FAQs On Workers Compensation

Workers’ compensation has existed in one form or another since 1911. It gives employees financial benefits in case of a work-related injury and absolves the employer of undue responsibility.
In the U.S, workers’ compensation is one of the most successful social insurance programs. It has become an essential part of the employees’ benefits package, and every employer should take it seriously.
Read on to find out all you need to know about workers’ compensation:

What is Workers' Compensation?

Workers’ compensation is an insurance policy that a company adopts to benefit employees who suffer in juries on the job. It usually covers both injuries and treatment obtained as a result of the job.
Workers’ compensation pays the bills and gives a cover for loss of income to an injured employee. Employers also get protection from lawsuits if they have a workers’ compensation scheme. Workers’ compensation is mandated by state laws in 49 states in America with different rules guiding the requirements for obtaining it.

How Does the Workers' Compensation Work?

Before Treatment

When an employee gets an injury or sickness from a work-related event, they should notify their employer then proceed to get medical attention. After or during the treatment, the employee should inform the medical personnel that the injury is work-related. This bit of info gives them enough notice to categorize the procedure accordingly when billing to insurance.

After Treatment

After the treatment procedures, the injured party can begin claims processing with the insurance agency. If an ongoing treatment lasts for an extended period, the claims process can start with a proof of medical intervention.
There is a time limit given for when employees can file claims and this time frame is determined by the state.Upon completion of the process and the approval of the claim by the insurance company, the employee will get the workers’ compensation benefits.

What are the Four Types of Workers' Compensation Benefits?

Employees gain several benefits from workers’ compensation, but they can be categorized into four. These benefits are relatively consistent in most states with a level of variation depending on the state laws. The four(4) types of workers’ compensation benefits are:

1. Medical Coverage

Most of the injured staff who file workers’ compensation insurance claims for injuries usually get medical care. This compensation covers the expense of workers being treated for an occupational accident or disease. Workers’ compensation includes fees paid for hospitalization, doctor visits, nursing services, prescription, physical therapy, medical diagnostic testing, and medical equipment such as wheelchairs and crutches.
Health coverage is not usually subject to co pays, deductibles, and dollar-limits. Coverage usually lasts until the worker has completely recovered from the accident. State laws may, however, place limitations on other types of treatments.A benefit covered in one state may not be provided in another. In several states, medical care providers are reimbursed with a fee schedule. With each form of treatment, the plan specifies the most a patient can receive.
A lot of states give their workers benefits under the managed care plan, which typically includes:

Medical Care Management: Supervise care to ensure the injured staff gets proper treatment and return to work as quickly as possible.

Provider Network: This is a group of healthcare providers and doctors who have contracted an employer or insurer to provide medical services, usually giving a discount. These professionals should have training in occupational medicine. Some states make it a requirement for injured staff to get treatment from providers within the network.

Pharmacy Benefit Manager (PBM): This is a prescription drug program administrator whose function is to control costs. A PBM negotiates deals with drug suppliers, establishes formularies, pays claims for prescription drugs, and smoothens contracts with pharmacies.

Utilization Management: A procedure designed to makesure that the type of medical care provided to staff iscost-efficient, necessary, and appropriate. Providers may be expected to get prior approval before some medical procedures are performed.

2. Rehabilitation

Most states offer some form of occupational rehabilitation/therapy to employees who are unable to return to their previous job due to an accident on the job. They can also offer psychological treatment if a worker has experienced mental trauma because of work.

3. Disability

Disability benefits are meant to cover a portion of the income that an employee loses because of disability arising from an accident related to the job. The amount of compensation a worker receives in their state depends on the extent of the illness. Benefits are typically measured based on an average weekly wage (the average weekly pay of the worker before the accident occurred). The calculated amount may be subject to thresholds (minimum and maximum). Each impairment is grouped into one of four categories:

Temporary Partial: The worker is only partially disabled because of a short-term injury. A worker generally gets their reduced pay (for work they can perform) plus a percentage of the difference between the worker’s regular wage and their reduced salary.

Temporary Total: The worker is disabled by the injury and is unable to work for a short time. Benefits are paid out over the disability duration. Generally, they are based on a percentage (such as 66.666%) of the worker’s average weekly salary.

Permanent Partial: The worker has suffered a lifelong disability that prevents them from earning as much money as they did before the accident, such as hearing loss. Some states split partial permanent disabilities into two categories: schedule and non-schedule.

