Revenue Cycle Management is hard. In fact, RCM is one of the main bottlenecks that make healthcare so expensive, slow and cumbersome.
Enter has developed the playbook for healthcare managers and administrators on how to run the most cutting edge revenue cycle management technology and operational infrastructure for your practice. This playbook will:
As we go through each of the tasks that must be performed inside of a proper healthcare revenue cycle, we want to highlight the following:
Administration of a healthcare provider's revenue cycle is one of the main reasons why healthcare is so expensive. Once you’ve seen all of the things that go into revenue cycle management, you will quickly understand why Enter exists and how we execute on our mission to lower the cost of healthcare.
Enter’s revenue cycle management platform connects and automates the entire claim revenue cycle journey (with the exception of coding).
A provider's EMR and the integrity of its data is the lynchpin of a good revenue cycle. The data from your EMR is what is used to create each insurance claim and patient bill. Bad data in your EMR gets converted into dirty insurance claims and Payers never pay a dirty claim - even a claim that is 99.9% clean is DIRTY and will get denied! 2 huge questions you should ask to your EMR vendor...
Your Revenue Cycle software or vendor must directly integrate into your EMR. If your RCM is not integrated into your EMR, no need to read further - go fix that first.
Cer.bo - fast, friendly and active team. Extremely helpful with transparent pricing. $19 - $219 / month / user (depending on the user).
OpenDoctor - robust solution that focuses on Radiology.
Allscripts - One of the top EMRs in healthcare. Allscripts supports major health systems along with practices.
eClinicalWorks - One of the largest cloud-based EMR software in the U.S.
pMD - Charge capture and MIPS registry.
Enter will fully manage the EMR integration process during the client’s implementation process, which we call the Tune Up. Enter’s Tune Up fee is $10,000 / Billing NPI.
$5,000 - $20,000 up front, integration fee.
$250 - $2,500 / month for hosting, management and ongoing management.
A chargemaster is a list of all the billable services and items that a patient or a patient's health insurance provider would receive from a Provider on a claim. Typically Chargemasters have CPT codes, Modifier codes, Charge amounts, Descriptions and more. These CPT codes, charges, and descriptions are also used to bill the patient once the payer has adjudicated the claim.
We like to think about the Chargemaster as a provider's menu of services. This can be as simple as a spreadsheet with 10 rows of different services and prices to a database with millions of rows representing unique Payer contracts and many modifiers. Maintaining a smart and accurate chargemaster is not just key to revenue integrity but also integral to decision making on Payer follow ups.
💡 Connectivity to most recent Medicare rates (updated quarterly via CMS) is also very nice to have for Chargemaster management because it will allow your CFO to run analytics on whether your Payers are paying below or above the medicare threshold.
Enter’s Smart Chargemaster is deeply integrated into our Contract Manager to ensure that each service line item has contract rates, expected rates, medicare rates and much more. This is fully integrated into the Denial Management system.
$2,000 upfront to build out the Chargemaster.
$100 - $1,000 / month for hosting and management.
Contract managers are mission critical in operating a great revenue cycle. A contract manager allows you to input all of the details of each of your payer contracts along with variables and metrics that govern how your team handles underpayments and denials.
One of the main issues with contract managers is that they are not really programmatically connected to your billing operation team and thus requires a lot of manual labor to check the contract manager and then make decisions.
One of the amazing benefits of Enter is that the chargemaster and contract manager are baked into the platform and deeply integrated. When a claim from an in-network payer is denied or underpaid, Enter's system automatically is able to detect this, generate a reconsideration or appeal and respond to the payer in a second without any human input.
Integration and implementation costs: $15k - $25k
Monthly cost: $1k - $10k (depends on size)
Eligibility Checkers can verify the date on which a person becomes eligible for insurance benefits and conditions that must be met in order for an individual or group to be considered eligible for insurance coverage. An eligibility check will also return expenses defined by the health insurance plan as eligible for coverage.
Practices should always check eligibility during the patient intake process to ensure that the Patient's insurance is up to date and their services are covered. This will reduce unpaid bills significantly.
Enter runs eligibility checks during the claim creation process. This double verifies that the claim goes to the correct payer and is mapped to the correct plan. This is particularly useful for providers who have to rely on inaccurate front desk intake processes.
