Transforming The Healthcare Revenue Cycle To Optimize Performance

revenue cycle in healthcare

According to the latest report by the American Hospital Association, since the year 2000, hospitals have provided approximately $745 billion in uncompensated healthcare to their patients. This means that nearly $745 billion’s worth of care was not paid for by a patient or insurer. This is an extremely significant gap in costs and revenue and has led to almost 30 healthcare facilities closing down every year across the country.

With such statistics, it is clear that it is up to healthcare providers to look for ways to optimize their payment collections process by transforming their healthcare revenue cycle.

Continue reading to learn more about how organizations in today’s industry are looking to transform the revenue cycle in healthcare.

What is the Healthcare Revenue Cycle?

The healthcare revenue cycle is a set of clinical and administrative processes in hospital billing that allow for the collection and management of revenue for the services provided to a patient. In simpler words, the revenue cycle in healthcare is everything that happens from the second a patient’s account with your facility is created to the moment your organization receives payment for the healthcare services you have provided.

As the fundamental financial circulatory system of any healthcare organization, the healthcare revenue cycle is an extremely complicated process involving several factors. Some patients may have no insurance and must be billed directly for the services rendered to them while others may be fully insured, in which case payment must be received from their insurance provider. In some cases, only a percentage of the patient service costs may be covered by the insurance company and thus both the insurance company and patient must be billed accordingly.

However, as complex as it is, the revenue cycle in healthcare is an essential component of any healthcare organization’s processes to maintain adequate cash flow and also ensure the financial stability of their facility.

The Need for Transformation of the Revenue Cycle in Healthcare

Healthcare organizations heavily rely on methodical and planned healthcare revenue cycle management strategies to effectively file medical claims and ensure that their facility is fully compensated for the services that they provide.

With the healthcare industry becoming more and more complex by the day, the revenue cycle in healthcare is about much more than just billing patients and collecting payments. Today, the healthcare revenue cycle is composed of several different stages starting from the minute any service is provided to a patient to the time when the hospital is reimbursed for the service it provided. These stages include:

  • Preregistration
  • Registration
  • Establishing Charges
  • Submitting Claims
  • Processing Remittance
  • Follow-Up With Insurance Companies
  • Patient Collections

These stages are designed to better manage the complex nature of hospital billing while also maintaining a healthy cash flow that allows hospitals to deliver the best standard of care to their patients.

With escalating demands and large volumes of revenue lost due to Covid-19 in recent years, traditional approaches to the revenue cycle in healthcare are simply not enough. In today’s complex landscape in healthcare, organizations need to not only focus on ways they can enhance the quality of care they provide but also look for ways they can enhance their healthcare revenue cycle to improve their bottom line and reduce inefficiencies.

With declining reimbursement rates, escalating costs and claims denial rates, increased complexity in coding, and a shift to value-based purchasing, healthcare organizations are constantly looking for new strategies to boost their financial standing. In today’s time, many of their efforts are centred on only reducing costs. However, these efforts will never prove to be fruitful unless these organizations pinpoint areas of inefficiencies in their revenue cycle in healthcare and break down the silos between their front-end and back-end processes to ensure a smooth and streamlined revenue cycle journey.

How Can Data-Driven Processes Help?

Data-driven healthcare revenue cycle processes are helping healthcare organizations in today’s time become more adaptable and resilient to the current changes in the ever-evolving healthcare industry. This is done by converting data into actionable insight that empowers them to optimize their daily processes and revenue cycle management.

Let’s take a look at how adopting a data-driven healthcare revenue cycle process can benefit your organization and its revenue cycle:

Reduced Denial Rates

Claim denials and their management alone cost hospitals across the country approximately $262 billion annually, significantly harming their cash flow and subsequently their bottom line.

Healthcare organizations can reduce this number by leveraging the power of analytics software that can analyse data from several different sources to identify the leading causes of the claim denials such as patient eligibility and missing claims data. Empowered with this insight, hospitals can better predict future claim denials and implement ways to prevent the denials from ever occurring in the first place.

If a claim is still denied, hospitals can leverage data analytics to also identify better procedures for recovering their denials and ultimately maximize their operating margins.

Revenue cycle analytics also provides practices with valuable insight regarding the effectiveness of their revenue cycle management processes such as claims submissions and denial management. With the help of key performance indicators, practices can better evaluate their processes and discover ways to improve them.

 Reduced Denial Rates

Increased Collections

In 2018, hospital bad debts amounted to almost $56.5 billion in the US. This statistic gives a brief insight into why healthcare practices need to adopt a data-driven approach to patient collection. With the help of data analytic tools, practices can create reliable predictive models that can anticipate the probability that a patient will pay their dues within a specific period. This can not only help the practice increase its overall patient collections but also avoid wasting resources on collections that have a very low probability of following through.

Reduced Revenue Leakage

Healthcare organizations generally lose about 1-5% of their revenue due to leaks in the revenue cycle. Every healthcare system has a process to identify the leaks in its revenue. However, not all of these processes are effective. Healthcare revenue management systems driven by data are the most effective way of combatting leaks in revenue.

Data analytic tools will take billing data such as billing code attributes and compare it with past data to examine the difference between them. This will help practices correct errors in their back-end processes and reduce possible chances of losing revenue. Over time, these data analytic tools will improve their analyses and give better results through the process of machine learning.

Improved DNFB Rates

Discharged not final billed (DNFB) accounts remain one of the biggest threats to a hospital’s revenue all across the country. These are unbilled accounts where the patient has been discharged by the healthcare facility but a final bill has not been submitted from the time of the patient-provider encounter. This may be due to many reasons such as inefficient internal review systems, gaps in coding, or inadequate documentation. Whatever the reason may be, DNFB cases present a significant challenge for hospitals and their revenue cycle.

With the help of robust data analytics software and a comprehensive automated auditing program, hospitals can significantly improve their DNFB rates. Data analytics applications can leverage your clinical, financial, and claims data to deliver detailed reports on inconsistencies in your workflows that may be negatively affecting your organization’s coding accuracy, data quality, and ultimately your revenue. Empowered by these insights, you can better identify the areas of your workflow processes that need improvement and work on creating more efficient workflows for your organization.

Because of the recent time’s mounting complexity in healthcare, organizations must work towards adopting more advanced processes to maintain their financial health so that they can meet the demands of their patients and stakeholders. Data analytics has the power to reveal critical ways in which organizations can improve their healthcare revenue cycle.

Tracking the Revenue Cycle in Healthcare with Key Performance Indicators (KPIs)

Now that we’ve established the importance of data in revenue cycle management, it’s time to take a look at how practices can track the health and efficiency of their revenue cycle with the help of key performance indicators.

By developing key performance indicators (KPIs), hospital leaders can track the performance of their revenue cycle and find ways to better allocate different resources and enhance its efficiency. Let’s take a look at some of the most important KPIs that provider organizations can use to measure their performance against their goals.

Days in Accounts Receivable (A/R)

When looking to assess the overall performance of your revenue cycle in healthcare, evaluating your days in accounts receivable can give you an insight into where your organization stands financially and give you an early warning sign of a potential crisis in cash flow.

But what are days in accounts receivable (A/R)? Simply put, your days in accounts receivable are the number of days on average it takes for your practice to get paid for its services. It is a measurement of how quickly your practice converts its outstanding payments into incoming cash.

Days in A/R is a critical KPI that helps to give an insight into the overall efficiency of your organization’s credit and collection efforts and how well you manage your accounts receivables. Monitoring this KPI will not only help you identify ways to improve your organization’s ability to collect payments but also assess how quickly payers process claims and pay the money that you are owed.

To calculate this KPI, first find your average daily charges by adding up the charges posted during a specific number of months and then divide those charges by the total number of days in those months. Then divide your practice’s total outstanding accounts by the average daily charges you calculated to get your average days in A/R. You want this KPI to be as low as possible for your organization to show that your practice is quick at collecting debts.

Denial Rate

Another useful KPI to monitor is your denial rate. It is the percentage of claims submitted to insurance payers that have been denied. A high denial rate can be catastrophic for your organization’s bottom line. Your practice’s denial rate gives insight into the efficiency of your claims processing system. A low denial rate shows that your organization’s cash flow is healthy and that more revenue is coming in while a high denial rate may be an indication of potential bottlenecks within your organization’s revenue cycle management process.

Divide the number of claims denied in a set number of months by the number of claims submitted within those months and multiply that by 100 to get your claim denial rate. While a denial rate below 5% is ideal, the average claim denial rate is around 5 to 10%.

Clean Claim Rate

Like denial rates, clean claim rates also help to identify any potential problems in the claims processing and submission procedure. It is a measurement of the number of claims successfully processed and reimbursed in the first submission. While errors are bound to occur and eventually do get resolved so that claims are reimbursed, improving your clean claim rate means reducing the amount of money spent on fixing these errors and resubmitting those claims.

To calculate the clean claim rate of your practice, divide the number of claims accepted in the first submission by the total number of claims submitted for billing. The average clean claim rate is 70-85% but every practice should strive for a clean claim rate greater than 90%.

Clean Claim Rate

Gross Collection Rate

Another important KPI is your gross collection rate which gives valuable insight into your organization’s payment collection process and cash flow. To calculate your gross collection rate, divide the money received from payments within a specified time by the total number of charges posted within that time. By studying the changes in your gross collection rate over the years, you can even predict what your future gross collections will look like.

Transforming the Revenue Cycle in Healthcare with AI and Automation

As AI tools and automation gain popularity, several different industries have started to use these advancements in technology to better optimize their processes and gain an upper hand over their competitors. The healthcare industry is no exception.