Scheduled injuries include a commonly used part of the body, including a leg, hand, or eye. A worker who permanently injures a part of the body specified in the schedule is eligible for some weeks of disability payments.When an employee has suffered a permanent partial injury not specified on a timetable, the state law determines their disability compensation.

Permanent Total: The worker suffered a permanent injury that they cannot recover from. As a result, the worker cannot gain additional income by doing the type of job that they were doing at the time of the accident. A permanently and fully disabled worker usually earns 66.666% (or any other defined percentage) of his average weekly salary for the rest of his life. Benefits stop in some states when the worker hits the official retirement age.

4. Death

If an employee dies due to a work-related injury, the worker’s spouse, minor children, and other dependents receive death benefits. The company also covers all costs associated with the burial.

What is a Third Party Administrator for Workers' Compensation?

A third party administrator is an organization that offers management services for workers’ compensation to another organization, such as handling claims and administering employee benefits under the contract. Insurance firms, self-insured businesses, and other companies often outsource the payment procedure of their claims to third parties.
Some of the functions and duties of a good third party administrator for workers’ compensation are to:

How Does FMLA and Workers' Compensation Work Together?

FMLA is a federal law that calls for employees to be given time to take care of severe health problems that render them unable to do their job. The time provided may be used for the employee’s sickness or the urgent medical needs of their immediate family members. Employees are usually allowed to take up to 12 weeks every year for leave. FMLA only applies to organizations with at least 50 workers.
In FMLA, medical and family leave is given to offer unpaid time off for workers to recuperate. Workers’ compensation during this time includes financial assistance both for housing and medical expenses. In certain circumstances, both can be applied simultaneously to a workplace injury or illness.

How to Qualify for Both FMLA and Workers' Compensation

Granting FMLA time at the same time as a worker’s compensation claim is permitted. The requirement is a medical report issued by the healthcare provider of the organization, stating that the accident or disability is the result of work. The report is to make sure the workers’ compensation requirements are met and taking time off as leave for FMLA is necessary.
Workers should be mindful that workers’ compensation leave may be counted against their FMLA leave entitlement. FMLA leave and workers’ compensation leave can run concurrently if the absence of the employee is due to a qualified, severe illness or injury. The employer correctly notifies the employee in writing that the leave should be recorded as FMLA leave.

How Long Can You Receive Workers' Compensation Benefits in California?

Every single case should be approached differently. Some people are eligible for disability insurance for days and others for months. Temporary disability payments in California often continue until one of the following incidents occurs:
When the condition needs a recovery time of more than 104 weeks, or it appears the person will never be able to return to work, they may be eligible for permanent disability benefits.

How Many States Require Workers' Compensation Insurance?

Texas is the only state in the U.S. that doesn’t make it a requirement for private employers to offer workers’ compensation insurance to their employees. Public employees are still expected to purchase workers’ compensation insurance in Texas. However, employers who don’t buy workers’ compensation insurance lack some essential protection against claims by injured workers. Uninsured companies may be liable for punitive damages if they lose a lawsuit.

Want to find out how we do it? Read on, or contact us for a quick chat.

How Does Social Security Disability Affect Workers' Compensation?

If some workers have work-related disabilities or accidents, they may be eligible for Social Security disability insurance and qualify for workers’ compensation insurance. However, workers cannot earn the full sum of payments from Social Security and, at the same time, the full benefits from workers’ compensation.
In most cases, Social Security needs a decrease in Social Security Disability Insurance (SSDI) payments. The average monthly payment a disabled person earns is not more than 80% of the amount the employee received while working without the disability. The method Social Security uses for adjusting disability payments to makeup for workers’ comp is called workers’ compensation “offset.” The guidelines on how social security measures workers’ compensation offsets are often complicated.
Worker’s compensation policies vary from state to state. Each state has specific regulations on issues like the overall workers ‘ compensation that can be paid out, the various types of benefits, and the ways through which a person can resolve a worker’s compensation case.

How Social Security Determines the Offset

To calculate the value of the offset for a single individual, Social Security first calculates what it terms as the “applicable limit,” or the maximum monthly cumulative amount of combined benefits that the beneficiary is permitted to receive under federal law.
When an applicant earns more money in any given month than the applicable limit, Social Security must compensate SSDI in the amount needed to get the sum back down to the applicable threshold. Workers’ SSDI insurance supplements apply most frequently among people who received lower wages than when they were working. Their applicable limits are smaller and can be easily surpassed once the worker begins collecting SSDI and workers’ compensation.

