Mar 7, 2025
Apr 15, 2025
Written By Elizabeth Cifers
Cash flow in the medical industry is unique since payments are not at the time of service, unlike in your grocery store – pay first and then get the product. Each service rendered must go through insurance claims processes, and each claim can move at its own pace—errors, denials, appeals, and collections can all delay reimbursement, pushing accounts receivable into 60, 90, or even 120-day (or more) buckets. After the insurance pays, then the patient billing cycle begins.
Your retina clinic has overhead costs and staff members that must be paid. How can you ensure a consistent revenue stream to cover expenses? Furthermore, how can you maximize revenue at your retina practice when the many steps required to secure it leave so much room for error?
Enter revenue cycle management for medical billing.
Healthcare revenue cycle management (RCM) is the financial practice of optimizing timely cash flow. It involves identifying inefficiencies and leakage points in the various revenue cycle stages and implementing changes that create efficiencies and shore up profitability.
As I mentioned, RCM is about cash flow and revenue generation. The purpose is to ensure your retina clinic has the money to meet monthly demands and receive every penny of payments you and your team earn for services rendered.
The revenue cycle can be organized in whatever way is most helpful to the individual managing your retina clinic. I find the following six (6) stages the most intuitive: pre-appointment, appointment, insurance claims process, remittance process, patient billing, and revenue cycle optimization.
The revenue cycle stages can be further broken down into steps taken within each stage. RCM is concerned with all aspects of the retina practice; however, for this article, I'll focus more on the financial side than the clinical side.
See my infographic below for a visual illustration of the revenue cycle:
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Almost every retina appointment starts with a referral from an ophthalmologist or optometrist. Once the referral is made, the appointment is scheduled. However, before the appointment can occur, several steps must be taken to ensure the clinic receives appropriate reimbursement for the services provided: patient registration, insurance coverage verification, and, if needed, a referral for the initial visit. Once the patient is established, reviewing whether additional referrals are necessary for each visit is imperative. Prior authorization may be required for established patients coming in for a procedure.
Scheduling can significantly impact the revenue cycle at your retina clinic if there are inefficiencies, numerous open appointment slots, or unusually long wait times where patients may leave or not come back. Optimizing your schedule means maximizing your flow and efficiency on a given day. Review your scheduling template to ensure the appointment slots are used efficiently with minimum rescheduling because the patient appointment is at an inappropriate time. Additionally, quick appointments, such as injection-only visits, can be done at the beginning and end of the morning or afternoon clinics while other patients are dilating. Consider using automated software to call or text your patients for confirmation, cancellation, or rescheduling.
Patient registration involves collecting data on the patient, such as demographic and insurance information, which may be done over the phone, through a portal, or in person at the time of the appointment. Many practices also include a medical history form for the patient to complete before or during their first visit. Accuracy for data entry for the demographic and insurance information is vital since mistakes can result in delays in treatment or payment, claim denials, or recoupments further along the revenue cycle.
Verifying the patient’s insurance coverage is imperative for RCM. Ensuring the practice and the physician participate with the payer and plan, there is active coverage, and obtaining the benefits and pre-authorization requirements are vital and can be gained from verification. Moreover, verifying insurance at each visit is necessary to confirm the insurance plan or payer doesn’t change. Avoiding errors at the beginning of the process is critical for effective RCM.
Once the physician establishes the treatment plan, if the patient needs an injection, laser, or surgery, it is essential to determine if prior authorization is necessary, if there are step-therapy requirements, or if particular facilities are in-network. Don't miss this step if needed! Prior authorization can't be added after the fact—that's why it's called prior authorization. Missing a prior authorization can mean no payment for your services (and drugs), affecting your bottom line.
Although the appointment may not seem like an opportunity for RCM, its flow and efficiency can affect profitability; since the physician is a limited resource, ensuring their time is used effectively with minimal interruptions is necessary. Additionally, adequate chart documentation during the appointment is crucial to RCM.
The chart documentation must support the claim submitted for reimbursement to the payer. Retina physicians and scribes should document the specifics of the office visit or procedure for the patient for the service date. The chart documentation includes the chief complaint, findings, or diagnoses with a treatment plan for subsequent visits. It may (as appropriate) include exam elements, procedures including lasers, administered retinal drugs, or other in-office procedures. For more information, see my article about how to improve documentation at your retina clinic.
Insurance claims are where the rubber meets the road in RCM. It's here you submit to receive payment for the services rendered.
