What is revenue cycle management for autism therapy?

Generally, healthcare revenue cycle management (also known as RCM) describes a step-by-step process through which the healthcare provider is paid by payers and patients. 

But the exact definition of RCM — when the process starts and ends, the chronological ordering of steps, and perspective through which the process itself is viewed (e.g., patient, provider, or payer) — tend to have different definitions depending on the context.

For autism therapy specifically, we will focus our definition of RCM to 4 major categories: initial clinic setup, pre-service preparation, post-service billing, and ongoing follow-up.

Initial clinic setup

Initial clinic setup covers the prerequisites for insurance billing and ongoing compliance for your entire clinic. This includes:

• Payer contracting and enrollment: You will need to sign agreements with payers to be in-network with specific reimbursement rates for your therapy services, then complete enrollments for each to begin submitting and managing your claims.
• Provider credentialing: Your therapists on staff are required to have the appropriate training and paperwork for each payer.

Pre-service preparation

Pre-service preparation involves asking for the proper confirmations and paperwork before the therapy session takes place. This includes:

• Benefits verification: During patient intake, you’ll need a confirmation from the payer that the therapy service is included as a benefit in the patient’s health plan to provide services.
• Prior (pre) authorization: Most payers require that you receive specific paperwork or verbal approval to confirm that they will pay for the therapy services according to a patient-specific treatment plan, both for 1-time assessments/evaluations and ongoing treatment.
• Patient eligibility: While patients should inform you when their health plan changes, checking your patients’ insurance eligibility every month will minimize unexpected payment issues before new sessions take place.

Post-service billing

Post-service billing include the steps to submit claims after the therapy session is completed:

• Coding: A specific treatment procedure code is assigned to the completed session depending on the specific medical treatment. Especially in autism care, the codes used are often pre-determined based on the intent of the scheduled session (e.g., an initial assessment).
• Claim submission: The information for a coded session will be translated into an insurance claim (parameters usually based on the CMS-1500 form) and submitted electronically (or by mail) — each payer can have its own rules for how they expect the form to be formatted.

Ongoing follow-up

Ongoing follow-up describes the recurring processes that follow in the weeks and months after initial submission. These include:

• Payment posting: The payer should eventually inform you that a batch of sessions has been paid by sending you an ERA (electronic remittance advice) or EOB (explanation of benefits) by mail, which document the breakdown of all the payments by therapy session. You’ll need to take that breakdown and apply those payments (or non-payments) to the specified sessions for internal tracking.
• Patient responsibility (e.g., copay): The ERA/EOB will include any copay, deductibles, or co-insurance that should be paid by the patient. This point is usually when you’ll invoice the patient for their responsibility (although you may choose to invoice copay before this point).
• Denials management: The ERA/EOB will also specify which sessions for which they’ve denied payment due to an error or issue. Depending on the denial's reason (also known as a “Claim Adjustment Reason Code”), you can work the original claim and resubmit — or write off the charges internally.
• Accounts receivable: Payers sometimes take significantly longer than expected to send you any notice of their payment decision. It’s up to you to track, review, and follow-up if necessary (e.g., by calling support).

We also sometimes refer to the former 2 categories (initial setup and pre-visit preparation) as the “front-office” function and the latter 2 categories (post-service billing and ongoing follow-up) as the “back-office” function. Large, multi-state autism clinics may have entire organizations dedicated to front- and back-office functions, with teams assigned to help support individual components within each.

For your own autism clinic, understanding the big picture of these different components and how they connect to each other is key to your clinic’s future growth and financial success.

Key takeaways:

1. Autism clinics need 4 revenue cycle processes to function: initial clinic setup & pre-visit preparation (aka “front-office” admin) and post-service billing & ongoing follow-up (aka “back-office” admin).
2. Consider a billing partner with autism-specific knowledge and experience to help set your clinic up for financial success.