Recent developments in Artificial Intelligence (AI) have provided healthcare organizations with the necessary resources they need to tackle the common challenges faced during revenue cycle management in healthcare. Let us take a look at how automation, AI, and machine learning can enhance operational excellence and reduce inefficiencies in different stages of the revenue cycle management process:

Patient Registration

When a patient enters your facility, they meet your front-desk staff first and foremost, who are responsible for entering their data into your system. The greater the volume of patients you encounter daily, the greater the likelihood of an error to be encountered during this crucial first stage of the revenue cycle management journey. Robotic process automation (RPA) and Intelligent Character Recognition (ICR) solutions can be used to automate high-volume rote tasks such as data entry and minimize the risk of errors.

Eligibility Verification

Verifying patients’ insurance eligibility is a very time-consuming task, especially if done manually. Shifting to electronic verification of insurance eligibility with the help of a built or custom API can not only save employee time but also reduce the risk of claim denials significantly by minimizing errors in this process of the revenue cycle.


The pre-authorization process can have not only a major impact on your claim denial rates but also on the health of your patients. Delays in this process can cause delays in necessary patient care which may even lead to serious adverse events in their lives such as patient hospitalization, permanent disability, or even death. An AMA survey shows that 94% of healthcare providers have experienced delays in necessary healthcare at some point in their career because they were waiting for health insurers to authorize the necessary course of treatment.

However, the good news is that electronic pre-authorization systems through today’s digital technology can significantly speed up the process and reduce inefficiencies. This reduces the risk of adverse patient outcomes caused due to delays in care.  A new study by America’s Health Insurance Plans (AHIP) even investigated the effect of electronic pre-authorization (ePA) systems on the pre-authorization process. The report showed that the median time between a pre-authorization request submitted and authorization received was reduced from 18.7 hours to 5.7 hours when electronic pre-authorization systems were implemented.

Charge Entry and Coding

Medical coding solutions are designed to streamline your charge entry and medical coding procedures by bringing all of your data into one unified solution. This helps to bring down costs by eliminating the need for keystrokes by the coder and minimizing errors in data entry.

Automated coding tools can streamline the coding process and maximize your practice’s efficiency by automatically prompting healthcare providers with proper codes during the documentation process. Not only will this make the coding process in your revenue cycle much more accurate but also simple since providers will only have to identify the correct codes from a selection of codes while documenting a patient’s visit at the time of the encounter. Healthcare providers can sign off on charts almost instantly rather than having to interrupt the patient’s care to look for the appropriate codes or having to wait till the end of the day to finish coding and close patient charts.

Claims Management

The claims management process involves the use of lengthy spreadsheets, burdensome documentation workflows, and time-consuming manual data entry processes. Automation, on the other hand, focuses on streamlining data entry methods, eliminating cumbersome tasks and error-prone spreadsheets, and improving the documentation of claims so that you can improve efficiency and improve the quality of service you provide.

In addition, automated claim denial management systems can optimize your entire denial management process and provide you with real insights into why your claims were denied. Such as system would also be capable of quickly identifying the necessary claims that need to be resubmitted or appealed.

Payment Posting

One of the most integral parts of revenue cycle management, payment posting provides a picture of the insurance payments receivable as per the Explanation of Benefits, payments that are receivable from patients, and insurance checks that are to be received from ERAs. It essentially gives you a snapshot of your practice’s daily revenue stream and allows you to identify any errors in the payment process early on in the revenue cycle journey.

However, manual payment posting is not only costly and time-consuming but also prone to a number of errors. Introducing automation and taking a software-driven approach at this stage of the revenue cycle can significantly enhance the revenue cycle process and eliminate errors caused by manual data entry. Artificial intelligence-based ICR solutions paired with the automated reading of Explanation of Benefits and Electronic Remittance Advices can enhance accuracy and speed up the process significantly. The digital solution automatically reads the EOBs and ERAs in little to no time for each service provided to automatically prepare a sheet that you can tally later on.


Automated collection processes are not an innovation anymore but rather a norm in today’s complex healthcare industry. An online collections process powered by RPA-based solutions will not only reduce costs but also drive accuracy and speed at this stage.

Outsourcing Revenue Cycle Management

To say that the revenue cycle management process is complicated would be an understatement.

With ever-changing rules and regulations and infinite complexities, healthcare organizations are realizing the importance of outsourcing revenue cycle management in healthcare. Even outsourcing a segment of your revenue cycle management process can help your organization elevate its performance and focus on what matters the most: providing patient care. Allowing experts who are experienced and trained to manage the revenue cycle in healthcare and handle your processes allows you to fix issues within your workflows and streamline operations.

See Also: What Is Coding and Revenue Cycle Management?

The Bottom Line

Today’s healthcare industry demands a revenue cycle that exceeds all expectations. While a complete transformation of your revenue cycle in healthcare won’t be achieved overnight, a successful revenue cycle in the future depends on what changes and strategic decisions you make today.

If you want to take your revenue cycle to the next level and boost your organization’s financial standing, allow Precious Hub to be your RCM partner at every step of the way. With state-of-the-art technology-driven solutions and industry experts, we are here to manage the administrative aspects of your practice to help you focus on improving patient-focused care.

How To Improve Medical Coding Quality

medical coding tips

If you notice reduced coding quality on one of your department’s ends and incomplete or untimely reimbursements, there is a possibility of repercussions for your medical organization. In most cases, this results in a loss of revenue. For efficient revenue cycle management, it is imperative to train your employees to execute quality coding by utilizing available technology and staying updated.

Regardless of whether you run a small clinic or a huge healthcare facility, regular analysis of your coding department along with the implementation of the following medical coding tips will certainly boost your coding operations and speed up the revenue cycle.

Consequences of Low-Quality Coding

To avoid your medical practice from being a target for intense scrutiny by the agencies that are responsible for analyzing and evaluating medical fraud at medical practices, it is important to adopt accurate and high-quality coding. Failure to do so might cause your healthcare practice to face sanctions and other punitive damages.

Inaccurate coding practice makes it likely for the coding team to be held responsible for falsifying claims. This commonly results in a vast decrease in your firm’s monetary gain. If this sort of medical abuse is ongoing at your practice and there is consistent evidence of falsifying claims or incorrect coding over a long period, your practice is very likely to be held liable for medical fraud.

In such large-scale corporations, it is impossible to prioritize intent over actions. If you send incorrect submission claims to the insurance agencies or government organizations, such as Medicare, for reimbursements, your mistake can cost you the future of your medical practice.

As terrifying as it is to be charged with falsification of claims and hefty fines, the most common consequence of low coding quality is less scary. Neglect in adopting medical coding tips and implementing them in your coding routine is likely to have insurance companies reject your submission for claims reimbursement. Incomplete or no reimbursements bring about a downgrade in revenue and your medical practice may cause significant financial loss, which may never be reimbursed.

coding quality

Medical Coding Tips to Improve Revenue

One of the core challenges that medical corporations face regularly is dealing with decreased medical coding quality and medical coding errors. During the global pandemic, the coding departments all around the world suffered greatly due to the lack of communication in remote work. In the section below, we have provided a detailed guide to a few of the possible medical coding tips that can be implemented at your healthcare facility to generate better revenue.


For any person to focus on their work, their work must go uninterrupted or undisturbed. Statistics show that for an average person who is interrupted working on a specific task with a deep level of concentration, it takes around 23 minutes for them to go back to the work with the same level of concentration. Even in general cases, such as children studying, once the work/study pattern is interrupted, it takes a while to regain the temperament.

Employees should be strictly advised to turn off their phone notifications during the time they are at work to minimize distractions. This effectively directs most of their concentration on accurate and high-quality coding.

Hiring a Coding Team

If you are well established in the world of healthcare, you may consider hiring a team solely dedicated to coding work. An outsourced team that is essentially qualified for coding could better handle the specific documentation required to improve the coding at a healthcare facility.

An alternate to this medical coding tip is training your staff regarding electronic medical records or EMR practices. This way you can train a handful of your employees and designate them to the coding department. A thorough understanding of medical coding and the medical coding tips required to boost revenue across the providers, support staff, coders, and revenue cycle specialists drastically decreases errors in coding and improves coding quality.

Limiting The Coder’s Tasks

The coders need to be assigned coding tasks. Any tasks outside the scope of a learned coder would overshadow their skills and not allow them to work on coding at their full potential. Overwhelming amounts of tasks, especially non-coding tasks, are bound to be tiring and the coders may not be able to deliver quality coding.

Establishing Effective Communication

Establishing an effective communication system between the provider and coding team ensures prompt and proper documentation of medical procedures. Communication qualifies as a medical coding tip as it allows the staff to not miss out on any procedural actions and modify the workflow to result in quality coding. Amid the release of numerous coding updates, a healthy and practical communication bridge should be established between the staff and the coding team.

Effective communication helps in coding compliance and staying up-to-date with the changed coding guidelines for all payments. Accurate coding of the said procedures saves up a lot of time amongst the hospital itself and the insurance companies associated with it during reimbursements.

quality coding

Using Technology

In today’s world, a great medical coding tip is to utilize various computer programs available for this purpose. These not only can effectively analyze healthcare documents, but also identify appropriate medical coding for a specific concern. This fairly reduces any room for errors, which may occur if coding were not digitalized. Computer assisting coding (CAC) software is a great option if you are looking to eliminate extra paperwork, speed up the coding process, and get greater coder satisfaction. Additionally, utilizing technology in the coding department is likely to boost your coder’s productivity and hence, increase revenue.