Enter clients can view all of the eligibility details inside of their Enter Cloud in each claim page.
Most eligibility checkers cost a minimum of $1k / month.
Medical Coding is the process of taking medical terminology and information and translating it into a universally understood language of medical professionals and insurance companies. The language is an established alphanumeric code (ICD, CPT, HCPCS) that coders apply to diagnoses, procedures, medical equipment, and medical services.
Medical coding is essential for revenue cycle management. At Enter, we strongly believe that medical coding is a deeply clinical process and should be managed with an in-house team or a direct vendor relationship and should be separate from your Billing team or vendor. Your codes are a direct representation of the decisions your doctors make and the services they provide.
Coding teams rely on the billing vendor to help shine a light on trends with Payers. Which codes are getting denied? Which are getting underpaid? If your billing software does not illuminate answers to those questions, you should likely look elsewhere.
The average cost for a full time in house coder in California is $68,000 / year or $33 / hour. One coder can typically review, code and submit about 79 claims per day.
There are really cool AI coders and hybrid AI coders (fathom, buddi, etc.). A.I. coding platform, Fathom Health, advertises that they can reduce the total cost of your coding operations by up to 70%. What is really neat about this solution is the ability to effortlessly add capacity to code millions of charts per day, cut coding turnaround by days, reduce claim denials and mitigate audit risk, and finally keep PHI secure with industry leading technology and protocol.
Outsource coders charge on a per claim basis with steep discounts for volume.
As mentioned above, Enter does not provide medical coding services. We do have some fantastic partners that we would be happy to recommend.
The EMR Billing Module is near and dear to our hearts, here at Enter. The Billing Module is a service that EMRs sell as an add-on that enables Providers to easily convert the data that is already living in their EMR into a claim and send it via the clearinghouse that the EMR partnered with. These Billing Modules are able to convert your EMR data into an EDI 837 transaction (a CMS 1500 claim) and send it to the Payer. Some Billing Modules even receive 835s (Electronic Remittance Advices - ERAs) and will post them into the Billing Module.
First, as you can see from the screenshot above, Billing Modules are rather old. They require a significant amount of manual labor to use them and they are not very well automated. Billing Modules were introduced 30 years ago and have been updated sparingly. The Billing Module was developed to organize human teams and provide them workflows for how to manage claims and payers - however, as Payers have increased in the sophistication of their adjudication systems like requiring prior authorizations or requesting medical records, the Billing Modules have not kept up.
Most EMRs only update their software on a quarterly basis. When you use Enter instead of the EMR billing module and you request a feature or an improvement, enter’s software team is pushing new code daily.
One additional issue with Billing Modules, they're not very interoperable. If you want to connect your Billing Module to a database or a business intelligence tool like PowerBI from Microsoft, Quicksight from Amazon, or Tableau from Salesforce... it is unlikely.
Enter is a 21st century billing module that you can replace your old one. Enter can seamlessly integrate into your EMR, manage all claims (electronic and paper), fully automate claim creation and scrubbing, claim management, denial management, payment posting and so much more.
$1,000 to $12,000 for a simple Billing Module. Other companies offer their billing module plus revenue cycle management services. These will typically cost $200 - $1,000/mo + 4% to 6% per reimbursement.
Clearinghouses are essentially electronic stations or hubs that allow healthcare practices to transmit electronic claims to insurance carriers in a secure way that protects patient health information, or protected health information. There are the file types that clearinghouses send:
Typically, your Billing Module is an integrated Clearinghouse that lets your EMR submit claims (837), receive remittances (835), check for claim status (276) and verify patient eligibility (270).
Clearinghouses charge minimum monthly fees along with per transaction fees. These are 3 of the top clearinghouses:
Enter uses a proprietary blend of these top clearinghouses to ensure maximum Payer connectivity.
$100 - $5000 / month depending on claim volume.
Claim scrubbers are a service offered by third parties to healthcare providers. Its primary purpose is to detect and eliminate errors in billing codes, reducing the number of claims to medical insurers that are denied or rejected. It is essentially a way of auditing claims before they are submitted to insurers. Some scrubbers will include NCCI Edits which are used to prevent improper payment when incorrect code combinations are reported. NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services.
Enter uses industry best claim scrubber in addition to our own in-house proprietary scrubber.
