Healthcare Revenue Cycle Management (RCM)
is the financial process that healthcare organizations use to track patient care episodes, from initial appointment scheduling and registration through final payment. RCM encompasses the entire lifecycle of patient financial transactions, including verifying insurance eligibility, managing claims, coding, billing, collecting payments, and following up on denied claims. This process ensures timely payment for services provided and minimizes revenue loss by optimizing each step of the financial journey. Effective RCM is crucial for healthcare providers to maintain financial health, streamline operations, and enhance patient satisfaction.
REVENUE CYCLE MANAGEMENT (RCM) OUTSOURCING
We offer end-to-end RCM solutions for clients in the US improving billing accuracy and revenue recovery. Our services include:
Front-End Revenue Cycle
- Patient Scheduling & Appointment Management: Efficient scheduling to reduce no-shows and optimize time.
- Eligibility Verification: Ensure accurate billing through verified insurance coverage.
- Prior Authorization: Seamlessly manage authorizations for services.
- Patient Registration/Demographics: Capture accurate data for timely claims submission.
- Pre-collections & Patient Calling: Effective communication for payment options and balances.
- Scheduling & Inbound Calls: Match patients with the right facilities and doctors.
Mid-Revenue Cycle Services
- Charge Entry & Audit: Accurate charge processing and audits for proper billing.
- Medical Coding Services: Certified medical coders ensure correct billing codes.
- Revenue Integrity: Regular audits to prevent revenue loss.
- Clinical Documentation Improvement: Enhance documentation for accurate coding and reduced denials.
Back-End Revenue Cycle Services
- Remittance Processing: Timely and accurate payment posting.
- Accounts Receivable & Denial Management: Maximize collections and minimize denials.
- Credit Balance Management: Handle refunds efficiently.
what makes us different
The values we live by
Improved AR Days: AR Days (Days Outstanding) maintained below 35 days
a) AR Days are a measure of how long it takes your practice to collect the outstanding bills from the payer.
b) The average range for AR days is 30 days to 70 days, although anything over 50 days could be indicative of financial trouble for your practice.
Denial Rates Reduction with No Recursive Denials: Denial Rates are reduced to less than 4%
By doing proper root cause analysis, we will be able to bring down your denial rate to less than 4% and also, we ensure to eradicate any recursive denial.
Net Collection Ratio
a) SHIMNS Global consistently improves the financial health of our clients by driving their Net Collection Ratio (NCR) to 95% and above.
b) By reducing denials and ensuring timely follow-ups and appeals, we maximize the amount collected on claims, reflecting the true revenue potential for healthcare providers.
c) Our focus on improving NCR helps ensure that clients capture nearly all the revenue they’re entitled to, optimizing their cash flow and overall financial performance
Real-Time Quarterly Revenue Forecasting
a) We meticulously analyze payment patterns, trends, and the liquidation rate of outstanding balances to provide accurate payment forecasting for the upcoming quarter.
b) Our forecasting process considers all unexpected events that may impact payments and is continuously updated in real-time.
c) This allows us to identify fluctuations early and implement strategies to ensure consistent revenue flow, minimizing the risk of any unexpected drops
Targeting & Tracking all Claims
a) We prioritize all claims, starting with high-dollar values while ensuring timely filing for insurances with shorter submission and appeal limits.
b) This guarantees that no filing deadlines are missed. Simultaneously, our expert analysts give equal focus to aging claims, specifically targeting those over 90 days.
c) By running parallel operations, we expedite the resolution of these older claims, ensuring they are processed and cashed out as quickly as possible
First Pass Ratio
a) we meticulously validate each claim before submission, ensuring that all necessary documentation, coding, and compliance requirements are met.
b) This rigorous process helps us achieve a first-pass resolution rate of 95% and above, where claims are paid upon the first submission without the need for corrections or appeals.
c) By minimizing denials, we accelerate revenue collection for healthcare providers, streamlining their operations and improving financial outcomes.
AI Technology
a) Achieve unmatched transparency and oversight to gauge productivity and resolve issues.
b) Our internal workflow management system allows seamless collaboration between teams by providing real-time reports and status updates.
Clean Claims Rate
The claims will be thoroughly checked for CCI edits before filing that ensures clearing house rejection, thereby, increasing the clean claims rate to 95% and above.