Performing Audits

The practice of performing audits is mainly for medical services that prefer quality over productivity and every medical platform prefers that. A coding compliance audit establishes a process that brings forward errors or coding inaccuracies. These can be addressed promptly, which without audit compliance, would generally be missed in final coding submissions. Performing audits might slow down your coding process but the speed would naturally have no merit if your codes were full of inaccuracies.

Explain to your coding department how their final goal of adopting all these medical coding tips and strategies is a sign of incoming and continuous professional growth, which is likely to have a largely positive impact on your revenue cycle.

Staying Up-To-Date On the Changes In Healthcare

Updates in ICD-10, HCPCS (health common procedure coding system), and CPT occur on an annual basis. Keeping track of every development in the world of coding, as slight as it may be, is imperative for accurate coding and billing. If your team or coding department fails to stay on top of every update in the coding guidelines or procedures, chances are you may risk losing scores for reimbursements. The cost of patient care is likely to get a feasible result following a deep understanding and implementation of new reporting guidelines and value-based care.

See Also: Everything You Need To Know About Urgent Care Coding Updates In 2022


To ensure high-quality coding, you must work to promote audit quality, and medical credentials, and provide sufficient training to your coding team. Precision Hub, along with the above-mentioned medical coding tips, offers you the best medical coding and billing services to improve the standards of patient care and increase revenue.

Accountable Care Organizations’ Pros And Cons And Their Challenges

accountable care organizations

Accountable Care Organizations are growing rapidly and are increasingly being recognized as a valuable part of the healthcare landscape. In a traditional payment system, providers are paid for every test, procedure, or service they provide, regardless of whether the patient needed it or not. ACO uses alternative payment models, such as capitation, to ensure that patients are receiving the best possible care.

With a huge 30% of healthcare spending considered wasted, there are many advantages to establishing an ACO. Compared to the current fee-for-service system, this new healthcare model helps reduce costs and improve quality care across the healthcare sector. They seek to improve patient engagement and clinical proficiency resulting in reduction of costs.

However, the current system has many problems. Accountable Care Organizations are not free from controversy. Moreover, there are financial incentives that can make them unpopular, and data challenges that need to be addressed. Considering the Accountable Care Organizations’ pros and cons is essential before making the final decision.


In the past few years, there has been much talk about Accountable Care Organizations (ACOs), and for good reason. ACOs have shared savings models in which payers and providers make arrangements to share the cost of care.

In exchange for sharing their cost data, healthcare providers receive a bonus if their costs stay below a set amount. ACOs are also subject to quality targets, so providers must meet them to receive bonus payments. ACOs don’t limit patients’ choices of doctors. Moreover, patients remain free to choose any other doctor they wish to see, and they are not locked into an ACO’s network.

The operating costs of an ACO vary widely. High-performing ACOs prioritize data interoperability and analyze claims data to identify opportunities to improve patient care and reduce system leakage.

While ACOs can build their own analytics tools, the cost of these utilities depends on the number of participants. On average, building analytics solutions in-house requires $24M upfront development. Annual costs for hiring analysts and data scientists are $6M.

Similarly, savings derived from ACOs vary greatly. The most commonly reported measure is the utilization savings. This measure reflects changes in provider patterns and relates to the ability of new payment models to improve healthcare utilization. However, it is important to remember that these savings are not purely internal and are shared between the payer and the ACO. They also tend to be lower than the savings from an ACO’s utilization. But the benefits of Accountable Care Organizations cannot be overlooked.


While hospitals and doctors’ groups claim to provide quality care, the question of how to define it is a difficult one. ACOs are a model of integration, designed to avoid the problems of previous efforts. Historically, ACOs were clustered around large hospitals, but these organizations have increasingly turned to doctor’s groups as their nucleus.

Primary care physicians, for example, understand patients better than most other physicians and are more likely to provide appropriate care. Pioneer ACOs include Atrius, a non-profit organization that has partnered with 32 hospitals and physicians to develop an organized care system for the purpose of sharing cost savings.

Pay-for-performance incentives are another important part of the ACO payment structure. While healthcare providers receive fee-for-service payments throughout the performance period, payers adjust those payments based on quality performance. Quality performance also determines eligibility for shared savings payments. Financial risk plays a key role here because ACOs tie payments to quality and hold providers financially responsible for their health care costs. The ACO payment structure requires physicians to provide higher quality care at lower costs.

Despite the many benefits of Accountable Care Organizations, it is difficult to implement a meaningful ACO without a strong reimbursement model. The reimbursement model, as designed by the Affordable Care Act, requires the healthcare system to bear the financial risk for quality care.

Financial Incentives

There are many financial incentives for accountable care organizations, including higher reimbursement and the opportunity to reduce costs. ACOs are more likely to be larger, have multiple payer contracts, and include a hospital.

However, the benefits of an Accountable Care Organizations contract go beyond financial incentives. For example, financial incentives may increase provider productivity and lower the cost of care by reducing hospital stays and emergency room visits. This is a significant goal for many providers, but ultimately, it will require a transition beyond ACOs to full financial responsibility.

ACOs have several types of members. Some are managed by insurers, while others are governed by physicians. Typically, the insurer is the sole payer for primary care, but a few ACOs receive capitated payments for all other care. Most of these ACOs are physician practices or hospitals with a long history of value-based care programs and an excellent track record of providing quality patient care. The current model is temporary and expires in 2026. ACOs are expected to serve two to three million Medicare patients by that time.

ACOs may choose to offer physicians financial incentives in exchange for quality scores. These measures can help reduce readmissions and improve hospital-physician alignment. In fact, many studies have indicated that ACOs can reduce leakage by as much as 10 to 30 percent. These programs can also extend to other parts of the healthcare system. So, why do hospitals want to be an ACO? Because they will receive more reimbursement and care management, they may want to invest in them.

As the ACO model begins to take shape, a number of challenges remain. The fundamental assumption underlying ACOs is that doctors work primarily for money, and this is an unproven assumption.

In reality, however, most physicians are motivated by other factors, which behavioral economists call intrinsic motivations. The incentives that come with an ACO undermine these intrinsic motivations. Ultimately, ACOs may encourage better quality care by promoting more integrated care and more efficient health services.

Data Challenges

The ACO model requires care providers to shift away from the siloed, disconnected nature of traditional medicine toward a coordinated, team-based approach. Health information technology is a critical enabler of the transition to the ACO model, supporting efficient data collection, analysis, and exchange.

Despite these improvements, data access remains a major challenge for ACOs. Identifying care gaps and tracking progress against program benchmarks require comprehensive data aggregation and analysis. Wait times can impede optimal performance.

The MSSP program requires that ACOs achieve financial and quality targets. These benchmarks are calculated by averaging historic expenses and risk-adjusted costs for an attributed population of patients.

While the ultimate goal of an ACO is to increase quality and lower costs, ACOs must successfully manage data to achieve these objectives. Some health systems refuse to share information and are resistant to ACOs’ requests for it. Moreover, Internet bandwidth and the adoption of electronic medical records vary widely across rural areas.

The ACOs also face a lack of standardized EHR systems. They would benefit from a single infrastructure that would integrate data from all participating providers. However, this is unlikely to happen unless member organizations work together to develop an infrastructure to synchronize data from multiple systems.

Data exchange technology could help ACOs achieve greater coordination and patient safety. Moreover, third-party payer investments in health information exchange technology could promote information sharing and analytics across multiple systems.

Accountable Care Organizations are built on collaboration and information sharing. These organizations are made up of various care sites and providers. They are typically a complex collaboration between care sites and providers, juggling different technologies and vastly varying levels of health IT sophistication.

The Pros and Cons of Accountable Care Organizations

The proponents of Accountable Care Organizations argue that they improve the quality of health care, increase access to quality providers, and decrease costs. But what are the cons?

As a healthcare provider, you may be wondering whether you should join one. If you are considering this option, you must be aware of the pros and cons of ACOs. The Medicare Shared Savings Program is the predominant model for ACOs in the U.S. ACOs are collaborative partnerships between providers who share patient records and cost information. The teamwork between providers cuts down on unnecessary testing and costs.

In addition, patients receive a care coordinator who ensures providers know what services they need. Patients will not have to repeat medical histories and undergo retake exams. Moreover, ACOs can result in significant cost savings, but only if the healthcare providers are willing to take on more risk.

Although the pros of Accountable Care Organizations outweigh the cons, the debate is still raging. Some providers are opposed to the idea, and others are recommending against it. The pros of Accountable Care Organizations are largely based on how they benefit patients. This new model involves grouping hospitals and other health care providers together to coordinate high-quality care for a large number of Medicare patients.

Among the pros of Accountable Care Organizations is reduced cost. It allows providers to focus on ensuring that patients get high-quality care, prevent medical errors, and cut unnecessary tests. It also reduces the burden on health care payers, since the ACOs are held financially responsible for the total costs of the patients they serve. In addition, if they can reduce costs through collaboration, they can receive a share of the savings. On the downside, ACOs can suffer losses if they go over budget benchmarks.

  • Ease of Use

ACOs help providers access and share critical patient information with other healthcare providers. This results in less paperwork and fewer hardcopy transfer of data. Electronic health records include CAT scans and MRIs, so collaborating with providers in an Accountable Care Organization can greatly benefit a patient’s health. However, the cost of building IT infrastructure can be prohibitive for some providers.