Most clearinghouses will offer a claim scrubber.
Top of the line claim scrubbers (like what Enter uses) will typically cost $1,500+ per month.
Coordination of benefits is the process of billing multiple insurances for one patient. Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their payment responsibilities (i.e., which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).
COB works, for example, when a member's primary plan pays normal benefits and the secondary plan pays the difference between what the primary plan paid and the total allowed amount, or up to the higher allowed amount.
From the billing perspective, managing COB can be very very tricky. First and foremost, a provider must collect and record accurate data during patient intake. If a provider mistakenly records the primary payer as the secondary and sends the claim to the wrong payer, the claim will be denied, require a half an hour of work from your team and payment will be delayed by at least 30 days.
Enter automatically manages Coordination of Benefits errors and saves your team hours of manual work. Enter also helps catch COB errors before they happen.
For each COB error, 20 minutes of a biller's time ($18 / hour) = $6 / claim + 30 days of delayed payment.
A lockbox is typically a vendor-operated mailing address to which a Provider directs their Payers to send their payments. The vendor opens the incoming mail, scans and organizes each piece of mail into a digital file system, correlates the piece of mail to the claim, deposits any received funds in the company's bank account, and records the payments and any remittance information. The scanned images are posted to a secure website, where the company's accounting staff can access the images and reports to reconcile payments to outstanding accounts receivable.
Healthcare lockbox services are essential for hospitals and physician practices overloaded with slow, time-consuming paper-based payments, also known as EOBs. Lockbox services streamline the revenue cycle, reducing manual back-office insurance and patient payment posting processes and enhancing the claim-to-payment life cycle. Your hospital or practice will process payments faster, which also means you get paid sooner.
Enter’s market leading lockbox is fully integrated into your Enter Cloud dashboard.
$90 / month
Payment recording is one of the most tedious tasks in RCM. Payment is recording is the process of finding every payment made by a Payer or a Patient for each and every claim and recording all of the data into your Billing Module. The tricky part is that payments from Payers come in a variety of formats. There can be Electronic Remittance Advices (ERAs) or there can be Explanations of Benefits (EOBs).
With ERAs, payments are remitted via ACH or wire transaction and the payment details are all transmitted to your Billing module via EDI 835 data interface. This is an example of an 835 ERA in a PDF format.
EOB payments are what make Payment Recording truly difficult. EOB payments are attached to letters (mailed by the Payer) via check format. Most billing modules will have the ability to record some information from an ERA however if a payment comes in via and EOB, that payment will have to get recorded manually. Each EOB payment recording can take anywhere from 5 to 30 minutes of human time. Additionally, humans make errors, especially when they're trying to record an EOB with 20 service lines into a Billing Module that hasn't been updated in 20 years.
Any time a Provider's billing team has to manually data enter an EOB payment, it will take 7.5 minutes (at best). For a practice with 1,000 claims / month and 35% of claims requiring manual EOB entry, that is 350 payments * 7.5 minutes = 43.5 hours / month. For a Biller making $18 / hour = $783 of the most miserable data entry work on earth. There is also a delay in processing speed which increases Days in Accounts Receivable. Most EOBs wont be recorded and appeal submitted for 15 days after the claim was adjudicated.
This is another service that Enter has fully automated and comes with the Enter RCM platform. Enter's EOB A.I. is able to read EOBs and record 100% of the data in seconds. This means that Enter is able to reduce the Days in Accounts Receivable after a denial by 50%.
43.5 hours / month. $783 per month per 1,000 claims in labor cost. 15 extra days to process denials.
Denial Management is one of the most important aspects of Revenue Cycle Management. Denial Management is also one of the main reasons why your staff is overworked and considering a different career. It is one of the reasons why healthcare professionals hate revenue cycle management.
Denial Management is the process of systematically investigating each claim denial or underpayment by analyzing why each line item of a claim was denied or underpaid. This process of analyzing denial trends to uncover a trend by one or more insurance carriers and redesigning or re-engineering the process to prevent or reduce the risk of future claim denials.
Denials are really hard to understand because Payers have their own adjudication language.At Enter we are obsessed with denials and building the adjudication Rosetta Stone.
To properly manage denials, a practice either needs a team or a software platform to constantly analyze the payment and reason codes for each line item of each claim.
