cycle companies offer services like follow-up calls, past-due billing, and collections management.

▪ Improve Billing And Collections Procedures. Many RCM companies offer practice assessments so that you can identify areas of your business where you could improve the way you bill for services. Allowing a third-party company to review your billing and collections procedures can also help you learn about potential revenue that is currently unaccounted for.

As an increasing number of medical personnel and medical billing companies are focusing on providing quality services to their clients by providing excellent healthcare outcomes, it is always advisable to find a good RCM company that would be able to provide high-quality revenue management services. The best RCM companies understand the compliance guidelines that your practice needs to abide by in order. Click here for more information regarding the success in revenue cycle operations   

●  Medical Coding Expertise.

The best RCM companies provide healthcare professionals with dedicated medical coders who are experts in their field. These highly-qualified professionals will ensure that your claims get processed properly so that you don't have to worry about paying fines or penalties for any submission errors.

Check out this article on healthcare administration degree plans for more information on the expertise needed.

●  Medical Coding Audits.

Health insurance companies regularly perform audits on the billing methods employed by healthcare facilities to make sure that they are compliant with their guidelines. Working with an RCM company will help you limit your vulnerability to audits as these agencies will submit claims for all of your procedures.

●  Experienced Medical Billing Team

It is always advisable to work with an RCM company that provides you with a well-trained medical billing team. These professionals will be able to handle all of the patient accounts receivables for your practice and ensure that claims get submitted correctly and on time.

The advanced services offered by top revenue cycle companies can help improve your compliance and cash flow. These agencies can also help you learn about revenue that is being generated by your practice but has yet to be accounted for.

●  Free Medical Billing Software with Specialty EHR

The best RCM companies often provide their clients with the medical billing software that they need to manage their practice. These providers should also be able to outfit your facility with an electronic health records system so that you can make the most of your technology.

Choosing a top revenue cycle management company for medical billing services is one of the smartest decisions that a medical practice can make. These agencies provide a vast range of benefits that can greatly improve your patient accounts receivable processes and cash flow. When choosing the right revenue cycle management company, always look for an agency that offers top-notch services with cutting-edge technology.

●  Faster Payments

A good RCM company will help you receive faster payments for the services that your practice provides. These agencies can also improve the way physicians are paid by providing them with electronic transfers of funds to their bank accounts on a daily basis.

●  More Time to See Patients

When you work with a dependable RCM company, there will be no need for your staff to spend hours making follow-up phone calls and sending out past due bills because these services will be provided by the agency. Working with an experienced revenue cycle management team can allow you to concentrate more on providing quality care to your patients instead of worrying about your cash flow.

●  A streamlined practice

A good RCM company will streamline your patient accounts receivable process so that you have more time to focus on your practice's core functions. Without a revenue cycle management team, it might take days or even weeks for your staff to receive payment for their services.

●  Local Customer Service

A good RCM company will provide patients with personalized customer service. These agencies can also work with your team to help you further improve the patient experience and build a strong rapport with your clients.

●  Compliance Expertise

When choosing a revenue cycle management company, always look for an agency that offers compliance expertise. These agencies should be able to ensure that your practice is in compliance with all state and federal regulations.

●  Access to Medical Billing Software

A good RCM company will provide you with the medical billing software that you need to optimize your accounts receivables process. These companies should also be able to outfit your facility with an electronic health records system so that you can make the most of your technology.

●  Paperless Option

It is beneficial to work with an RCM company that offers a paperless option because this practice helps the environment. Many revenue cycle management companies are now creating cloud-based medical billing software so that you can provide your clients with services without using paper.

Click here for more information on the overall steps in the RCM flow chart 


There you have it. A revenue cycle management company can drastically improve your accounts receivable process so that no money is left on the table because of delayed payments. If you want to learn more about how an RCM agency can benefit your practice, contact us today at Enter Health.

We are currently looking for partners in all medical practices. Please e-mail us at support@enterhealth.co for more information.

Enter Health is a medical billing company that specializes in providing small to large sized practices with affordable, secure, and efficient revenue cycle management services. EHR provider since 2010, we are 100% cloud-based and offer electronic health records software for physicians' practices. We also provide free support for all clients.

Feel free to contact us at sales@enter.health or visit our website at enter.health. You can also follow us on Twitter or check out our blog!

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