  • Risk-bearing Contracts

An ACO’s success depends on its ability to track its patients. In a risk-bearing contract, physicians must track patients from various facilities. As such, ACOs must develop data analytics and health information exchange capabilities.

See Also: 5 Most Common Billing Errors in Healthcare


ACOs are more than just a network of healthcare providers. The goal is to optimize the quality of care by analyzing data, eliminating gaps, and coordinating care across the healthcare continuum. Ultimately, they aim to increase patient safety and reduce costs while delivering better outcomes for healthcare dollars spent. Most ACOs comprise hospitals, specialists, nursing homes, and other healthcare facilities. And they may also reduce access to care for certain populations.

Are you looking for a reliable medical billing and coding solution? Precision Hub is a leading RCM consultancy dedicated to improving your medical practice through data-powered solutions. To learn more about our services, subscribe to our periodic newsletter.

The Fundamentals Of Pharmacy Billing And Reimbursement

pharmacy billing process

Understanding how the revenue management cycle works in a pharmacy is vital to navigating the nuances of the pharmacy billing process and reimbursement. While medical coding and billing ensure that patients and payers reimburse the healthcare providers for the services availed, pharmacy billing and reimbursement focus on payment collection on the provision of prescription medicine by the pharmacy as the pharmacist’s compensation.

In pharmacy billing and reimbursement (PBR), both the pharmacy and hospital outpatient department are part of the reimbursement process. The physician, for instance, writes the prescription and orders the drug on behalf of her/his patient. The pharmacist, on the other hand, completes the order by issuing the drug to the physician, and bills the insurance company for it.

In due time, the prescription is accepted by the health insurance company. The payer compares the charges to the patient’s benefit plan to determine how much the patient owes or what the insurance plan will cover. Information is then returned electronically to the pharmacy. The claims adjudication in a pharmacy takes place in a matter of seconds. This process helps to prevent errors and delays in reimbursement.

Managing the flow of pharmacy billing process, from entry to reimbursement, can be challenging. Nevertheless, understanding and efficiently handling the various stages of the pharmacy billing process is key to improving both income outcomes and patient care.

The Costs of Providing Pharmaceutical Products

The U.S. pharmaceutical industry spends $83 billion a year on research and development (R&D) of new drugs. Many of these drugs have valuable medical benefits. However, they are also very expensive, contributing to the rising cost of healthcare. Many policymakers have considered lowering drug prices and reducing federal drug spending, but those policies would reduce the industry’s incentive to develop new drugs.

Currently, the cost of brand-name prescription drugs is on the rise due to manufacturers raising prices for their current medications and the entry of new ones. An assistant professor at the University of Pittsburgh School of Pharmacy, Inmaculada Hernandez, compiled data on the price of 27,000 prescription drugs.

According to her research, the price of brand-name oral and injectable prescription drugs increased on average by 9% per year between 2008 and 2016, as compared to the general inflation of only 2% in the same period. It is, therefore, crucial to identify and address what is driving up costs for providing drugs to patients.

The Costs of Providing Pharmaceutical Counseling

The costs of providing pharmaceutical counseling vary greatly. Some costs can be avoided entirely, while others are reduced or eliminated altogether. One example is cost avoidance, where a pharmacist can suggest discontinuing a potentially inappropriate medicine and saving the patient the cost of hospital admission or referral to a physician.

Other costs can be avoided or reduced to a large degree, such as by eliminating the actual cost of the medicine. These savings, however, are often less apparent than the potential costs of not providing pharmaceutical counseling.

Another method of reducing the cost of medication is by engaging clinical pharmacists. Research has shown that engaging pharmacists is an effective way to reduce the number of prescriptions written and the costs incurred. For example, engaging pharmacists in the clinical setting can help hospitals avoid the negative financial consequences of improper medication administration and lead to better quality care for patients. The effective use of pharmacists in the healthcare team requires that physicians view them as full-fledged practitioners.

adjudication in pharmacy

The Pharmacy Billing Cycle

Obtaining a National Provider Identifier

Obtaining an NPI is an important step for pharmacy businesses. In order to be reimbursed for pharmacy services, a business must have an NPI. A business can obtain more than one NPI, such as if it is involved in both OCD (over-the-counter dispensing) and DME (durable medical equipment). However, if the business has a combination of both, it may only need one NPI.

The National Provider Identifier (NPI) is a 10-digit identification number issued by the Centers for Medicare and Medicaid Services to all health care providers. This number is used in health care claims and electronic health records, and it may be tied to notes made by the provider. In addition to health care claims, NPIs are also increasingly being used to match providers to data.

Getting a Detailed Contract

If you’re looking to improve your revenue and increase your profitability, it’s crucial to get a detailed contract for pharmacy billing and reimbursement services. The current state of health care has made it necessary for pharmacy practices to bill for prescriptions.

According to the latest statistics, $325 billion of prescriptions are paid for annually, and this number is only expected to increase after the Patient Protection and Affordable Care Act takes effect in 2018. The current process involves entering patient information and processing insurance claims. A pharmacy’s billing and reimbursement services should make this process as smooth as possible for both patients and pharmacists.

When choosing a third-party administrator, get a contract that outlines the process. The contract should outline what each party will do and will not do to ensure payment of prescription services. It should define which fees are included in the reimbursement process.

This document should also address 340B pharmacy fees, which apply only to independent pharmacies. To get the most out of the partnership, focus on the most important parts of the contract. Each decision may have an impact on inventory, cash flow, and financials. It’s best to have everything work in harmony to ensure a smooth operation.

Getting Paid For Services Rendered

If you’re a pharmacy provider, you’ve probably heard of the many challenges that come with billing and reimbursement. It’s an important part of the pharmacy business, but not everyone is ready to take the plunge.

The first challenge you’ll face in the pharmacy billing process is figuring out how to bill for services rendered. Because pharmacists are not federally recognized as medical providers, they must work within the legal system of their state.

This requires them to use the CPT/ICD-10 codes for medical provider services when they bill for clinical care services. They must also track the outcomes of these services, register with a National Council for Prescription Drug Programs database service, and implement a professional pharmacy billing software such as QS1.

Strategies to Improve Revenue Cycle Management

Managing the revenue cycle is an important mission-critical activity for all healthcare providers. When performed correctly, revenue cycle outcomes impact the quality and efficiency of patient care, including clinical documentation, timely reimbursement, and communication between payers and providers.

Over the last decade, many healthcare organizations have automated RCM processes, leading to greater efficiencies and improved patient experiences. However, significant challenges remain.

Implementing new technology and processes can help improve the overall efficiency of the revenue cycle. In addition, hospitals should ensure that their formularies meet the requirements set forth by payers. These changes should be implemented at the earliest possible time to maximize the financial and clinical value of their medicines.

In addition to implementing new technology, pharmacies must ensure that their processes capture maximum revenue and minimize the risk of losing reimbursement. To do this, pharmacists must understand the demands of the payers and develop processes to ensure that they are compliant.

adjudication pharmacy

Tips for Pharmacy Billing and Reimbursement

Pharmacists must understand how to manage the pharmacy billing process and reimbursement to maximize profits. The cost of dispensing a prescription and the total reimbursement rate determine the profit of a pharmacy.

Pharmacy revenue depends on both. This is why pharmacies need to be very careful in determining the cost of a prescription.

Proper documentation is required for every prescription. It is important to collect information from the patient and the prescriber, including insurance and DEA numbers (Drug Enforcement Administration). Pharmacy claims must contain accurate information to avoid denials by insurance companies.

Pharmacy workflow includes planning the entire process from ordering from a wholesaler to delivering a claim to the patient. To avoid a delay in payment, the pharmacist must have accurate information at all times.

Paying patients directly is possible in many circumstances. Many patients have private insurance or Medicare. However, a large portion of the U.S. population is uninsured or underinsured. While the percentage of patients paying directly for prescription drugs has declined since the passage of the Medicare Modernization Act, it still exists in some instances.

In such cases, pharmacy reimbursement formulas are similar to those described above. The patient is ultimately responsible for the amount of money he or she pays for a drug. Sometimes this is referred to as the “usual and customary” price.

Pharmaceutical goods are reimbursed in one of three ways: private insurance, public insurance, or cash. Private insurance plans are provided by the employer or family member. Individuals can also purchase insurance through the government or buy a health insurance plan themselves.

Public insurance, meanwhile, is provided by the government and subsidized by the government. If an individual does not have health insurance, he or she may pay for the drugs themselves.

See Also: Avoiding Prior Authorization Denials

The Bottom Line

The healthcare industry is complex. There are numerous layers of data handling and the complexities of the revenue cycle involved. Pharmacy claims may be distinct from hospital claims and may have HIPAA compliance requirements.

Consequently, pharmacists should understand how to manage this revenue cycle to ensure optimal patient care. If they are unsure about the proper way to bill patients, pharmacy management software can help. It is the best way to avoid pitfalls.

While pharmacists are increasingly becoming involved in clinical care, the pharmacy billing process and reimbursement process is not always flexible. The process can cause big losses in revenue, practice, and patient satisfaction. As a result, pharmacists should be aware of these risks and implement a flexible billing system.

A pharmacy management solution like revenue cycle management can streamline the billing process by providing comprehensive tools to optimize reimbursement for covered items. It is also the best way to stay up to date on new guidelines and regulations.

At Precision Hub, we offer end-to-end solutions for healthcare providers and pharmacists to help them meet their revenue goals. From BI tools and reports to coding services to finance and accounting, we provide complete revenue cycle management solutions to help you unlock the benefits of professional pharmacy billing and reimbursement.


