Revenue Cycle Management vs
Third Party Administrator
RCM is
a process or software to perform end to end providers activities (Patient
registration, claims processing etc), where as TPA is a person or organization
who works on behalf of payers, providers or members.
TPA
can perform all steps in RCM cycle if they work for a provider.
RCM (Revenue
Cycle Management):
It
is a financial process/medical billing software that healthcare facilities
(providers/hospitals) use to track patient care episodes from registration
and appointment scheduling to the final payment of a
balance.
Purpose
of RCM Systems:
Healthcare
providers use revenue cycle management systems to store and manage patients'
billing records to interact with Payer Systems to receive the payment and other
health IT systems -- such as electronic health record (EHR) and medical billing
systems -- as patients move through the care process.
TPA
(Third Party Administrator):
A
Third Party Administrator (TPA) is a person or an organization that works on
behalf of other healthcare parties like Provider, Payer or Member etc.
Types
of TPA’s:
1.
Works
on behalf of self-insured employers
2.
Works
on behalf of Providers and members
o Performs all RCM functional
operations
3.
Tasks
traditionally handled by insurance companies
o Policy maintenance
o Membership functions
o Premium Billing
o Claims processing
o Provider networks
o Utilization reviews
4.
Other
areas
o Actuarial (Analyzing potential
risks, profits and trends)
o Loss control (Part of Risk
Management)
o Provider service
o COBRA
o Mental health administrations
o Plan Administration
Various
TPA Pricing Models:
1.
Per
Claim basis, Percent of Incurred, and Percent of Paid
2.
%
of revenue
3.
Per
employee per month (PEPM)
4.
Per
member per month (PMPM)