Applicable Limit (Highest Possible Amount of Benefit)

The applicable limit is the highest value of one of the following:
The 80 percent of earnings will be higher for most SSDI recipients, and Social Security will use that number in the offset estimate.Worker’s compensation lawyers also seek to negotiate mediation settlements to mitigate any SSDI benefits offset. Social Security must analyze the terms used in the workers ‘ compensation contract agreement to assess how much of the contract is subject to liability.

How Much Does Workers' Compensation Pay in Texas?

Compensation of workers pays for all medical treatment necessary for a work injury, as long as it is recommended or approved by the doctor.Here is a rundown of the benefits offered by Texas legislation for workers’ compensation:

Temporary Income Benefits

If you have to miss work while recovering from your injury, or if your injury prevents you from earning your usual salaries, you may be able to collect temporary benefits. Texas calculates these benefits using a formula: 70% of the difference between the workers’ average weekly wages and the wages they can earn after the injury, or 75% if they made less than $10 an hour.
State law sets upper and lower limits for the benefits. The maximum and minimum amounts depend on when the employee was injured or started receiving occupational illnesses benefits. The maximum for injuries that occurred between October 2019 and September 2020 was $971 per week, and the minimum is $146.
When the medical progress reaches its completion, the doctor will examine the employee to assess whether the work accident has left them with a permanent loss of function or disability (impairment). If so, the physician should rate the severity of the condition from 1% to 99%.
Over a period determined by the disability level, the employee would be entitled to receive benefits: three weeks for each percentage point. In Texas, these payments are called impairment income benefits (commonly known in many other states as partial permanent disability benefits).
The weekly compensation total before the accident would be 70 percent of the average weekly salary. There are boundaries here, again. The upper limit for disability compensation payments was $639 for accidents during the fiscal year 2018.

Supplemental Income Benefit

If the workers meet all the requirements below, they will be entitled to seek additional income benefits after their disability income benefits have run out:
As long as the workers qualify, they can receive up to 401 weeks of additional income benefits. The difference between 80 percent of the pre-injury wage and post-injury wage is used to calculate the weekly benefit amount. You will earn 80 percent of the amount, subject to the same maximum and minimum as impairment income benefits.

Supplemental Income Benefit

Texas also allows benefits for lifetime income, but only for a few serious types of impairments:
Lifetime income benefits account for 75 percent of the regular weekly pre-injury pay, with the same maximum and minimum as temporary income benefits. However, unlike other forms of benefits, lifetime income benefits are raised every year by 3 percent, irrespective of the cap.

What are Federal Workers' Compensation Benefits?

The Federal Employee Compensation Act (FECA) offers protection for workers as compensation to federal employees who suffer from job-related accidents or diseases. The law also guarantees certain employment rights for employees upon recuperation. Upon returning to work, employees will be treated as if they had never left when it comes to rights and benefits.
FECA offers insurance coverage for disabilities to U.S. civilian workers due to personal injuries suffered while in service or employment-related illness. FECA also makes provision for the payment of benefits to dependents if the injury or disease causes the employee’s death.

What are the Different Types of Workers' Compensation?

The different types of workers’ compensation are:

Missed Wages: If your employee is forced to miss work, the worker’s insurance can cover the missed wages.

Health Bills: The accrued work injury-related medical expenses.

Repetitive Injury: This category can be related to back injury or chronic carpal tunnel issues. If a repetitive action at work causes the injury, medical care is covered for that injury.

Illness: If something at work causes an illness, it is also part of the policy to cover the medical bills for that.

Disability: The insurance must cover all medical costs and missed income if the incident or illness has caused permanent disability to the employee.

Funeral Costs: The policy covers the cost of interment in the devastating event that an employee loses his or her life on the job.

Ongoing Treatment: If there is a need for ongoing medical attention after the incident or injury, medical treatment is provided.

What Benefits are Available Under Workers’ Comp?

As stated above, there are four types of benefits under workers’ compensation: medical coverage, rehabilitation, disability, and death benefits.

When Do I Report a Workplace Injury?

After a work-related accident, you must report the accident to your employer as soon as possible. You may not know instantly that you are injured. In this situation, it’s best to inform the employer of any incident within 14 days.