Many practices forgo thousands of dollars annually in revenue through denied or underpaid healthcare claims. These denials typically stem from a lack of strong denial management policies and procedures, overworked staff and limited resources. Here are some great stats:
There are a few ways a Provider can, formally, respond to the Payer after a claim denial or underpayment. Each of these responses require between 15 minutes to an hour of human time to create a PDF, print the PDF and finally either fax or mail the package to the Payer. Improtant Note, locating the proper fax number or accurate mail address for the claim denial department is not a trivial task and if you submit to the wrong address, you will likely extend the payment for another 45-60 days.
Enter has fully integrated and automated both the Denial Analyzer and Denial Responder and they come baked into Enter’s price of 2.9% + $0.30.
Denial management is extremely expensive. Each Medical Record Response or Reconsideration will take 30 minutes of human time ($18 / hour) = $9 / claim. This also really stretches a team thin. If your practice does 1000 claims / month with 10% of claims denied or underpaid, that is 100 claims denied, resulting in 50 human hours and $900 of labor per month.
Enter has fully automated this process and charges $0.
$900 per month of 50 hours of human labor.
A really useful Denial Management tactic that a Revenue Cycle Management team can take is to use Usual and Customary Benchmarking.
Usual and Customary Defined: A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company. The insurance company then uses this information to determine how much it's willing to pay for a given service in your area.
When a claim is underpaid or denied from the Payer, it is really useful to run a Usual and Customary analysis on the payment. This requires accessing a variety of private and public payment databases.
Enter partners with Fair Health to provide this service for free for each of our clients. Each Enter reconsideration or appeal will have Usual and Customary benchmarking from Fair Health. This increases reimbursements significantly.
These databases typically cost $5,000 per year, paid on a quarterly basis or $500 per month for a month to month contract. Additionally, it would typically take a human biller about 10 minutes per reconsideration or appeal to research and attach these benchmarks.
Average of 10 minutes of human time ($18 / hour) = $3 / claim. This also really stretches a team thin. If your practice does 1000 claims / month with 10% of claims denied or underpaid, that is 100 claims denied, resulting in 10 human hours and $180 of labor.
$500 per month for access to the database + $180 per month of 10 hours of labor.
Healthcare Providers need to send a lot of mail in order to run a great revenue cycle. Unfortunately, the state of the healthcare claims universe, Payers still require providers to send supporting documentation via the mail. Need to send medical records or submit a reconsideration or send an appeal? You're going to need to mail it.
Another key use case for mail in the healthcare world is Patient Collections. When the Payer finishes adjudicating your claim, often times, there will be a Patient Responsibility amount that needs to be billed. You're going to need to mail that invoice.
A Mail Vendor will provide the following services. Important note: make sure they are HIPAA compliant.
Enter offers a fully integrated, HIPAA compliant, mail suite for claims, payer follow ups and patient statement mail with a competitive pass-through pricing of $0.20 / page.
Typically HIPAA mail vendors charge $0.25 to $1.00 per page. Assuming that a provider has to send 100 pieces of mail (averaging 5 pages) at $0.50 per page = $250 / month.
$250.00 per month
Healthcare Providers need to transmit electronic protected health information (ePHI) by fax on a regular basis. They need to ensure those transmissions are completely secure and fully protected at all times. This is not only a matter of protecting patient privacy and your business’s reputation — it’s also the law.
Fax is a much better solution for Payer correspondence and follow up than mail. It is typically less expensive and much faster. Providers can also get much faster receipt confirmations.
Enter offers a fully integrated, HIPAA compliant, fax suite for claims, payer follow ups and patient statement mail with a competitive pass-through pricing of $0.10 / page.
Outsourced HIPAA compliant fax vendors can be quite expensive. Some charge as much at $0.25 per page. Enter charges a competitive rate of $0.10 per page. Assuming that a provider has to send 500 pages of fax at $0.25 per page = $125 / month.
$125 per month
The big question that often goes unasked is "Where do I mail my medical records?" or "What is the proper fax number for Aetna's appeal office?" Most billing teams have to figure this out every single day.
The problem. Imaging a claim is denied and requests medical records - your biller packages up a medical record response in an envelope and mails it to the Payer's mailbox that they Googled. If they mailed the appeal to the wrong address, how would they know?
