Preventing Revenue Cycle Avalanches: A Guide to Revenue Cycle Operations and Optimization

By Paula Santiago, Andrea Hagen, on February 22nd, 2024

By neglecting to review your revenue cycle operations, you could be increasing your organization’s chances of experiencing a revenue cycle avalanche. A revenue cycle operations review is imperative to preventing this. The review evaluates all the processes involved in the management of the revenue cycle, including the practices that are critical to billing, accounts receivable and collections. Continue reading for tips to consider when trying to predict and prevent a revenue cycle avalanche.

Credentialing Best Practices for Timely and Accurate Enrollment

Timely submission of your credentialing packet is key. You should be asking yourself, who is responsible for this task? Credentialing should begin as soon as an offer letter is offered out to a clinician that requires credentialing because it can take between 90 and 120 days to become effective. Does the credentialing individual know how or who to contact to make sure that your EHR system has been updated accurately with their new information? Sometimes it is not just the NPI that gets filled out, there’s actually a taxonomy code that’s specific to the contract or there might be a specific payer ID.

When it comes to credentialing an enrollable practitioner, you have two options for Medicare—you can either submit via a paper application or online. The PECOS system is the online version. You go from submitting that paper application that usually takes no less than 90 days, where in PECOS they are generally getting approvals within 30 days because it is a direct linkage right into the Medicare system. Reviewing these are often quicker and easier than paper. When you are submitting using paper, ask yourself, do you have the most up to date paper version of the enrollment application? If you are not submitting on the correct paper form, they will return that application as unprocessable and then you have to start the process all over again. When it comes to Medicaid, all the initial applications must be done on paper, however, Medicaid now has a provider enrollment portal, Medicaid PE portal, and there are many things that can be updated directly via this portal without having to do a paper application.

Organizations should also consider how it addresses uncredentialed providers. Do you go ahead and let the uncredentialed provider see patients and then run the risk of losing revenue? If you think their enrollment is going to be back dated, have you figured out a way to put a claim hold on in your billing system so those claims aren’t submitted to a payer until that enrollment is finalized?

Enhancing Front Desk Procedures for Improved Demographic Data Management

How your front desk team verifies and obtains demographic information may impact the accuracy and the overall effectiveness. Developing a script that all staff will say every time they engage in any sort of a registration duty is recommended. Training should be provided and access to tools must be available for the front desk team. There are many staff members that do not have access to payer portals, or if they do, they don’t know how to interpret the eligibility information that’s being presented on that portal.

Fostering Open Communication Across Revenue Cycle Teams

Open communication is so important, and the entire revenue cycle must have open lines of communication. Misalignment within your teams can hinder open communication. Furthermore, poor communication among front desk, back office, and clinical staff can result in revenue cycle performance issues. The back office team is responsible for correcting all of those front end errors and then hopefully not making too many more of their own.

Coding and Documentation: Ensuring Accuracy and Timeliness

The coding and documentation duties are critical to the revenue cycle. If it hasn’t been documented, it hasn’t been done. If you don’t see it or don’t read it, it didn’t actually happen. It is crucial to be as specific as possible, however that specificity can’t happen unless the provider is documenting that specificity. Ensure that the coder and clinician are on the same page. Providers are ultimately responsible for coding, there has to be open communication to ensure an understanding between the coder and clinician. Another important aspect is having timely documentation. Try not to exceed 72 hours—it is a best practice to strive for the same day.

Managing Credit Balances: Policies and Procedures for Refunds

You should also have a policy for your credit balances. This policy should include all credit balances being reviewed on a monthly basis. Once they have been reviewed, if they determine that they truly are a credit balance, they should be refunded within 60 days of identification.

Identifying and Utilizing Key Performance Indicators for Success

Last but certainly not least, you’ll want to identify the KPI’s that are important for your organization, and you should be doing this as a team approach, making sure you are celebrating those successes.

If you need further guidance or have any questions on this topic, we are here to help. Please do not hesitate to reach out to discuss your specific situation.

This material has been prepared for general, informational purposes only and is not intended to provide, and should not be relied on for, tax, legal or accounting advice. Should you require any such advice, please contact us directly. The information contained herein does not create, and your review or use of the information does not constitute, an accountant-client relationship.

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Written By

Paula Santiago Jul15
Paula Santiago
Director, Beacon Solutions Group
Andrea Hagen Oct13
Andrea Hagen
Chief Operating Officer, Beacon Solutions Group

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