Ensuring the services rendered are correctly submitted using the appropriate Current Procedural Terminology (CPT),¹ Healthcare Common Procedure Coding System (HCPCS),² and International Classification of Diseases, Tenth Revision (ICD-10)³ codes helps determine whether your claims will be approved, delayed, denied, or potentially recouped. The coding team, whether physician/scribe or physician/biller/coder, is crucial to payment. Regularly providing the opportunity for training in coding and billing is essential to stay abreast of the changes in the retina world. It's also wise to perform regular internal and external coding and documentation audits to educate physicians and staff about mistakes before payers do. See my chart audit brief for more information about payer audits.
Once the charges supported by the documentation are coded, it's time to submit the claims to the patient's primary insurance provider. Ensuring accurate information is on the claim can be the difference between payment and denial.
Wouldn't it be nice if, when you submitted a claim, the claim was paid, and that was it? We know it works for many claims, but not all of them, but it's what makes RCM so important.
When you receive the payer's electronic remittance advice (ERA or RA), some claims will have comment or denial codes (instead of payment) that indicate what to do next. How each is handled affects the revenue cycle timeline to adjudication. If a claim contains an error, fix it and ensure your resubmission is error-free. Since the clock is ticking, the denials should be worked promptly.
Efficiency in claim submission and payer adjudication is not the only process in which timeliness is essential; patient billing is also.
Once you receive payment from the insurer, bill the patient in the next billing cycle—weekly, bi-weekly, or monthly, depending on staffing and workflow. Patient payments can be problematic for practice cash flow, especially due to high-deductible insurance plans. This is another area where patient satisfaction must be balanced with revenue goals. Although not ideal, payment plans can decrease patient accounts receivable and foster patient relationships and, in turn, the revenue cycle.
Turning a patient account over to a collection agency to collect overdue payments can be challenging, but sometimes it must be done. When hiring a collections agency, ask questions concerning tactics for collection, what percentage of payment they keep, and talk to references. Understand that aggressive collections can affect the longitudinal patient relationship, which may or may not be a concern for your practice.
The final stage of the revenue cycle is reporting, optimization, and annual maintenance for better RCM. This stage is fun if you enjoy solving challenges and seeing the results of your work like I do!
Many RCM systems offer dashboards that provide insights into key performance indicators (KPIs). These metrics may include Net Collection Rate, Days in Accounts Receivable, and more. If your Practice Management (PM) system does not have a dashboard for KPIs, you can manually create them using the data. Comparing these KPIs to industry benchmarks can help you identify the hiccups in your revenue cycle and act to fix them.
Tackling your revenue cycle's inefficiencies and leakage points can be challenging, but it can be accomplished. Remaining objective and willing to consider all possibilities when assessing the issue is key to finding the source of the inefficiency or leaky places causing a revenue loss. The cycle is never-ending—review the data, adjust the process, review the outcome, and repeat.
RCM requires a few scheduled updates to confirm the accuracy and availability of new fee schedules, CPT,¹ HCPCS,² and ICD-10³ codes.
For all of these codes, check with your Electronic Health Record (EHR) and Practice Management (PM) vendor(s) to verify that the changes, additions, and deletions are available for use if you do not control these updates within the practice vs. with the vendor.
Fee Schedules
Annually reviewing and updating your fee schedules based on the current year allowable is an additional step to ensure you are not leaving money on the table. For example, if you have a charge that never has a write-off, you may be undercharging that payer, so you are not receiving the full payment for the service.
CPT¹ Updates
CPT1 code changes, additions, and deletions become effective on January 1st. Typically, the information is available sometime during December.
HCPCS2 Updates
HCPCS2 code changes for new or deleted drugs occur quarterly (January 1, April 1, July 1, and October 1) and are typically known the month before the latest quarter. The annual HCPCS2 code changes, additions, and deletions are effective each January 1st. Usually, the information is available sometime during December.
ICD-103 Updates
ICD-103 code changes, additions, and deletions are effective each October 1st. Typically, the information is available sometime during September.
The revenue cycle is long, with many opportunities for error, but revenue cycle management is about achieving a consistent revenue stream. Efficient scheduling, attention to detail, automating what you can, and active monitoring of RCM KPIs contribute to cash flow and profitability.
Hiring an objective third party skilled at identifying revenue cycle roadblocks can be transformative. That's where I can come in. With decades in the medical industry, I know the ins and outs of RCM by heart. I have a knack for developing practical solutions to seemingly far-fetched revenue challenges in retina, and I'd be happy to put that to work for you. Let's talk. You can find a spot on my calendar here.
¹CPT is a registered trademark of the American Medical Association. CPT copyright American Medical Association. All rights reserved.
²Medicare's HCPCS national codes, level II (1987). Downers Grove, Ill. Medical Administration Publications,
³American Medical Association. (2023). International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Chicago, IL: American Medical Association.
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