How Should I Inform My Employer if I’m Injured?

The first person you can tell, including human resources, is your direct boss or someone in an authoritative role. The notice can be verbal; it need not be in writing. Your boss will provide you with a form to fill where you’ll share the specifics of what happened.If your employer does not wish to file a claim on your behalf, you can go directly to the Workers ‘ Compensation Division and file a claim yourself.

How Much Time Do I Have to File a Workers’ Comp Claim?

Usually, the deadlines for making lawsuits are between one to three years after the incident. However, some states require more time. If your employer offered any medical benefits before you made a claim, the filing period does not begin until such benefits end. Many states include a few limited exceptions to the time limits for filing claims, even when the injured employee was unable to file a claim immediately because:

What’s a First Report of Injury or Illness Form?

This is an incident report that has to be filed by your employer within seven days of death, illness, or serious injury. It provides an objective description of the incident and information about the conditions in the workplace that could have contributed to the claim. There are also fields where witness information is included for further investigation.

What Laws Govern Workers’ Compensation?

State laws govern and make policies for workers’ compensation for employers, depending on their location. The rules and policies in place may vary wildly from state to state.

Can I Get Workers’ Comp if My Job Makes Me Sick?

Yes, you’re eligible for workers ‘ compensation benefits if you become ill due to your workplace environment or duties.

What if My Workplace Injury was My Fault?

Part of the workers ‘ compensation scheme aims to offer insurance to injured employees without the need to prove who was responsible for the accident. There are some instances, though, where a worker will not receive benefits. For example, a worker does not obtain compensation for self-inflicted injuries, wounds arising from fighting or horseplay, or injuries that occur while the worker is under the influence of alcohol or illegal drugs.

Can I File a New Claim if I Already had a Medical Condition and an Accident Makes it Worse?

Yes, you can. However, you or your attorney will have to prove that your worsening condition is precisely due to your workplace or duties. You would need to prove that due to your job, the condition got worse or reappeared again.

What Does Workers’ Comp Pay if I Die on the Job?

Each state, insurance company, and policy has its provisions and variations. In general, workers’ compensation death insurance will help in the following ways when a job accident causes the death of an employee:

Can I Go to My Doctor for Treatment for My Work Injury?

This depends on your state’s laws and the workers’ compensation insurance policy requirements for your employer. Ask your boss if a particular doctor must treat you or whether you can choose your doctor.

What Can I Do if I Need to See a Doctor for My Work Injury, But My Employer Won’t Approve My Claim?

The first thing you need to do is find out why your employer won’t support your claim. Whatever the reason for that, you still need medical treatment. In this event, to find out what to do next, we suggest working with a worker’s comp lawyer. You have the right to see a doctor, so you should not be depriving yourself of medical attention, but you will need legal protection to ensure coverage.

How Long Do I Have to Wait to Start Getting Workers’ Comp Benefits?

You will start getting compensation benefits within 14 days, once your claim is accepted. However, this is a general guideline and may be unique in your case.

What if I’m Permanently Disabled from My Work Injury?

If an accident at work has left you with permanent damage, you may be entitled to permanent total or lasting partial disability benefits (in some states), as explained above.

How Much Does Workers’ Comp Pay for My Lost Wages?

Workers’ comp pays, with a maximum and minimum limit, about 70 percent of your average weekly wages (AWW). These amounts change each year and will depend on your state.

How is My Average Weekly Wage (AWW) Determined for My Workers’ Compensation Payments?

This figure is determined by adding the cumulative earnings of the injured worker for the year before the accident and dividing that amount by 52 (number of weeks in a year).

If I’m Permanently Disabled, Can I Just Get a Lump Sum Instead of Weekly Payments?

Payments are usually given on a continuing weekly basis, but there may be occasions where a lump-sum is an option. This situation typically happens when you’re being asked by the insurance provider to surrender the right to seek further reimbursement. Talk to your workers’ compensation lawyer before you approve the terms of a lump-sum.

Can I Sue My Employer Instead of Going Through Workers’ Comp?

No, the workers’ compensation laws protect employers from such employee lawsuits. Consider that the “no-fault” policy is a trade-off. However, your rights are still fully protected, and any claims filed are subject to reimbursement by compensation for the workers. There may be cases where a claim is denied, which may require proceedings. An attorney can be of great help in instances like this.

