Revenue cycle management (RCM) is a fundamental process that covers the financial operations and the administrative and clinical functions of healthcare organizations. RCM involves managing the patient journey from registration to reimbursement, enabling organizations to maintain their financial viability and solvency while focusing on patient care.
In behavioral health, RCM is particularly critical, as it can handle complex and ongoing patient cases, varying levels of care, and multiple funding sources. Here, we’ll discuss the 13 steps of revenue cycle management specifically tailored for behavioral health organizations. We’ll also look at the role that technology — like comprehensive electronic health record (EHR) systems — plays at every step.
RCM Challenges for Behavioral Health Organizations
Medium to large behavioral health and human services (BHHS) organizations face unique challenges due to the complex nature of their services, multiple funding sources (each with its own requirements), and the varying levels of care delivered. BHHS organizations often provide a range of services from outpatient care to intensive inpatient care, residential or transitional care, and clinical consultation. Since each care level has different documentation requirements for coding and billing, ensuring the accurate capture and coding of services provided can be a significant administrative burden.
Further, BHHS organizations often rely on multiple funding sources, including private insurance, Medicare, Medicaid, Veterans Affairs (VA), grants, scholarships, and direct or private payments. Each funding source has rules and processes for eligibility verification, claims submission, and documentation of treatment and outcomes, which are tied to reimbursement. Moreover, each government program attaches complicated regulatory requirements that may lead to reduced reimbursement rates.
Coordinating these different payer processes while maintaining compliance can be a major challenge and requires expert knowledge, rigorous attention to detail, and a robust and comprehensive RCM system. You must also be concerned with mitigating claim denials to ensure timely reimbursements and maintaining documentation for eventual audits.
These RCM challenges highlight the need for targeted strategies that streamline workflows, improve accuracy, and optimize or shorten the revenue cycle. In terms of technology, you'll need an EHR solution that supports the 13 steps of revenue cycle management with features specifically designed for behavioral health and human services.
The 13 Steps of Revenue Cycle Management for Behavioral Health Care
Healthcare revenue cycle management is critical to the success of all organizations, even (or especially) those that offer services at no cost or reduced cost, such as the RCM process for health systems like Certified Community Behavioral Health Clinics (CCBHCs). Having a comprehensive yet flexible RCM process is also important due to the complexity and scope of behavioral health and human services.
The following overview of the 13 steps of revenue cycle management for BHHS includes ways that each step can be enhanced, simplified, or improved using a unified EHR solution.
1. Patient Registration
The first step of the revenue cycle begins before the patient makes an appointment. During registration, the patient, referring physician’s office, or community agency provides the patient's demographic, financial, and insurance information. EHR solutions can streamline this step by automating patient intake.
With an integrated EHR, patients or referring providers can begin the registration process online. EHRs utilize an active confirmation process that not only saves time but also improves accuracy. Registration introduces the patient to the EHR system and allows them to create a login and access their patient portal – a central hub for communication and collaboration.
2. Health Insurance Eligibility Verification
Next up is verifying the patient’s insurance coverage. EHRs automate this step by quickly checking the patient’s insurance coverage and benefits. If patients don’t have insurance, you need to know this upfront so that you can advise them of other options such as social safety net programs, Medicare, or Medicaid.
3. Medical Services Scheduling
In this phase of the revenue cycle, patients can schedule their appointment. Manual scheduling in a behavioral health setting can be a chaotic and time-consuming, painstaking madness. Appointments frequently must be coordinated between multiple providers and across various levels of care, and often recurring over long periods of treatment.
Schedulers have to match open time slots with a patient’s availability, account for staffing needs, keep track of cancellations, and manage callbacks for rescheduling, all while navigating regular daily disruptions like overbooking, double-booking, work-ins, no-shows, and emergencies.
Research shows that patients heartily approve of self-scheduling. The right EHR solution can fully automate the appointment scheduling process and transform a source of stress into a seamless workflow. EHR systems provide real-time access to scheduling calendars to allow for quick and efficient scheduling. EHR scheduling features can help you automate reminders to be sent to patients over text, through email, or by phone to reduce the number of no-shows.
Meanwhile, EHRs collect data that can help you improve the patient experience while increasing your operational efficiency by shedding light on scheduling trends, information gaps, and staffing needs.
