One of the quite complex and ever-evolving components of running an ABA or other healthcare organization is understanding and managing the organization’s revenue cycle. A healthcare provider’s revenue cycle encompasses several interconnected processes that can impact its financial stability and long-term sustainability. ABA providers should thoroughly understand all aspects of revenue cycle management (RCM) to best position themselves for maximized revenue potential. Let’s dive into more about what revenue cycle management entails.
What is Revenue Cycle Management (RCM)?
Revenue cycle management (RCM) is a healthcare organization’s financial process for tracking client care from intake to the final payment. A robust and effective RCM strategy is necessary to support your ability to provide superior ABA services to your clients.
RCM can create challenges for organizations of all sizes, from start-ups to large-scale providers. No ABA organization is immune to the unique complexities of ABA billing. However, smaller organizations often have added challenges, such as limited resources and a lack of internal billing specialists to optimize operations. Regardless of the size or resources available, all organizations must establish a process that works for them and consistently evaluate and resolve pain points to maximize reimbursements, thus ensuring financial stability.
The first step in an organization’s revenue cycle management process is getting approved to work with a payor, either in-network or out-of-network. Contracting is the process of becoming an in-network provider with a funder. The provider must submit an application with each payor to begin the contracting process. Upon approval, the payor and provider agree to terms including agreed-upon paid rates for services. Contracting with payors can take several months, so it is important to plan ahead accordingly. Plan for this process to take anywhere from 3-6 months from start to finalization.
Credentialing, also referred to as rostering, is the second step in an ABA organization’s revenue cycle management process. Credentialing entails a payor verifying that each individual is a medical provider qualified to provide specified services. Payors consider the provider’s background, education, certifications, and licenses when determining whether they are qualified. It’s important to note that credentialing is not the same as obtaining an authorization or contract. Becoming credentialed with a payor does not mean that the practice or individual provider is pre-authorized to provide services for a particular client. Instead, it enables the practice to render services under their contract based on the provider’s approved qualifications.
As with contracting, credentialing can take time to complete. Credentialing time may vary between providers, but expect it to take 1-4 months for processing and approval. You must be credentialed with a payor before providing services in order for those services to be billable. This is important to keep in mind, as you should not attempt to begin services with a client whose funding source you are not yet credentialed with unless you have a single case agreement in effect.
Each payor has different requirements. However, the following information is generally required as part of the credentialing application:
- Applicant’s personal demographics and organization’s information, including work history, educational information, licensing, and certification
- Taxpayer identification number
- National Provider Identifier (NPI)
- Liability and malpractice insurance documentation
- CAQH Provider ID number (Note: If you’re not using CAQH, you may need to provide additional documentation)
- Practice specialties, appointment availability, and languages spoken
Verification of Benefits
Before you take on a client, it is ideal to have a robust verification of benefits check performed to each client. This process could be critical to identifying the claims routing, primary or secondary status, benefits max limitations, deductible limits, and claims information such as a home plan or local plans for out-of-state insurance.
Plans such as Medicaid are often a payor of last resort, so knowing if the clients have completed their coordination of benefits for all their payors will prevent claims denials or recoupments. Ensure all known insurances are obtained and cross-check each for proper details and priority.
Some things that are key to ask on a verification check.
- Are there any other plans identified by the payor for the client. Does the Secondary know there is a primary payor?
- Does the client have two plans? Which one falls within the birthday rule and is correctly identified as primary?
- Does the plan cover CPTs needed for services?
- What DX is required to be billable?
- Plan max limits (age limits, benefit dollar max)
- Where do these claims need to be sent?
- Payor ID for this payor (may vary depending on the clearinghouse)
- Coverage year, self
Always get a reference number for the verification call and record the details.
Once credentialing is complete, organizations can take on clients who have insurance funding that they are credentialed with. However, they still need to receive authorization to provide services for a particular individual. If the client’s funding source requires authorizations, an organization must receive one from each payor, including secondary and tertiary payors, before rendering services.
Each payor and benefit plan will have specific requirements for authorization requests. However, most will require the following general information:
- Subscriber and client’s name, date of birth, and contact information
- Subscriber member ID and group information
- Provider information, including name, credentials, and NPI
- Documentation of the client’s diagnosis
- CPT codes and units requested for each code
- Referring provider’s information
- Location of services (E.g., home, office, clinic)
- Dates of services
- Treatment plan outlining services that will be provided and goals to be addressed
Authorizations need to be closely monitored to avoid over or underutilization. When an authorization is overutilized, you risk claims being denied by the payor. When an authorization is underutilized, you may be leaving money on the table and, more importantly, potentially under-serving your client. A robust practice management system can help your organization better manage your authorizations for maximum profitability.
The next step in revenue cycle management is claims processing. As services are rendered, documentation is completed to verify service delivery and the client’s response to care. Before submitting claims to a funding source, the BCBA and a billing team member should conduct a billing scrub to double-check for completeness and accuracy. If everything looks good, the billing team submits it to the payor(s) for payment.
Each payor will have different requirements, but generally, the following information is required when submitting a claim:
- Client’s identifying information
- Service date, time, and duration
- CPT codes
- Diagnosis code
- Location of service
- Name of the rendering provider
- Data and session notes–This information may not need to be submitted with the claim but must be completed and saved in case of a denial and/or audit
Claims may be rejected or denied. If a claim is rejected on the front end, this means required information is missing or incorrect. If a claim is denied, this means it has been processed by the funder, but payment has been denied. The payor should provide you with a reason that explains why the claim was denied. Some of the common reasons for denials include medically unlikely edits (MUEs), authorizations, eligibility, and modifiers.
Many organizations work with a clearinghouse to reduce the likelihood of submission errors and subsequent denials. Clearinghouses verify accuracy and confirm billing codes, then send your claims to the correct payor. It is beneficial to have an extra individual verifying claims before submitting them to achieve the highest possible collections rate. Another benefit to using a clearinghouse is the reduced workload for you and your team. They eliminate the need for you to visit each individual payor portal to submit claims, saving you significant time that can be better spent on the clinical side of your organization.
Accounts Receivable & Collections
Accounts Receivable (A/R) refers to the outstanding payments that are due to your organization. As you submit claims or send an invoice, that amount is added to a running total of outstanding A/R. It’s important to closely monitor key performance indicators (KPIs) related to your A/R, including the average days in A/R and gross collection rate. Using a trusted practice management system, you can track claims processing, A/R aging status, follow up on collection issues, and more.
Enrolling each of your payors in electronic remittance advice (ERA) and electronic funds transfer (EFT) is recommended for more efficient RCM reporting and faster claims resolutions.
If you need to contact a payor about a claim, be sure to have the following information on hand:
- Your company’s name, tax ID, and NPI
- Client’s member ID, group name, and date of birth
- Claim number
- Date and location of service, CPT codes, and amount billed
The majority of organizations only recoup 81-85% of what they bill. To improve collections rates and get paid faster, many organizations opt to outsource billing. A managed billing service such as CR Billmax can streamline your billing and collections processes.
CentralReach offers comprehensive and integrated solutions to optimize your revenue cycle management. Gain efficiency and optimize earnings with CentralReach’s Practice Management system. Choose CR Billmax as your managed billing solution to scale care and improve revenue flow.
Learn more about these solutions and how they can enhance your revenue
- Anthem Blue Cross Blue Shield. (n.d.). https://www.anthem.com/docs/inline/evidence2021eoc.pdf
- Get Credentialed. UHCprovider.com. (n.d.). https://www.uhcprovider.com/en/resource-library/Join-Our-Network/Credentialing-for-Care-Providers.html