One of the big benefits of working with Enter - we maintain a comprehensive rolodex that always stays up to date of the most current addresses and fax numbers for every payer.
This is include with Enter. We haven't found any existing Payer Rolodexes on the market. We may open source ours in the future.
Providers can perform patient collections from a variety of different ways. They can hire their own internal staff, outsource it to a patient billing vendor, or partner with a software platform. Collecting from patients requires really good data in your EMR, fast payment recording after the claim has been adjudicated, the ability to generate patient invoices, and funnel patients into a mobile payment processing solution.
The absolute minimum requirement for patient invoicing is to generate a patient statement and mail it to your patient’s home after their claim has been adjudicated. Typically most providers will submit two statements. Each statement will have a cover letter a section informing the patient of how they can pay, and the invoice itself.
Enter built one of the most comprehensive Patient Statements in the industry, complete with rich data like a cover sheet, history and details of past visits and payments and each invoice.
Patient statement and billing solutions typically will have an implementation fee of $1,000 to $5,000 and can range from a monthly minimum spend of $1,000 and up.
Providers can partner with text messaging services to also follow up with patients after the provider has sent the patient statement. One important note is to ensure that the SMS service is not sending any PH hi data otherwise you’re looking at a HIPAA violation.
Additionally these SMS services are often times pretty challenging to use because they require more manual input because of the SMS solution is not integrated into your billing module.
Enter’s patient SMS follow up system is perfect for staying engaged with patients and reminding them to pay their bills. It is fully integrated with the patient collection system and is synced with each patient statement.
SMS solutions will likewise have an implementation fee of $1,000+ along with a monthly minimum of $500+.
Want to give your patients the fastest and best way to pay their bill? Then you need to collect credit card or ACH payments from your patients. This needs this means that you need to partner with a payment processor like Stripe, or Braintree which is a PayPal company, or Adyen. Each of these solutions will enable Your patience to pay via their mobile device or computer. Enabling mobile payments dramatically increase the likelihood of a patient paying their invoice by up to 80%.
These solutions are fairly priced, however, the challenge comes with the integration into your billing module and linking each payment to each claim.
Enter’s mobile billing patient payment solution is perfectly integrated and connected - removing manual entry, bad data and slow processing speeds while delivering Patients the best experience in healthcare.
Services will range from 2.9% + $0.30 - 10% of patient collections collections.
A Patient Portal offers patients a white label webpage to pay for any out of pocket costs. Ideally, your patient portal will be:
Beautifully Simple: Patient’s simply go to your website, click "Pay My Bill", input their invoice number and birthday and pay.
Fully Integrated: All patient payments are tracked, recorded and searchable in your Enter Cloud. Also - payment methods are securely stored for easy future payments.
Secure: The Patient Portal is 100% HIPAA compliant and payments are secure.
Patient portals will typically have a monthly subscription fee of $500.
We have reviewed a lot of different inputs, features, and services that all contribute to running a top-of-the-line best in class revenue cycle for your healthcare practice. The final piece that cannot be overlooked is business intelligence and reporting. Do all of the features and inputs discussed in this post integrate into your reporting? If they don’t, you are likely missing answers to some very important questions.
There are some great off-the-shelf solutions that providers can use to connect all of the different services of their revenue cycle Into the data management platform. Microsoft Power BI, Amazon QuickSight, Salesforce’s Tableau and many more offer comprehensive solutions for your data.
Enter’s business intelligence suite comes standard with the platform. Enter also has
To integrate Microsoft Power BI, Tableau or Quicksight will require months of database engineering along with $1,000 / month.
At the clos of each month, Enter will send clients a consolidated financial report containing the following sheets:
These static reports should provide your accounting team with everything they need to close your books. Enter also offers monthly reconciliation meetings to match EOBs and ERAs to each bank account line item.
As mentioned above and evidenced in this post, Revenue Cycle Management has a lot of moving pieces and requires 25+ different software and service vendors to make it work. The great challenge, though, of any RCM is to connect all of these software and service vendors together into one cohesive infrastructure.
If you would like to learn more about how Enter has done this, please reach out!
This article is about the difference between medical coding and billing, as well as an overview of what each entails in the changing healthcare landscape
A clinical transformation consultant helps healthcare organizations improve their clinical processes and outcomes, keep reading to learn more.