Avoiding Prior Authorization Denials

authorization denial

The prior authorization process haunts physicians and steals the precious time that could be spent on delivering quality care. Authorization denials hinder the care process by delaying the necessary service delivery.

The survey by AMA, i.e., the American Medical Association, reveals eye-opening statistics related to the burden of prior authorization faced by American doctors. As raised by prior authorization, the administrative burden of healthcare practices damages providers and slows patient care. According to the survey results, medical practitioners complete 41 prior authorizations per week and spend an average of 2 days per authorization. 88% of respondents deemed prior authorization a high hardship. 940 out of 1,000 physicians had to wait longer to assist their patients owing to prior authorizations (PA), and 8 out of 10 physicians indicated that their patients discontinued treatment during the delay.

Despite healthcare providers’ efforts to limit the amount of prior authorization claim denials, insurance companies continue to seek authorization for new consultations and procedures. Consequently, the number of denied claims has grown.

Do you also face difficulty related to prior authorization denials that disrupt the whole process of your workflow?

Let’s explore everything about authorization denial here. This article also discusses the types of authorization in medical billing.

Authorization Denial

In medical billing, “authorization” refers to the payer’s agreement to pay for specified treatments before execution. These services are also referred to as preauthorization and prior authorization. As the name suggests, the insurance provider must authorize the planned treatment or service. Failure to do so leads to authorization denial.

A variety of procedures require insurance company approval before they can be performed. When determining an individual’s eligibility for insurance, it is necessary to establish whether some services require prior authorization. The request will be made based on the patient’s health insurance coverage. Before granting coverage, insurance companies must approve requests for necessary medical treatments and benefit conditions. The preauthorization number must be included on the final claim form submitted following the treatment. Preauthorization is a component of medical billing that guarantees claims are processed efficiently and error-free. If there is no pre-approval, invoices are not paid.

Let’s find out the reasons for authorization denials and how to avoid them:

Claim without

1. Claim without Prior Authorization Number

Automated systems process the claim; if there is no prior auth number, the system denies it. A manual check is necessary to prevent authorization denial because of a lack of numbers. Double-checking the claim before submitting it is a good practice to save time and money.

2. Claim with only one Pre-Approved Service

A claim can be refused because just one of the claimed services was authorized beforehand. Personnel responsible for billing and coding must pay special attention to all services specified on a claim. Staff members responsible for billing and coding must cooperate with providers to ensure that providers understand which services require prior authorization and that all authorizations are received before the delivery of services.

3. Failure to Obtain Authorization Prior Treatment

It might be challenging when you need to treat a patient in an emergency and do not have time to seek pre-authorization. It is particularly significant when the patient’s condition is critical. In an emergency, payers are typically more likely to cooperate. On the other hand, they are typically quite rigid regarding non-emergency care.

4. Incorrect Claim Process

The incorrect processing of the claim by the payer leads to authorization denial. It is thus crucial to identify why the claim is wrongly processed. Warranting the reason is vital for preventing it. Identifying the error’s reason helps in the future by avoiding the mistake.

Incorrect Claim Process

Types of Authorization in Medical Billing

The common types of authorization in medical billing are prior and retroactive authorization.
Retroactive authorization requests the payers for approval after the treatment is provided. It is provided in emergencies when the patient is mostly unconscious and immediately needs the service.

Prior authorization, as explained earlier, is the approval made before the provision of treatment or service.
Medical practitioners and organizations can take several measures to make managing pre-authorizations easier. Since insurance companies modify the requirement for pre-authorizations depending on the standards, healthcare providers must remain current on the constantly changing clinical criteria for each illness state. When a patient orders a prescription drug in a manner that deviates from the norm, they are frequently required to receive prior approval from their health insurance company. In this case, preparing a list of the medications and treatments covered by each plan may be useful. These lists can also be incorporated into an electronic health record to alert physicians if they seek something that requires prior approval. Delays can be reduced in patient care by remaining up-to-date with insurer policies and formularies.

It may be advantageous to reduce the time doctors spend on the phone with insurance companies by designating and training individual staff to handle prior authorization requests. Having a Prior Authorization Certified Specialist on the team to aid with the administrative procedure is advantageous in multiple ways.

It is essential to establish effective documentation policies. The approval procedure will be a lot quicker if you maintain track of everything you’ve attempted in the past. Long-term maintenance of detailed records of past authorization requests can help facilitate renewals.

See Also: Billing And Coding For Pulmonary Procedures


Doctors strive to deliver the best possible care to their patients as quickly as possible while ensuring that their treatment options are effective, legal, and cost-efficient. Prior authorizations and claim denials are time-intensive procedures that might delay emergency medical care. However, outsourcing this complex process to Precision Hub (PH) can save time and energy. We are among the leading medical billing firms in the industry to handle all your prior authorization needs.

PH is an all-inclusive revenue management solution for the physician in the US. We aim to improve the financial health of your practice. Our experts are proficient in handling denied claims and preventing them in the future. It helps your practice generate more money.

With our years of experience in medical billing and coding, we build a solution to your clinic’s specific needs. Get in touch with our experts at Precision Hub to learn more about how we help manage authorization denial or support your medical practice.


Improving Pain Management Services For Patients

icd 10 codes pain management

Following the global pandemic, healthcare facilities all over the world have suffered chaos and the loss of an adequate system in various sectors. The efficiency that has entailed in the regular measurement and analysis of different medical departments has led to decreased revenue and patient satisfaction. Even before the world was hit by COVID-19 and its multiple variants, around 80% of patients in the United States faced inadequate postoperative and persistent pain management services. With ICD 10 codes for pain management, the documentation for pain has been made easier, paving way for further improvement in pain management services.

What Are Pain Management Services?

Pain management specialists may provide pain management services in healthcare setups via at-home remedies, exercise, lifestyle changes, medications, procedures, counseling, and therapy. Pain management involves documentation for pain and devising a treatment plan, which involves the adoption of a singular approach or a combination of several approaches, to reduce or relieve pain.

You can see a pain management specialist for any sort or degree of pain you may be experiencing. The time till pain relief depends mostly on the cause of pain and the type and duration of treatment received.

ICD 10 Codes in Pain Management Services

One of the most frequent findings in healthcare systems that lack proper pain management is inefficient documentation for pain. During this process, ICD 10 codes for pain management are often wrongly entered or misinterpreted. A few of the most common ICD 10 codes used in pain management services include

Ankle / Foot

  • Plantar fasciitis – M72.2
  • Tarsal tunnel syndrome – G57.50

Back (Thoracic, Lumbar, and Sacral Spine)

  • Low back pain or Lumbago – M54.50
  • Lumbar herniated disc – M51.26
  • Lumbar radiculopathy (radiculitis) – M54.16
  • Lumbar spinal stenosis – M48.061
  • Lumbar spondylosis without myelopathy – M47.817
  • Lumbar sprain – S33.5XXA
  • Thoracic Sprain – S23.3XXA
  • Vertebral fracture (pathologic)


  • Golfer’s elbow or medial epicondylitis – M77.0X
  • Tennis elbow or Lateral Epicondylitis – M77.1X

Hand / Wrist

  • Carpal tunnel syndrome – G56.0X
  • Cubital tunnel syndrome or Ulnar neuropathy – G56.2X

Head / Face

  • Headache or Occipital neuralgia – R51.9 , M54.81

Hip / Pelvis / Thigh

  • Hip osteoarthritis – M16.0 ,  M16.1X
  • Piriformis syndrome or mononeuritis – G57.0X
  • Trochanteric bursitis or Gluteal / Ischial bursitis – M70.6X


  • Knee osteoarthritis – M17.X

Neck (Cervical Spine)

  • Cervical herniated disc without myelopathy – M50.2XX
  • Cervical radiculopathy or Radiculitis – M54.1X
  • Cervical spondylosis without myelopathy – M47.812
  • Cervical spinal stenosis – M48.02
  • Neck pain or Cervicalgia – M54.2


  • Chronic pain syndrome – G89.4
  • Peripheral neuropathy – G60.9


  • Glenohumeral (shoulder) Osteoarthritis – M19.01X
  • Subacromial bursitis – M75.5X

Repercussions of Poor Pain Management

Repercussions of Poor Pain Management

Pain could be classified as postoperative, psychological, functional, inflammatory, or neuropathic. Inadequate management amongst any of the above-mentioned pain classifications is common in the U.S. and is widely associated with multiple negative consequences. All of these combined are known to adversely affect the patient’s scope of recovery and quality of life.

Chronic pain

Inadequate management of acute or any degree of pain could result in chronic pain. Mismanagement as a result of irregular follow-ups or incorrect entries of ICD- 10 codes for pain management in postoperative pain results in chronic postoperative pain. This mismanagement could either be failing to follow up on the patient’s condition or failing to record an adequate dose of painkillers or sedatives for the patient.


Persistent pain could likely result in impairments in muscular function, immune function, and wound healing. It could also cause malfunction in:

  • Cardiovascular system, leading to diseases such as coronary ischemia and myocardial infarction
  • Pulmonary system, leading to diseases such as decreased vital capacity, hypoventilation, and pulmonary infection
  • Gastrointestinal system, leading to diseases such as reduced motility, nausea, vomiting, and ileus
  • Renal system, leading to diseases such as increased urinary retention, oliguria, and sphincter tone

Impaired Function

The normal functioning of someone suffering from persistent pain is greatly affected. The impact of impairment is relative to the severity of pain of the patient. People who endure postoperative pain due to poor documentation and mismanagement are likely to show a significant decrease in their mental health and physical and social functioning. Many patients face interference with their sleep cycles, and hence experience altered emotional states and unusual mood swings, impairing their social life.