A Holistic Approach
The revenue cycle can run like a well-oiled machine. The right holistic approach allows for the identification and correction of errors in the revenue cycle that create a backlog of accounts receivables, essentially fixing the problem before it starts.
Patient Scheduling Services
Effectively book and manage patient appointments, including scheduling initial consultations, follow-up appointments, and medical procedures.
Overview
When your healthcare organization sees hundreds or thousands of patients each day, optimizing the patient scheduling experience is key to managing patient volumes, minimizing late cancellations and no shows, and increasing referrals. When done incorrectly, it can create a significant financial burden and result in wasted time for staff and clinical personnel.
Our experts at SHIMNS Global can help manage calls for appointments and streamline your patient scheduling process. Our talented team can also verify the patient’s demographic information and support inbound and outbound calls.
- No Show Reduction: We ensure to reduce No shows by sending reminders and seeking confirmation
- Optimizing physician calendars: We match patients with available providers which avoids wait times
- End-to-end tracking of patient payment history and outstanding payments: We track the patient payment history and outstanding payments that saves time at the time of visit to collect money and manage billing.
Insurance Eligibility & Benefits Verification Services
Maximize insurance claim reimbursements, avoid back-end denials, and eliminate administrative burdens.
Overview
Verifying a patient’s insurance coverage and benefits to determine the cost of medical treatment can be a challenge due to the complexity of insurance systems and inconsistent data. Checking the patient’s insurance policy, copay, deductible, and coverage limitations can often lead to staffing issues, high call volumes, and inaccurate determinations. However, identifying patient responsibility in advance is crucial for managing receivables and preventing issues with delayed payments, reworks, patient satisfaction, errors, and non-payment.
SHIMNS Global insurance verification services to free up staff to focus on performing other patient access services to deliver a better patient experience. Our services include insurance validation prior to appointments, determination of in and out-of-network benefits, and support for the No Surprises Act billing estimates for out-of-network and uninsured individuals.
- Reduces up to 45% of the claim denials from Payer by verifying all information before the patient’s visit
- Optimal Revenue and increased cash flow
- Assurance of accurate and complete data.
- Improved patient satisfaction & Quality
ROBUST APPEALS MANAGEMENT PROCESSES
Timely Appeals Submission
Once a claim is denied, we act swiftly to submit the appeal within the set timeframe, ensuring no appeal rights are lost. We understand that each appeal has a limited window from the date the claim was processed, and missing this deadline could result in a permanent loss of potential revenue.
Courtesy Appeals
Even in cases where we lack sufficient medical documentation, we still submit courtesy appeals. We believe that every claim deserves a chance for reconsideration, and through strategic courtesy appeals, we may still recover payments for claims that otherwise would be lost.
Comprehensive Documentation for Appeals
For cases where substantial medical records are available, we gather all necessary documents and submit a compelling appeal to demonstrate why the claim should be paid, minimizing the chances of further denials.
Proactive Denial Management
Our teams monitor all denials in real-time, identifying trends and taking immediate action to address any underlying issues causing repeated denials, ensuring smoother operations in the future.
ON-TIME CLAIM FOLLOW UP IN ACCOUNTS RECEIVABLE;
we understand that timely follow-up is the cornerstone of successful healthcare claim management. Delays in follow-up can result in postponed payments, increased claim aging, or even missed filing deadlines, all of which can negatively impact your cash flow. That’s why we are committed to providing unmatched operational excellence in claims follow-up and payment collection.
Consistent and Timely Follow-Ups
Real-Time Claim Monitoring
Avoiding Unwanted Write offs
Accelerated Payment Collection
Referral Management & Prior Authorization Services
Secure timely approval for covered benefits and required authorizations before services are administered.
Overview
SHIMNS Global specializes in implementing streamlined workflows and managing standardized prior authorization processes with government and commercial payers, such as Medicaid, Medicare, managed care plans, and third-party insurance. Let us help you minimize denials and maximize your revenue.
- Comprehensive analysis of policy/payer details for assessment of coverage.
- Rapid determination of prior authorization requirements of each patient.
- Accurate paperwork preparation and timely submissions to the payer.
- Persistent follow-ups on submitted prior authorization requests.