4. Charge Capture and Medical Coding
Whenever you provide a service, it’s essential to thoroughly document and code the service or visit for billing and reimbursement. EHR systems can help you automate this process by integrating practice management software. Charge capture and coding features translate the services you provide into universally accepted or standardized codes. These codes make sure that you have the right documentation and authorizations to receive the maximum amount allowable.
In behavioral health, charge capture and coding is particularly challenging due to the complexity and variety of services provided. Errors and inaccuracies at this stage can lead to claims denials or delays in reimbursement, which can significantly impact your organization’s cash flow. By using an EHR system to automate charge capture, you can minimize human errors, avoid gaps in documentation, and ensure accurate billing for your services.
5. Prior Authorization
Some services in BHHS require pre-authorization from the insurance provider. An EHR system that is comprehensive and integrated can initiate the authorization process, and send and track the necessary documentation to ensure that you receive reimbursement for the services you plan to provide.
If there’s a problem, the system can prompt administrative staff to resolve deficiencies or discrepancies within the documentation, add patient information, and resubmit it prior to the patient’s appointment.
6. Claim Submission
During this step, the billing department prepares claims for reimbursement and submits them to payers. An EHR system that directly interfaces with the insurance companies or clearinghouses can automate the claims process. Not only does this shorten the revenue cycle, but it also reduces clerical errors and mitigates claims denial.
7. Payment Posting
When claims reimbursements or payments arrive in the office, they must be posted to the correct patient accounts. A unified EHR system helps ensure this is done in an accurate and timely manner by automatically tracking accounts receivable and posting payments to the correct accounts.
8. Denial Management
Sometimes insurance claims get denied. An EHR system aids in denial management from the moment a patient registers and at every step after. In the event of a denied claim, an EHR system can help you identify any deficiencies or errors in documents that would have caused the denial. Furthermore, it can facilitate timely resubmission after addressing the issues.
9. Reimbursement Follow-Up
To ensure that you’re not leaving any unclaimed revenue on the table, your EHR solution should help you follow up with insurance companies and government payers regarding any unpaid claims. By following up after the billing process, you can help patients avoid collections that are costly for everyone.
10. Patient Collections
After insurance payments, there may be an outstanding balance that the patient is responsible for paying. An integrated EHR system often identifies this upfront so you can let your patients know ahead of time what they will have to pay. Through built-in automation, EHRs can inform the patient of their patient responsibility amounts such as deductibles, copayments, and outstanding bills, and can also send out electronic remittance advice to help keep the revenue cycle moving.
11. RCM Reporting
Due to the complexity of funding sources and their various requirements, it helps to have an EHR with advanced reporting capabilities. Comprehensive financial reports help stakeholders understand your financial solvency as it corresponds to the revenue cycle. Reports provide insight into operational efficiency, patient collections, trends in claims denial management, and your reimbursement timeline.
12. Compliance Management
BHHS organizations operate in a complex regulatory environment and must comply with guidelines and requirements set by federal and state governments, accreditation bodies, and payers. EHR systems can play a significant role in ensuring regulatory compliance. They secure patient data with encryption, provide audit trails, and control access to sensitive information. EHRs can also facilitate accurate and compliant coding and billing, with built-in error-checking features and updates to coding standards.
13. Monitoring for Continuous Improvement
EHRs are your organization’s ally when it comes to supporting continuous improvement by offering real-time monitoring of the billing and RCM processes. EHRs can improve disruptions and inefficient workflows and identify areas for process improvement, which can lead to better efficiency and improved patient and employee satisfaction.
Unlock the Power of Efficient and Comprehensive RCM
For behavioral health organizations, navigating the intricacies of RCM is fraught with challenges. These challenges are made manageable by using a robust EHR system with advanced RCM features that cover the 13 steps of revenue cycle management.
With a deep understanding of the complex nature of behavioral health and human services, ContinuumCloud designed a multifaceted EHR solution that can be tailored to your organization’s needs.
From simplifying patient registration to streamlining the scheduling of appointments, automating charge capture, and ensuring rigorous claims denial management, our EHR solution covers each of the 13 steps of revenue cycle management discussed here.
To learn more about ContinuumCloud’s EHR and how it can help you experience a more efficient and profitable revenue cycle, connect with us today.