What Can I Do If My Employer Doesn’t Have Workers’ Compensation Insurance?

All the states in the U.S. except Texas require workers’ compensation insurance from all public employers. You may need to sue the employer directly to recover your expenses and receive compensation when an employer violates this law.

What Do I Do if My Employer and/or Their Insurance Company Denies My Claim?

If you were denied your initial claim for workers’ comp benefits, you could take steps to get your compensation. After your initial denial, the first step is to lodge an appeal with the Department of Workforce Development. An appeal is a demand for a formal hearing, and the process may be lengthy and complicated.
Next, you should collect all the supporting evidence, including medical exams, financial information, and more.After that, you need to fill out the Readiness Certificate, and then you can file all of the paperwork and schedule your hearing date with the Hearings & Appeals Division (DHA). We highly recommend that you get an attorney for these processes because it could be long and complicated.


Worker’s compensation is compulsory in all states in the U.S., save for one, but the policies and procedures might vary by state, organization, and insurance provider. Find out about the policies and rules of your company or insurance provider, so that you’re not at a disadvantage in case of a workplace injury.
There are almost no drawbacks to worker’s compensation for either the employer or employee because it allows both sides to bear fewer risks. Your employer gets protection from lawsuits and you get access to the benefits you deserve.
Revenue Cycle Management

FAQs on Revenue Cycle Management

What are RCM services?

RCM services refer to all the administrative duties and tasks that constitute the capture, management, and collection of revenue offered by your patients.
Depending on the size of your health institution, you might opt to deal with RCM services in-house. With time, your increased operations and scope will require you to hire a third party for more professional RCM services.

What are RCM services?

There are many things you’ll need to be on the lookout for, but most importantly is the reputation of that particular provider. For a start, make a comparison with various providers, read their customer reviews on Quora and leading industry publications. This will help you see what others have experienced with that RCM service provider.
A good service provider should have a proven record of enabling health facilities to turn around their finances. What is their client base? How many years of experience do they have as an RCM service provider?
Evaluate your prospect by analysing their professional affiliations. Customer service is also a key component you need to consider. A good provider should be able to respond to calls from their clients who need help at anytime.
To stay ahead of everyone else, your service provider should embrace continuous learning. Ongoing training and certification of its staff will ensure that the team remains appraised of all current trends in the industry. This will help guarantee that employees are aware of any changes in the RCM guidelines.
It would also be useful to inquire from your colleagues about their opinion on the current RCM service providers in the market if they’ve tried any of them in the recent past.

Are certified coders in charge of your account?

Authentic service providers are key elements in any industry, especially the health sector. In medical billing, most of the claim rejection comes from wrongful coding. This is why it is critical to ensure your service provider is working with certified coders.
A certified coder without a doubt means that they are properly trained and qualified on matters regarding coding.
Coder’s certification is undertaken by the AAPC and the AHIMA in the United States. They ensure their members can demonstrate practical coding experience. They also ensure members have the required pass for getting coding credentials. Certification is done on a rolling and renewal basis to ensure that the coders continuously update their knowledge in matters coding.

How much does RCM Services cost?

Every organization wants to be appraised of the cost of integrating RCM services. This is helps you to better understand the cost impact on your organization. It is important to note that the cost impact will be different in each case. For instance, it will be dependent on the number of patients you serve, the different insurers you’ll be dealing with and your amount of patient encounters. The state your practice operates from also plays a huge role in the cost implications of RCM on your organization.
Due to the various uncontrollable factors that affect the cost of RCM, it is prudent to instead look at how much your practice will save in both the short and long term.
Hiring new staff to handle the increased revenue compared to the cost of doing the same using a certified RCM service provider will give you a better perspective of the cost benefits.
RCM has many cost advantages, including minimizing losses that arise due to claim denial and speed of revenue flow when a good RCM provider is hired.

Does the provider offer denial management on current claims?

Claims denial forms a persistent source of revenue losses. This is why you need to employ an RCM service provider who will offer you proper claim denial management on your current claims. According to HealthCare News,most executives of health facilities use an RCM vendor to manage their denied claims. Only 31% use manual processes,while another 18% of executives prefer using in-house tools to manage denial of claims.