Pre-Registration & Pre-Service Collections
Secure patient financial responsibility and payment details prior to appointments or services.
Overview
SHIMNS Global streamlines patient registration by gathering essential information in advance to improve pre-service collections and obtain upfront financial payments. Effective communication and simplified procedures for reviewing patient financial responsibility help reduce claim denials and ensure timely payment for services.
- Improved productivity and accuracy of patient demographic information capture.
- Increased clean claim submission.
- Reduced demographic related denials.
- Real-time collaboration and reporting through our client portals.
- Detailed status updates and reporting on a weekly basis.
Patient Registration / Patient Demographics
Overview
Inaccurate capture of patient demographic information causes claim denials, and consequently, and delayed payments. Research shows that healthcare organizations lose as much as 7% of their annual revenue due to errors in demographic data capture. Establishing a clear and standardized process for collecting patient demographic information helps safeguard against critical mistakes being made at an early juncture. Accurate demographic collection increases the rate of clean claim submissions while reducing payment delays and denials.
Utilize SHIMNS Global’s Patient Registration Services to improve accuracy and optimize your revenue cycle.
- Improved productivity and accuracy of patient demographic information capture.
- Increased clean claim submission.
- Reduced demographic related denials.
- Real-time collaboration and reporting through our client portals.
- Detailed status updates and reporting on a weekly basis.
Medical Coding Services
Streamline your revenue cycle with improved processes that address staffing challenges and increase profit margins.
Overview
Healthcare organizations must have clear, concise, and comprehensive pictures of their patients’ health and medical conditions. Proper coding ensures patient records are accurate, care team members have necessary data and documentation available in real-time, and the revenue cycle is healthy and strong.
Inaccurate coding practices are the leading cause of claim denials, resulting in reduced reimbursement. With the pending adoption of ICD-11, code complexity and volume will continue to grow. Furthermore, recurring Centres for Medicare & Medicaid Services (CMS) code changes bring an additional level of complication.
Leveraging technological advancements improves the efficacy and efficiency of medical coding. SHIMNS Global can reduce the cost, time, error margins, and effort required for processing and clinical coding to provide quick and accurate expertise in near-real-time.
Payment Posting Services
Accurate processing, tracking, and recording of payments to avoid revenue leakage and ensure proper and timely account resolution.
Overview
Whether you’re dealing with labor shortages or need your staff to focus on more complex tasks, SHIMNS Global can help you maintain accurate financial records by tracking and managing your payment postings.
Our experts offer full transaction services including payment processing, manual and electronic posting, routing of denied claims, and reconciliation to ensure timely account resolution.
Get the support you need to gain an accurate view of your organization’s financial health with payment posting services that include:
- Processing and reconciliation of automated clearing house (ACH) and lockbox payments.
- Manual and electronic posting and reconcilement process.
- Report unusual adjustments while processing payment posting.
- Routing of denied claims to appropriate coding and denial management team.
- Fasten the patient billing process by updating patient responsibilities.
Scope of AI Implementation in Revenue Cycle Management (RCM) Services
Our AI-driven solutions streamline and optimize key areas of the Revenue Cycle Management process, bringing speed, accuracy, and efficiency to the forefront. Here’s how AI transforms our RCM services
Demographics Entry
• Automated Data Extraction and Entry: AI-driven Optical Character Recognition (OCR) technology scans documents to capture and verify patient demographic details accurately, reducing manual entry errors and time.
• Data Validation: AI cross-references demographic data with internal databases and third-party sources to ensure accuracy and completeness, minimizing claim rejections due to incorrect information.
• Real-Time Updates: AI syncs demographic data across platforms in real time, ensuring that all parties in the billing cycle have the most accurate and up-to-date patient information.
Chatbots for Accounts Receivable (AR) and Denial Management
• Preloaded Scenarios and Solutions: Chatbots powered by machine learning can handle common AR inquiries and denial cases with preprogrammed scenarios and solutions. This streamlines responses to frequent inquiries and resolves issues quickly without waiting for human intervention.
• 24/7 Availability: Chatbots ensure around-the-clock support for claim status updates, follow-up queries, and payment assistance, enhancing efficiency and reducing AR backlog.
• Escalation Triggers: When a chatbot reaches the limit of its programmed capabilities, it seamlessly transitions the case to a human agent, ensuring that complex cases are prioritized and addressed by skilled AR specialists.