Prolonged Opioid Use

Incessant and poorly documented pain during a course of treatment or after surgery may include extreme dependency on opioids or analgesic medications if they are required in large doses or for prolonged periods. Although these medications show the best results in minimizing and controlling the pain effectively, their doses should be limited to prevent any short or long-term side effects. Prolonged opioid use may result in addiction, nausea, vomiting, respiratory depression, bowel dysfunction, etc. These not only prove to be a substantial burden on the quality of life but also show the record of consistently increased hospital costs and prolonged stays.

Effects on Quality Of Life

Poor documentation of pain regardless of the ICD 10 codes for pain management potentially impairs sleep and takes a toll on the patient’s physiological and psychological health. The patient may suffer from sudden weight loss, loss of appetite, demoralization, and bouts of anxiety.

Ways to Improve Documentation for Pain Management Services

The idea of improving documentation for pain management consists of assessing and reassessing interventions that aim to individualize care. The following means ensure effective documentation system for pain.

Adopting Electronic Means

Electronic medical records are the best way to improve documentation for pain management. With electronic records, little to no room is left for errors in data input and coding. The ICD 10 codes for pain management are entered, analyzed, and extracted correctly to further aid this process. Electronic medical records help doctors and pain management specialists to keep track of data.

Effective Communication

Effective Communication

Communication between the physicians, nurses, and the administrative department is essential to improve documentation for pain management. A medical examiner is required to engage with the patient in a friendly and welcoming manner to establish trust. This enables the patient to confide in his/her doctor completely about their medical condition or symptoms. With a thorough medical examination, healthcare facilities potentially reduce their chances of making errors in the documentation of pain management services.

For patients who are unable to communicate the intensity or location of pain, the doctors are advised to carry out behavioral and physiological assessments to make accurate conclusions and diagnoses. These include interpretation of behavioral changes, such as facial expressions, sounds of cries, tears, negative shifts in mood, and/or stiffness in limb movement.

Assessment Tools

An accurate assessment of pain should be documented comprehensively while preventing any errors in ICD 10 pain management coding and billing. This assessment likely includes pain history, location and radiation pattern of pain, and the pain intensity. In many cases, pain scales are used where the patient is asked to rate the intensity of their pain on a scale of 1-10.

Other methods of assessment include lengthy questionnaires, which cover a wide range of pain dynamics the patient is feeling. Some of these are sophisticated and include a body outline, where the patient is required to shade the area of pain. Others may be far simpler, including a numerical scale or verbal indicators.

See Also: How To Improve The Patient Registration Process To Enhance Patient Experience


The most common cause of patients receiving inadequate consultation or treatment for pain relief stems from improper documentation. In many cases, inaccurate entry of ICD 10 pain management codes in patients’ medical records and poor assessment of pain is the source of inappropriate dosage prescriptions and intervals. However, this can be changed by adopting effective strategies to ensure the correct entry of ICD 10 odes for pain management.

At Precision Hub, we explain to you how proper medical coding and billing can be ensured at your healthcare facility to prevent any loss of revenue. Check out our website where you can find RCM consultants, who work with you to deliver patient-centered care.

Provider Credentialing Guide 2022

provider credentialing process

If the Covid-19 pandemic has taught us anything, it’s that not all heroes wear capes. Frontline healthcare workers have proven themselves to be heroes in the fight against the Covid-19 virus and even before the pandemic, healthcare was ranked as one of the most respectable and trusted occupations. But what makes this profession so trustworthy?

Patients consistently choose to place their trust in their healthcare providers, thanks to a trusted system of checks and balances. This system ensures that their healthcare providers have the necessary credentials required to offer adequate healthcare. Healthcare providers who wish to work at a healthcare facility are required to undergo a comprehensive vetting process called provider credentialing.

Continue reading to learn more about the provider credentialing process and steps in provider credentialing used by healthcare facilities to ensure that all their providers have the qualifications required to carry out their duties responsibly.

What is the Provider Credentialing Process?

While many people think of the patient and healthcare provider’s relationship to be a one-to-one relationship, several hospital operative functions not only contribute to but also share the responsibility of ensuring their patients’ safety. This is done via a rigorous verification of the providers’ skills, licenses, qualifications, and history, including their professional and educational background, known as the provider credentialing process.

All providers looking to gain practicing privileges must first undergo the provider credentialing process to assure healthcare organizations that they are competent enough to provide top-quality and safe healthcare services at their facility.

Provider credentialing is quite a time-consuming procedure that can take anywhere between two to three months, so make sure to start the process way before you intend on beginning practice. Even the slightest mistake in the provider credentialing process can lead to significant delays, which can keep healthcare providers from doing what they do best: provide quality care.

Why is the Credentialing Process in Healthcare Important?

Before we delve into the provider credentialing process in detail and its steps, let’s first discuss why the credentialing process in healthcare is so important?

The credentialing process in healthcare validates a provider’s credentials that reflect extremely well on their resume. It enables patients to trust their healthcare provider knowing that they are a qualified professional who is a part of a reputable medical association.

Apart from validating that a healthcare provider meets the necessary standards required to deliver high-quality clinical care, provider credentialing is a crucial process needed to process insurance claims. The credentialing process allows providers to enroll within a wide range of insurers’ networks. If healthcare providers fail to undergo the credentialing process, these insurance payers may refuse to reimburse them for the services they have rendered.

Apart from this, credentialing isn’t a one-time procedure. It’s an ongoing process that requires providers to be re-credentialed every few years. This ensures that providers continue to remain fit within the insurer’s network and are still capable of doing the job. In turn, this reduces the risk of medical errors and enhances the quality of healthcare services provided to patients.

Steps in Provider Credentialing

As we discussed, provider credentialing can be quite a tedious and cumbersome process. However, breaking down the procedure into a few quick steps can significantly simplify the procedure and ensure that your providers receive their clinical privileges timely.

credentialing process in healthcare

Here are the steps to follow in provider credentialing:

  1. Identifying the Documents Needed

Before you can start the verification process in provider credentialing, you must first identify the documents you will need from the provider to verify their credentials. Each insurance payer has different requirements and requires different documents for credentialing a provider. These include documents such as:

  • Proof of licensure
  • Insurance proof
  • Driver’s license
  • Social Security card
  • Personal information such as email address, street address, phone number, ethnicity, gender, citizenship, etc.
  • Career history
  • Copy of National Provider Identifier (NPI#) documentation and confirmation letter
  • Education and residency information
  • UPON number
  • Federal Tax ID number
  • History of past malpractice claims
  • Permanent Resident Card, Green Card or visa status for non-US citizens
  • Residency diploma
  • Current CME (CME activity for the past three years)
  • ACLS/BLS certification
  • DEA certificate

Make sure that you have all the necessary documentation required by each insurer your organization works with. Even a single missing document can delay the procedure by weeks or even months.

  1. Prioritize Insurance Payers

Since you will have to submit individual applications to each insurer you want to enroll with, it may serve better to prioritize the insurers you want to submit your applications to first. If a large portion of your medical claims is billed to a single insurer, submit the credentialing application to that insurer first. Some insurers even provide a shorter application for providers who are already credentialed within that same state so it’s important to stay up to date with each insurer’s regulations.

  1. Ensure Accuracy

As we mentioned earlier, the slightest of mistakes in your credentialing application such as incorrect phone numbers or dates of employment can lead to delays of up to months or worse, and even can face rejections. This is why taking out the time to ensure complete accuracy of the information you are providing to the insurer can prove to be significantly beneficial.

Before submitting your application, make sure to conduct your abbreviated verification process by which you can verify your licensing, certifications, and educational history. Failure to accurately report any history of past malpractice claims can lead to the disqualification of your application.

Ensure Accuracy

  1. Complete the CAQH

Except for Medicare and Medicaid, many insurers require healthcare facilities to apply for credentialing through the Council for Affordable Quality Healthcare (CAQH). When submitting your application, most insurance companies will ask you for your CAQH number ID as a part of your application. To register your CAQH ProView Profile, visit the CAQH ProView website and take out at least one to two hours of your time to fill out the required information on the website.

Once you’ve set up your CAQH ProView Profile and gathered all the documents and information, you are now ready to submit your credentialing application to the insurer. Insurers will access your CAQH to verify your demographic and professional information. An incomplete, inaccurate, or unattested CAQH ProView Profile can lead to your credentialing application getting rejected.

  1. Wait for Approval

Once you’ve submitted your application, the next step in the provider credentialing process is to wait for the insurance company to verify your credentials. This can be quite a long process and can take anywhere from 60 to 150 days to complete. Consider following up with the insurance company if you don’t receive a response from them within 120 days. Consistently following up with your credentialing application is crucial to expedite the credentialing process.

See Also: The Importance Of Provider Credentials In Medical Billing

The Bottom Line

While the provider credentialing process may seem like an insignificant paperwork task, the fact of the matter is that it is a crucial process required to cultivate trust within the industry. It not only ensures that practitioners are equipped with the necessary skills and knowledge to do the job but also serves to protect your organization from potential lawsuits.

Unfortunately, provider credentialing in healthcare is a complex and expensive paper-based process that can take up much of your organization’s resources. The good news is that Precision Hub can help. Our state-of-the-art credentialing services are designed to help you simplify the provider credentialing process and get credentialed with all your payers much faster.

Why Should You Hire A Medical Billing Company?

What is Medical Billing?