Outsourcing RCM services to seasoned professionals improves your practice’s bottom line. It will bring down the number of denied claims considerably.
A common solution process employed by RCM vendors when dealing with claim denial management is automation of tasks, which easily shows the source of a claim denial. The automation also subsequently speeds up the resubmission process.
Organizations that rely on outsourced RCM services can improve their bottom line when they rely on experienced professionals to lower the number of denials as much as possible. Part of the solution is for the RCM services provider to automate tasks to get to the root cause for denial and speed up the claim resubmission process.

Will they analyze and track all of my rejected claims?

What is causing so many rejected claims for your organization? A knowledgeable medical billing service provider can effectively tackle all the denied claims for you. They take up less time to get to the root cause of the claim denial compared to your staff.
The data analytics provided by your providers as to why certain claims are denied more frequently compared to others will prepare your staff on how to deal with such in the future. Data analytics is essential in determining quick future payments that are made on time as compared to the waiting that comes with clearing up coding errors and all the common issues that normally delay your income flow.

Will investing in RCM Services make us a better practice?

The goal of RCM services is to improve the bottom line of your practice. Bringing professionals into the picture who are well versed with efficiently dealing with issues that compound revenue loss can help make your practice better. You can also expect the RCM service vendor to be adequately updated on RCM best practices.
Additionally, investing in RCM services gives you an extra pair of hands. This allows you to focus more on patients’ well being as the RCM professional labour for you on the revenue collection side.

Will investing in RCM Services save us money in the long-term?

How much time and resources does it cost you to request claims workers to handle the claim processing? If you continue handling these tasks in-house, think of the cost in terms of time and resources that you stand to incur. Recruiting and evaluation of new billing staff, as well as their ongoing training and certification, can take a big chunk of your profits.
You can choose to invest in an RCM service provider to save you all that hassle. Moreover, such companies work with professionals who are passionate about their job and who want to build and maintain a good reputation for working with a company that is focused on revenue management.
Take advantage of the expert’s efficiencies and expertise to streamline your revenue flow. They’ll do what you’ve struggled to do in-house but only in a better and quicker way. This will speed up your income flow, which also equates to more disposable income at your organization.
That is what will make your practice better in the short and long term if you choose to invest in RCM services.

Why shouldn't I just manage my billing in-house?

No law restricts you from taking care of your billing in-house. It is especially not an issue if your practice deals only with a few patients and fewer insurance providers. Dealing with billing in-houses in such cases helps to keep your services lean and small.
However, this means more work handed over to your staff. Besides, in case your staff are on sick leave or vacation, this can cause a huge inconvenience. You’ll be required to hire replacement workers temporarily. If not, then you’ll be forced to divert your in-house human resources, which then forces you to make up for the staffing deficit in your budget. This will eventually eat into your profits.
In-house billing deprives you of the chance to work with third party professionals who are experienced and dedicated in matters of revenue management. The expertise they have garnered from always focusing on RCM for different health organizations can be of great value to your practice.

Does the billing company prepare you ahead of time for fee schedule changes?

Have you considered that your revenue losses are due to your team not being appraised of governmental and industry changes with regards to the payment process for medical services provided? For instance, Medicare updates it’s fee schedules periodically, and your staff needs always to be updated of such. Moreover, they should always anticipate what to expect in the near future.
RCM service providers you hire should also monitor such information. If you’re well prepared in advance about any changes in fee schedules, you’ll easily plan, especially if you expect your income to dip the following year after the revised fees. RCM service providers, therefore, make up an integral part of your yearly budgeting.

How does RCM work in medical billing?

Note that medical billing denotes the paperwork that goes into the filing of medical claims for reimbursement from an insurance company. On the other hand, RCM includes services such as reporting and analyzing the flow of income as well as the patient’s financial services. RCM extends over and above filling out medical billing claims.
Medical billing is just a subsection of financial management that we refer to as RCM. Revenue cycle management is crucial to your organization’s successful handling of medical billing processes. It supplements the billing components by analyzing, tracking, and managing the process of patient claims on accounts receivables.

Want to find out how we do it? Read on, or contact us for a quick chat.

What are the six stages of the revenue cycle?

Step 1: Patient Pre-authorization

After procuring an RCM software, the first step in the revenue cycle is the patient pre-authorization. According to the U.S government,it is defined as a decision by a health insurance company to acknowledge the necessity of prescription medication, medical procedure or service and equipment. In case of a medical emergency, the patient’s pre-authorization is often an exception.

