The Healthcare Revenue Cycle for Pediatric OTs, PTs, and SLPs Explained

Revenue Cycle Management (or RCM) is no small undertaking. The process of creating and submitting claims to insurance companies is complicated, let alone the fact that a good portion of insurance claims are denied requiring more detail or better data for payment. After all, even if you’re seeing a great number of patients, your clinic may be struggling financially because of an ineffective revenue cycle. Meaning you’re not getting paid what and when you should be.  

On a path with so many steppingstones like RCM, it’s easy for revenue to get lost along the way. With an understanding of the different steps of the revenue cycle for Speech, Occupational and Physical Therapy, you can be better prepared to create a more profitable organization. 

Insurance claims are a critical part of the healthcare revenue cycle.
Insurance claims are a critical part of the healthcare revenue cycle for OT, PT, and SLPs.

The Steps of the Revenue Cycle 

1. Payment Policies 

Effective Revenue Cycle Management begins before any patients schedule appointments. It’s important to sit down as a provider or practitioner and draw up payment policies. These not only help you communicate with patients but can act as a roadmap for accepting payments. Determine what kinds of payment you will accept and how you will accept it. Don’t forget to lay out how long self-pay patients will have to pay and the consequences of nonpayment. Also consider how you will work with HSAs and what will happen if a client misses an appointment.  

2. Benefits Checking 

Once appointments are made, or ideally, as part of the appointment process, you should check the patient’s eligibility and insurance coverage. Doing so before any treatment takes place can prevent surprises down the line and help patients and caregivers better understand any cost sharing responsibilities they may have, reducing nonpayment.  

Determine the patient’s primary and secondary insurance status and coverage before submitting claims. It’s also a good idea to make a copy of your patient’s insurance card and keep it on file in case you need to reference it later. 

A health insurance card for a physical therapy client that will come in handy during the healthcare revenue cycle.
Taking a copy of a client’s health insurance card should be on every provider’s intake checklist. 

3. Charge Creation and Coding 

Alright, so you’ve created a payment policy, verified coverage, and started with treatment. Time to bill. Here’s where it gets tricky.  

As physical therapy professionals, your mission is to treat clients and bring healing into their lives. But running a clinic involves income and creating charges for services rendered. This process is not so easy to manage, especially with constantly changing billing codes and regulations. In fact, issues with coding are a common reason claims are rejected. Also, watch out for under or over coding, creating a claim that doesn’t match up with the care provided.  

Ultimately, understanding what could cause a claim denial can better inform your charge creation. This will help get money back into your accounts by reducing the number of denied claims and making sure you don’t accidentally sell yourself short to insurance payers.  

4. Reviewing and Submitting Claims 

Before you submit claims, make sure you know the W’s of claim submission for each payer. Who, when, where, and how. Double check your claims before submitting. Remember that copy of the patient’s insurance card? It’s worth giving it another quick look. Make sure no information has been accidently left out or there are any of the coding errors like we talked about before.  

EHRs equipped with PT, OT, and SLP billing may be able to enlist a clearinghouse to review or scrub claims before submitting to make sure they aren’t missing key information or contain obvious errors and are less likely to be denied. They do say you should measure twice and cut once. The same goes for insurance claims. 

5. Status Reporting, Payment & Denial Management 

At this point, the claim has been submitted on time and as accurately as possible. Now, we wait. Make sure to check on the status of your submitted claims. If they are approved with no problems, great, but you still need to follow up to make sure the payment ends up in your account. An EHR with claim status reporting is a great way to keep an eye on claim progress.  

Let’s say a claim is denied. It’s important to act quickly to correct and re-submit the revised claim. The more delays that occur in the claim management process, the longer it takes for you to see the funds in your cash flow. Thankfully, the insurance company can provide remittance advice – their reasoning for why the claim was denied.  

If you’re able to submit claims electronically through your PMS or a clearinghouse, ask if you’ll be able to receive Electronic Remittance Advice (ERA) as ERA could save you even more time. With the notes you need to revise your claim delivered instantly, you can get revised claims resubmitted ASAP rather than having to wait for the mail.  

Get Help Managing Your Healthcare Revenue Cycle 

And so, the cycle of follow-up continues until all claims are reflected in your account. And, hopefully, if you’re seeing a steady stream of patients, this process is never-ending.  

As you’ve seen, there’s a lot of moving parts involved in building an effective revenue cycle. Just thinking of all that needs to be done to make sure claims are properly submitted can give someone a headache. A key takeaway? Let your EHR handle it.  

Trusting your EHR with your billing means your staff are freed up to focus on other initiatives. At every point in the billing process, your EHR’s billing services are taking small loads off your staff’s shoulders. And those small assistances add up. Claim submission, denial management, and following up on stuck claims are key functions where outsourcing billing through your EHR can add value. In addition, with a team of experts at your back, you won’t have to train additional billers to meet demands.  

Have Everything All in One Place 

You already trust an EHR with so many aspects of your practice. By enlisting your EHR’s billing services, you’re bringing all your patient care to one accessible log-in. If you’re ready to take your billing to the next level, find an EHR that can help. Fusion’s RCM services through our Assisted Billing solution are designed to help OTs, PTs, and SLPs get more out of the dollars and cents of their business. Schedule a demo of Assisted Billing today.