Medical Billing & Revenue Cycle Management (RCM)

Overview:
Medical Billing is a service offered by Outcomes in the Outcomes Premium Clinical Module. The Outcomes Medical Billing product incorporates Revenue Cycle Management (RCM) ensuring pharmacies can efficiently submit claims, verify eligibility, track payments, and optimize their financial performance.

With streamlined clinical workflows and the medical billing automation of the Outcomes Clinical Module, pharmacies can focus on patient care while reducing administrative burdens.

Key Components of Medical Billing Services:

1. Comprehensive Medical Billing Solutions:
   1. Guided Clinical Workflows: The Outcomes system captures clinical data efficiently and manages the electronic medical record (EMR) through structured, guided workflows. This ensures that the right data is captured during every patient interaction, supporting accurate and compliant billing.
   2. Pharmacy Integration: The Outcomes system integrates seamlessly with pharmacies, enabling an easy billing process without the need for patient data entry for patients that have filled prescriptions at your pharmacy.
   3. Simplified Coding for Pharmacies: Once clinical data is captured, the Outcomes system automatically selects and recommends the appropriate ICD-10 and CPT codes. This eliminates the need for pharmacies to have in-depth medical billing knowledge, streamlining the coding process and reducing administrative burden.
   4. Automated Claim Generation: Upon workflow submission, the Outcomes system transmits the generation of the 837 medical claims This step minimizes manual intervention while maintaining compliance with billing standards.
   5. Claim Status Visibility: Pharmacy users have real-time access to claim status, allowing them to track progress and understand payment of their medical claims.
   6. Real-Time Eligibility and Benefits Verification: The platform provides real-time verification of patient eligibility and benefits, ensuring pharmacies can confirm coverage before services are provided.
2. Core RCM Functions:
   1. Custom Fee Schedules: The system offers flexible fee schedules tailored to the pharmacy's unique needs, ensuring accurate pricing for services.
   2. Claims Submissions: The platform automates the submission of claims to payers, reducing manual work and speeding up the reimbursement process.
   3. Payment Posting: Once the record of payment is received from the payer via 835, payment details are posted to the accounts receivable record, helping reconcile payments and track financial records for the pharmacy.
   4. Accounts Receivable Management: The platform provides tools to manage accounts receivable, ensuring timely follow-up on outstanding claims and payments.
   5. Denials Management: If needed, the Outcomes team handles denials management to address denied claims, and file a formal appeal if needed, helping pharmacies reduce the risk of lost revenue.
   6. Financial Reporting: Outcomes offers financial reports to give pharmacies clear insights into their claim records.
3. Claims Processing & Remittance Management:
   1. Claims Transmission to Payers: Outcomes works directly with a clearinghouse, TriZetto. This enables Outcomes to send 837 claims to over 7,000 payers, ensuring that pharmacies can submit claims to a broad range of insurance providers.
   2. Payer-Specific Edits: TriZetto supports claim submission by applying additional payer-specific edits before submission, helping reduce claim rejections and improve first-pass acceptance rates.
   3. 835 Remittance Files: The system receives 835 remittance files, which include details on payments, denials, and adjustments.
   4. Real-Time Eligibility Verification: Trizetto supports real-time eligibility verification within the Outcomes platform, ensuring that pharmacies can confirm patient coverage in real-time and avoid claim issues later in the process.

What This Means for Pharmacies:

Pharmacies that adopt a Medical Billing technology and service can expect the following benefits:

• Streamlined Operations: With automated workflows and data capture, pharmacies can significantly reduce manual tasks, improving staff efficiency and minimizing errors.
• Faster Payments: Automation of claim submissions, payment posting, and eligibility verification ensures a faster and more accurate reimbursement process, leading to improved cash flow.
• Improved Cash Flow & Financial Visibility: Real-time tracking of claims status, accounts receivable management, and financial reporting allows pharmacies to stay on top of their revenue cycle, identify trends, and take timely action to address any financial issues.
• Reduced Denials & Rejections: Payer-specific edits, real-time eligibility verification, and automated claim management reduce the likelihood of claim denials and rejections, helping pharmacies maintain a steady revenue stream.
• Better Patient Care Focus: With administrative tasks automated and streamlined, pharmacy staff can focus more on patient care, enhancing the overall patient experience and fostering stronger patient loyalty.
• Regulatory Compliance: The system ensures that all claims and data are compliant with industry regulations, reducing the risk of audit issues and penalties.

By integrating these key components of Revenue Cycle Management, pharmacies can achieve greater financial stability, optimize their operations, and deliver better care to their patients.