Healthcare providers often dedicate time, money, and resources for providing patients with the highest quality care. Receiving appropriate compensation for this work is a necessity for hospitals and other healthcare services to have enough capital to run their operations smoothly.

The lengthy process of managing accounts, billing, administrative work, and medical codes can become a great burden for hospital administration and staff. Hiring medical billers has proved time and time again to be the most effective strategy in today’s rapidly growing healthcare industry.

Healthcare providers often face a delay in receiving payments from insurance companies such as Medicaid, Medicare, and other insurance providers due to flaws in coding or filling forms. In an industry where $125 billion remains uncollected each year due to faulty claims, hiring medical billers can help take off the burden from hospital staff and administration. Neglecting the importance of outsourcing the critical billing procedures can be damaging, not only to the revenue management cycle of your practice but also to its reputation and the quality of service it provides to patients.

Continue reading to find out how hiring medical billers can benefit you immensely and run your practice as efficiently as possible.

1.Lower Labor Costs

Hiring in-house medical billers to work directly for the healthcare facility comes with several costs. Facilitating the process of hiring medical billers, paying salaries, providing benefits, additional training, etc., represent a high cost of doing business for healthcare providers and hospitals, also consuming much of their time before effective systems are put into place. According to a survey undertaken by The Commonwealth Fund, administrative costs per physician amount to $83,000 per annum, four times the amount incurred by a Canadian physicians.

Hiring a medical service provider and outsourcing this responsibility allows experts in medical billing to take over and shift the responsibility to those who have the necessary training, command, expertise and experience in this field. Medical billing companies will be responsible for incurring the costs of hiring, training, and paying the medical billers. Ultimately, this will reduce the number of claims being denied and promote greater reimbursement.

hire a medical biller

2. Increased Data Security

Patient data is constantly under threat as hackers and other cyber-criminals attempt to hack into and steal valuable patient data that can be used by insurance companies and other financial institutions. This information is very sensitive as it contains patient information, family information, addresses, patient history, diagnostic results, medication, and other important personal details.

Medical billing companies have often taken advanced measures and precautions to prevent this via the most up-to-date digital security software to protect sensitive patient data. This is done as billing companies follow HIPAA security rules and conduct risk assessments and risk management of all systems. Breaching Health Insurance Portability and Accountability Act of 1966  1996 (HIPAA) regulations can result in major fines and charges which can be detrimental for startups and independent medical practices.

Data security can also be enhanced with the use of innovative technology in the healthcare industry. For example, electronic health records (EHR) permit the practitioners to send, use, and monitor private and sensitive data most securely.

3. Decreased Logistics Costs

In-house medical billing staff requires their own office space, software, computers, and dedicated time from the HR department, all of which come with a substantial monetary price tag. Advance medical billing software requires experts to run and integrate it with currently existing systems in the hospital.

Hiring a third-party medical billing company shifts this responsibility and relieves the medical practitioner from this burden. Medical billers operate in their own offices, within their separate companies, and will use their own software. With a third-party medical billing vendor, the leftover space and business resources can be dedicated to therapeutic, diagnostic, pharmaceutical, and surgical facilities. Staff can also be hired or allocated to different areas of the practice where they may be of greater help and more productive.

4. Greater Revenue for Practitioners

Healthcare practitioners often bear substantial losses in revenues annually due to denied insurance claims. According to AARP, 1 in 7 claims is denied, resulting in over 200 million denials per day.  This occurs due to a broad spectrum of reasons. A few examples include incorrect medical coding, claim form errors caused by inaccurate information, missed deadlines, and insurance coverage issues. It is said that nearly 30% of all insurance claims are either ignored or denied.

In-house administration costs alongside errors in form submission that can result in long delays with insurance claims are also greatly reduced. An expert medical billing company increases the net revenue collection and corrects any deficiencies within the preexisting revenue cycle.

A greater revenue stream will allow the medical practice to grow and expand into other fields of medicine, improve patient care, or provide increased benefits to staff, to name a few advantages of outsourcing. Additionally, medical billing organizations can help identify areas of strength and weakness within your payments and collections system.

hire a medical biller

5. Streamlines Daily Billing Operations

Medical codes and insurance policies are ever-changing, and only someone deeply familiar with them can follow and apply them adequately. A coding specialist is well-versed and experienced in medical billing, coding, and the workings of the Affordable Healthcare Act, Medicaid, and Medicare.

Expert medical coders and billers can effectively identify compliance issues to limit insurance denials and allow the medical practice to receive greater cash flows and maximize revenues. Reclaiming rejected insurance claims will now be the responsibility of the hired medical biller, thus, reducing your stress and allowing you to dedicate more time to improving patient care or expanding your medical practice.

Maintaining and upgrading software solutions can take a large amount of capital and may also take up a lot of time. Outsourcing this responsibility of constantly updating and adopting newer software can be immensely beneficial in cost savings.

6. Greater Accountability and Reporting

Almost every medical biller relies on smart software that streamlines and automates the entire process of the revenue management cycle. This allows the greatest level of accuracy and prevents human error from interfering with the financial performance of your practice.

Hiring medical billers relieves the healthcare facility of most of the capital expenditures associated with acquiring and operating new software. Moreover, medical billing companies are fully compliant with HIPAA and follow all regulatory standards. A reputable medical billing company will also assist your practice in staying up-to-date with market trends, state laws and regulations, and codes.

7. Greater Financial Transparency and Analysis

Transparency in medical billing is a challenge. Healthcare professionals and hospital staff can help strengthen the patient experience greatly by streamlining the critical processes involved in billing and payments.

By hiring a professional medical billing company, a medical practice can easily reduce costs and delays. By automating and restructuring your billing operations, a medical billing vendor will be able to accelerate cash flows and improve operating margins. The subsequent operational transparency and financial efficiency will help you enhance the patient experience in turn, thus, enabling business success.

8. Reduced Errors in Billing

Hiring a medical biller will help you reduce potential errors in form submission and insurance claims. Almost four in five medical bills contain mistakes of some kind or the other, undermining your ability to receive timely reimbursement for services rendered from insurance providers.

A research study undertaken by NerdWallet reveals that nearly 49% of all Medicare claims contain errors. Other errors that practitioners should be cautious of include incorrect procedure codes, mishandled underpayments, missing information, and upcoding.

Hiring a medical billing company will help you prepare and dispatch error-free documentation and process insurance claims quickly. Relying on their billing experts means cutting down on coding and billing mistakes, better office management and compliance, and more savings per patient. Outsourced billers will help you save time in many ways, which you can then utilize more productively in enhancing your clinical practice.

See Also: The Importance Of Provider Credentials In Medical Billing


Medical billing is a complex field that is prone to errors and mismanagement. As the costs of managing medical billing processes in-house increase, so do the pressures of keeping up with multiplying rules and regulations in the healthcare industry.

Hiring medical billers can transfer this burden of administrative and financial duties from the medical professionals to those who are qualified and better able to handle them. If you are struggling with medical billing and need a reliable partner for assistance, Precision Hub provides the latest and most innovative tech-optimized medical billing solutions.

Let the experts take care of your outstanding claims and medical bills, while you focus on patient care! Hire a medical biller and let us handle all your billing, coding, bookkeeping, financial reporting and analysis.

What Is Coding and Revenue Cycle Management?

coding and revenue cycle management

In healthcare, managing the revenue cycle is a crucial and demanding task influencing the organization’s capacity to continue in business. Revenue cycle management abbreviated as RCM is the method of tracking and collecting payments for all of a healthcare organization’s services and products. When a company’s coding and revenue cycle management process is robust and efficient, it is much simpler for them to concentrate on providing excellent patient care. It helps bring in money on time, maintains steady collections, and keeps the firm afloat.

RCM consists of billing, validating insurance, determining who is qualified, obtaining pre-approvals, filing claims, and collecting post-payments. RCM aims to ensure that patients are billed for services on time and that payments are collected consistently. By implementing and maintaining an effective RCM process, organizations can improve their financial stability and guarantee that patients receive quality care.

Keep on reading to learn more about coding and revenue cycle management.

This article covers all the important information about revenue cycle management in medical billing. Let’s explore what coding and revenue cycle management are.

What Is Coding and Revenue Cycle Management?

Coding and Revenue Cycle Management refer to the administrative and financial processes related to patient registration, benefits verification, coding, claims processing, payment, and collection. These are all crucial revenue-generating operations for a firm. Medical coding turns complex medical information, data, and documents into alphanumeric codes to facilitate patient communication, billing, and collection.

RCM is a financial procedure used by healthcare organizations in conjunction with medical billing software to track individual patient treatment episodes. This process begins when a patient registers with the institution, schedules an appointment and continues until the patient has paid off their entire amount.

It bridges the gap between the administrative and clinical parts of the healthcare industry by linking administrative data. It includes patient’s name, insurance provider, and other personal information, with clinical data, such as treatment and health information.

All administrative and clinical actions that contribute to the capture, management, and collection of patient care revenue constitute the “revenue cycle.” The entire patient account life cycle is covered, beginning with appointment scheduling and concluding with payment acceptance.

revenue cycle management in medical billing

Process of Revenue Cycle Management in Medical Billing

The process of RCM in medical billing comprises the following components.

Patient Registration: This stage initiates the RCM operation. It entails obtaining the necessary information from patients. It may include their home address, email address, telephone number, date of birth, and insurance information. The patient also goes through the stage of prior authorization. The process encompasses determining that the service, procedure, or medication is covered by insurance.

