How Claim Conflicts Affect RCM

A vital part of a hospital’s revenue cycle management (RCM) is managing claims. In many cases, patients simply can’t, or at least not fully, pay hospitals out-of-pocket. Instead, their payment will come in the form of an insurance or government benefits program. The insurance provider or the government will hand the payments to the hospital but not before a claim is made and approved.

The claims process can be quite complex. Take social security disability for children as an example. Individuals under age 18 may receive benefits from Social Security based on their parents’ earnings record. This may also apply to a person who’s over 18 but was disabled before that age, defined as a “disabled adult child”.

The government has to be strict in determining the qualification of claimants to the program as the benefits must be given to those who are actually eligible. Fraudulent claims are not unheard of, after all. However, the decisions may not be agreeable to the concerned parties all the time. So, difficulties in payments and other conflicts arise – causing problems to the RCM of a hospital. As such, eligibility determination services are a beneficial addition to the RCM as it enables faster and more accurate decisions when it comes to benefits claims.