Insurance Verification
• Automated Payer Communication: AI directly interfaces with payer systems to verify patient benefits and eligibility, retrieving up-to-date details on coinsurance, copayments, deductibles, and prior authorization requirements.
• Prior Authorization Flags: Ensures AI identifies whether a service needs prior authorization, enabling proactive management and reducing denial rates.
• Efficiency in Coverage Validation: AI quickly validates coverage details, eliminating the wait for manual insurance verification and expediting the patient intake process.
Automated Notes Documentation
• Smart Documentation: AI-based tools capture AR representatives’ inputs and automatically generate concise, structured notes. These notes are directly integrated into the practice management software, ensuring that all claim activities are thoroughly documented and easily accessible.
• Actionable Insights: AI analyzes claim status updates provided by AR users and suggests potential next steps based on historical data and industry best practices. This guidance helps agents make informed decisions more quickly.
• Audit and Compliance: AI systematically tracks all updates, creating a secure audit trail that meets regulatory standards and enables efficient compliance management.
Accounts Receivable (A/R) Management Services
Track and collect the outstanding revenue that you deserve with greater efficiency and improved financial performance..
Overview
Healthcare organizations in the US are losing millions of dollars annually in unrecognized net revenue due to rising denial rates and underpayments. This can be a frustrating and resource-intensive challenge, as finding and recouping lost revenue can be difficult, and choosing the right revenue cycle solution can be even more so.
SHIMNS Global team of experienced A/R specialists can help you pursue full eligible reimbursements and mitigate future denials. Our insightful analytics help identify the root cause of these issues, enabling customers to develop effective strategies for denial prevention and payer contract optimization, which can improve their financial health for years to come.
Get the support you need to gain an accurate view of your organization’s financial health with payment posting services that include:
- SHIMNS Global will analyze your current AR processes to determine areas of improvement through best practices.
- A Holistic Approach: The revenue cycle can run like a well-oiled machine. The right holistic approach allows for the identification and correction of errors in the revenue cycle that create a backlog of accounts receivables, essentially fixing the problem before it starts.
- Technology: Achieve unmatched transparency and oversight to gauge productivity and resolve issues. Our internal workflow management system allows seamless collaboration between teams by providing real-time reports and status updates.
Denial Management and Prevention Services
Prioritize and resolve denials quickly, while gathering the insights necessary to proactively address denials before they occur…
Overview
Each year, billions of dollars in denied claims are never resolved because organizations don’t have the resources to work them properly. SHIMNS Global offers deep expertise in denial management and appeals writing to ensure our customers can capture every possible dollar of revenue owed.
In addition, we also provide the insights needed to identify the root cause of denials so your organization can take corrective action to improve your clean-claims rate, reduce denial rate and prevent revenue loss for your medical practice.
SHIMNS Global powered by technology and industry experts will help you maximize your revenue while providing prescriptive solutions for improving efficiency and mitigating risk.
- Denied claims are identified, analyzed, categorized, and prioritized to ensure prompt resolution.
- Following review, appeals are written and submitted to successfully improve net revenue collections and cash flow.
- Detailed trend analysis and reporting is provided to improve first-pass resolution rates and support future payer contract negotiations.
Pre-Collections & Patient calling
At SHIMNS Global, we provide healthcare providers and facilities with a robust pre-collections and patient calling solution to ensure efficient revenue flow and patient preparedness. Our dedicated team engages with patients directly to remind them of outstanding balances, facilitate payments over the phone, and assist with pre-appointment preparations. Through personalized and proactive outreach, we manage a range of essential patient communications that relieve your team’s administrative workload and improve patient compliance.
Outstanding Balance Reminders
We remind patients of any pending balances, guiding them to make timely payments. Our team can collect payments over the phone via multiple methods, including sending secure links through email or text and providing QR codes for direct, convenient payment.
Data Retrieval
When essential information is missing—such as coordination of benefits or additional medical records—our team contacts patients to collect these details and ensure all records are complete.
Pre-Appointment Instructions
Before scheduled appointments, we call patients to communicate specific preparation instructions. Whether they need to fast, stay hydrated, or use prescribed eye drops, we ensure they’re fully informed to help their appointments run smoothly and effectively.
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