Charge Capturing: All pertinent patient information is obtained to alert them of the service costs.

Coding: Numerous codes are used in the medical billing industry to indicate various medical treatments and illnesses. When it’s time to pay out, doctors and hospitals provide insurance companies with reference codes.

Claim Submission: The claim is forwarded to the insurance company once the charges have been converted into codes. Each medical code has its fees and repercussions.

Communication: If your health insurance provider can process your medical claim, you will receive payment as soon as possible. However, if your insurance company discovers errors in your claim, they may send it back to you for correction.

Denial Management: The RCM professionals resolve the issue in case of claim rejection. Denial management ensures that the claim is free of coding errors and is timely submitted.

Billing: Patients must frequently pay for a portion of their medical care out of pocket. After the patient’s insurer has paid, this sum is calculated.

Mounting Revenue: Now that the payment procedure has been completed, it is time to investigate all RCM operations. It determines how well and how long this procedure works and what could be done to improve it. Adjusting these coding and revenue cycle management areas will boost your income and payment receipt more rapidly.

Process of Medical Coding

Following are the stages that comprise medical coding:

  • Utilize VPN connections to access patient medical records and evade the secure network.
  • Coders in the medical industry verify the accuracy of papers before grouping them for processing.
  • Both coding rules and client preferences are considered when assigning all code requirements.
  • Coding is performed according to NCCI and LCD standards.
  • The quality is examined to verify that it is satisfactory.

Outsourcing Coding and Revenue Cycle Management

Due to the significance of expanding and enhancing healthcare, revenue cycle management is gaining importance within the sector. As a result of the efforts of organizations specializing in RCM, the Healthcare RCM industry has been gradually expanding.

Numerous small and medium-sized doctor’s offices in the United States struggle with billing and payment. RCM is becoming increasingly difficult due to the complexity of establishing an independent medical practice.

As government rules, payer standards, reformed coding, and performance measures evolve rapidly, billing departments of physician practices may experience confusion. RCM Teams struggle to survive, putting at risk a practice’s financial flow and medical income.

If your practice needs assistance, it may be prudent to outsource your RCM to third-party experts like Precision Hub. Outsourcing your coding and revenue cycle management can avoid 90% of claim denials. It will also help you earn significantly more money and resolve several concerns. Your healthcare organization requires efficient revenue cycle management to earn money more quickly and prepare for the future. An efficient RCM streamlines the revenue cycle and ensures that payments are processed with minimal impact on the organization’s ability to care for patients.

See Also: Everything You Need To Know About Urgent Care Coding Updates In 2022


Healthcare providers must boost their bottom line by ensuring they have the proper documentation and coding. It can be accomplished by generating more revenue. Collaborating with a company specializing in coding solutions, such as Precision Hub (PH), is one method to offer experienced services, such as coding, billing, and audits, to providers as needed.

Precision Hub’s unique blend of delivery resources is advantageous to any Revenue Cycle Management team seeking to boost their ROI. It results in an affordable solution for coding and revenue cycle management.

As a partner in end-to-end revenue cycle management solutions, PH understands the importance of precise, efficient, and comprehensive medical coding for a high-performing revenue cycle.

Our revenue cycle coders are trained and proficient in ICD-10, CPT4/HCPCS, MS-DRG, and other classification systems. They provide payers with revenue coding services that are high-quality, accurate, and timely. So, hire us now to improve your coding and revenue cycle management. Moreover, if you have any questions regarding revenue cycle management in medical billing, please get a consultation with one of our RCM consultants.

Healthcare Consulting: What It Is And How It Works

what is healthcare consulting

With over hundreds of policies, regulations, potential job opportunities, professions, and laws, it is important to have a system in place that tracks all the complexities of healthcare. It is critical to professionalize and revolutionize your system in the fast world. Since a lot is going on at healthcare facilities, such as daily developments in medical treatments, diagnosis, and drug research, healthcare consultants are mandatory. However, if you are looking to establish an efficient monetary system at your healthcare facility, it is first important to know what healthcare consulting is.

What is Healthcare Consulting?

Healthcare consulting may seem like a hassle but it is one of the most crucial aspects of the healthcare system. As the name suggests, they provide consultancy services within the health sector to aid them in maintaining patient care in hopes of growing their business. While you can hire healthcare consultants at your workplace, it is even better to outsource their services to an external company that specializes in dealing with medical-related businesses.

Identifying problems in the healthcare sector and providing effective solutions is practically the entire idea of healthcare consultancy. Recruiting healthcare consultants to work for you saves time and resources, which may be wasted away if your business is not handled properly. With their ability to work with a wide range of healthcare organizations, health consultants have just the right exposure needed to provide expert insights and maintain job security via industrial advice.

The Rise of Healthcare Consulting

Post-Coronavirus pandemic, the healthcare systems suffered drastically but healthcare consulting successfully transformed the structure via multiple interventions. Instead of hiring more doctors or nurses, many healthcare providers have been investing in healthcare consultation companies, and rightfully so. Every time a problem arises at any business organization, you are left to question whether the solution is hiring more manpower or considering a dive into deep-rooted systemic issues. For instance, imagine a car with a malfunctioned engine. Would you require more manpower to push it throughout your journey or would you hire a professional mechanic to fix the internal issue in your car engine?

Most businesses or healthcare organizations team up with healthcare consulting services to derive a conclusion for such problems. With constantly evolving patient needs and the emerging technologies that streamline your health services, it is important to hire at least one or a team of health consultants to better manage your revenue cycles.

health consultant

Who Do Healthcare Consultants Work With?

Healthcare consultants may be self-employed or working for a large-scale company. Their recruitment can either be outsourced or directly at the healthcare facility they are working for. Their job expands over a multitude of medical-related tasks. Since it is unusual for healthcare consultants to work individually, their job mostly requires them to work in close association with healthcare providers, such as nurses and doctors, the healthcare company’s directors, and other executives, such as the administrators and vice president, etc.

Contrary to common belief, the work of a healthcare consultant is not restricted to just hospitals. It may extend to other sectors of healthcare such as:

  • Biotech companies
  • Government agencies
  • Health insurance companies
  • Hospitals
  • Nursing homes
  • Pharmaceutical companies
  • Physicians and physician groups
  • Private clinics

Types of Healthcare Consultants

Healthcare consultants are equipped to tackle problems and offer pragmatic solutions to specific departments. Some healthcare consultants possess expertise in offering services to the public, while others may be better at providing services to private sectors of healthcare. Similarly, some healthcare consultants work best for specific departments.

The departments that require healthcare consultancy the most include:

  • Behavioral Healthcare
  • Healthcare business
  • Healthcare IT
  • Healthcare management
  • Healthcare strategy
  • Independent healthcare
  • Internal medicine

healthcare consulting

Importance of Healthcare Consulting

It is not a secret that healthcare companies have to deal with a multitude of challenges every day. By seeking help from a health consultant, they may be able to put their worries to rest. The versatility of healthcare consultancy allows them to cater to overcoming obstacles and increasing patient load to improve the revenues of the healthcare system. With their expertise in customer behavior, marketing dynamics, and policy demands, healthcare consultants recognize a company’s business needs and offer solutions accordingly.

These professionals are healthcare analysts who review the company management and suggest ways of improvement for monetary benefits, healthcare efficiency, and administration. The main goal of healthcare consultants is to create and implement strategies that resolve healthcare obstacles and enable their clients to achieve their benefits effectively, efficiently, and professionally.

Flourishing Business

To put it simply, better contracts bring better profits. By hiring a healthcare consulting firm, you open your doors to a wider network that you may not have had previously. For instance, Precision Hub, as your healthcare practice consultant, can specifically tailor a step-by-step process to revamp your revenue generation system.

By showing a healthcare consultant your books, you will be able to bridge the gap between the managerial staff and the needs of the patients. The healthcare system in the US requires strong business recommendations and only a healthcare consulting company can help them with that. Flourish your business with better management of contracts, monitoring of revenue cycle, and overall increased productivity.

Patient Care

While the managerial staff may usually just be focused on their healthcare business, patients always come first. By implementing a system that takes a patient onboard with new developments and management processes, you will fairly improve the efficiency of your business.

Better management of appointment and walk-in systems could help manage the patient load on the administration. Furthermore, by identifying areas that lack efficiency, health consultants present recommendations to directors or make their system better equipped to deal with all sorts of business problems.

Structured Organization

After laying the foundation of your organization, it is important to plan and ensure that the structure only strengthens for years to come. Leave it to healthcare consultants to keep your healthcare firm from jeopardy and build cohesion and competency within your system. Healthcare consulting involves stimulating a healthy work environment to boost practice profits. By increasing job understanding amongst staff members and training the next generation of physician executives, you may equip your healthcare organization to handle business challenges.

See Also: 5 Most Common Billing Errors in Healthcare


From simple tasks such as the implementation of new technologies correctly to more complex ones such as dealing with a higher number of managed care contracts, everything can seem daunting when your company is on its own. Now that the Affordable Care Act has expanded its coverage to those individuals who were previously uninsured, there is also a rise in patient levels. The overall process of managing a practice is getting increasingly difficult. The only way around seems to be resorting to healthcare consulting services.

With Precision Hub, focus on your business growth and remain competitive in the field of healthcare. Optimize your revenue cycle management with the best medical billing company in America and allow us to cater to all the management needs of your healthcare practice. Ranging from credentialing to coding services to finance and accounting, we offer multiple services that will provide you with cost-effective solutions to your complex problems. Reach out to us today and feel free to inquire about whichever medical services your facility requires!