Revenue cycle management (RCM) is the process by which the required data for billing care management services is captured and entered to successfully submit a claim for processing. RCM plays a significant role in the financial viability of the health home by creating processes for successful claim submission and payment, thereby ensuring proper reimbursement of services. Each CMA is responsible for performing several key functions, such as eligibility verification and service delivery and documentation, to ensure each step can successfully move forward.

Beginning in January 2017, Hudson Valley Care (HVC) has implemented several new initiatives to assist CMAs in the revenue cycle management process. Site visits were conducted to discuss key workflow procedures and barriers, with follow up conference calls to assess improvement. In April, financial indicator reports were released to HVC’sCMA network as an ongoing improvement tool to indicate deficiencies in certain key billing and documentation areas. Ongoing monitoring and TA will be performed to provide support to our network with the goal of achieving above benchmark scores for billing and documentation activity. HVC is committed to becoming one of the leading health homes in revenue cycle management.

Tips on Improving Your Organization’s RCM

• Verification of member eligibility is a key first step in the revenue cycle management process. Services should not be provided to members who are not eligible. Ineligible enrolled members can be assisted in the recertification process to have their Medicaid reinstated.
• All billable activity should be documented within three business days of the date of service. Encounters should be properly documented with the correct encounter type and status. All HMLs must be completed each month for all enrolled members.
• Best practice for RCM requires a 98% billing rate. To achieve this goal, CMAs need to be vigilant in maintaining accurate rosters. Only members that are actively engaged with the health home and being serviced should be active in the care management platform.