Step 2: Eligibility & Benefits Verification

The second stage is the front office’s task of checking the eligibility and benefits of the patients according to their insurance cover. RCM software helps to speed up this process as manual tracking over the phone can be gruesome and quite tedious.

Step 3: Claims Submission

After the eligibility verification, the payment process only becomes forthcoming when a claim is submitted. RCM facilitates the claim submission process flawlessly and speedily. Automation of this process saves time and provides the option to submit claims in batches. It’ll also help to detect any errors in the claim submission process. RCM service providers also make claim resubmission a quick task.

Step 4: Payment Posting

The payment posting step is where the insurer is now able to pay for the services received by their subscriber. RCM software generates billing statements conveniently. You can also use the system to send messages to patients electronically with a “click here” to pay option to encourage them to reimburse you more quickly.

Step 5: Claim Denial Management

How frequently does your facility get its claims denied? The claim denial management stage is set up to investigate and minimize revenue losses due to denial of claims.
When properly executed, denial management can significantly boost your organization’s earnings, especially if money has lately been slow because of problematic claims.

Step 6: Reporting

Reporting is the final stage of any revenue cycle process. This stage generates reports for your meetings to help your organization plan and meet future targets quickly and easily.
It is good practice to utilize RCM software that can customize reports, including financial data, management information, and key performance indicators.

What is RCM in audit?

Your medical organization needs to perform revenue cycle audits at least once every 3 months. Depending on the size and scope of your practice, you might need an audit once every month.
Technological advancements are steadily evolving. This has forced companies to integrate EMR and billing systems.A review of each patient encounter is necessary,especially at the point of occurrence and before the bill is sent to the insurer.
The purpose of RCM in audit is 2-fold;
Audits in RCM captures insight into how well the overall process of revenue capture is working.

What is RCM in risk management?

In risk management, RCM is mainly used to develop a list of maintenance tasks and strategies. The RCM maintenance tasks are based on; how reliable the system is, the components of the system and the failure impact. This is how RCM and Risk Management go hand in hand.
The 7 common steps between RCM Process and risk management are:

What is the revenue cycle process?

The revenue cycle constitutes all the administrative as well as clinical functions that contribute to the capture, management, and collection of revenue of patient services. In the most basic terms, it is the entire life cycle of patient accounts from creation to the payment.
Your revenue cycle process must integrate best practices for billing and collection of payments in accordance with insurer or payor requirements. All services within the revenue cycle must be paid in full.

What is front end revenue cycle?

The front end revenue cycle is made up of the patient scheduling, registration, insurance eligibility verification and authorization, and finally, the upfront patient collections.
The front end revenue cycle relates to the processes of direct patient interaction. However, it is different from the back-end since the latter relates to claim management and reimbursements. Although they operate differently, the front-end is critical to the success of the back end processes.
All medical billing processes commence at the front desk. And there must be synergy between the front and back-end process for a successful revenue cycle.

What are the five business activities of the revenue cycle?

In business, the revenue cycle relates to activities that constitute the exchange of goods and services for monetary payment. The revenue cycle business activities may vary slightly depending on the size and type of business but are basically categorized into the 5 activities below.

1. Selling Product or Service

The cycle starts with the selling of a service by a business company to a client. This stage involves proposals and pitching to potential customers. The proposal includes disclosing terms of the sale, warranties, and any incentives that may be provided.

2. Documenting an Order

In business, the revenue cycle relates to activities that constitute the exchange of goods and services for monetary payment. The revenue cycle business activities may vary slightly depending on the size and type of business but are basically categorized into the 5 activities below.

3. Service or product delivery

Service delivery is the revenue cycle process at the center of a company’s business activities. It is a critical stage that affects the subsequent stages, especially in case of any delays.
Verification of any information on the business contract should be done to avoid costly mistakes in the revenue cycle. Besides, changes made during the delivery stage of the revenue cycle necessitates a review of the entire contract to incorporate the changes.

4. Billing

As with any revenue cycle, billing is the business activity that is most looked forward to by the business entity. The time taken by this process depends on how the practice operates.
Some businesses work on pre-payment while others operate on post-payment. The billing can be done prior to or after the service has been delivered, depending on the mode of payment.

5. Collections

The last business activity is the collections. This is where a medical practice puts measures in place to collect any outstanding patient payments. Some practices may write off some debts as bad debts while others pursue other means of collection to recover their payments fully.
The collection process is just as essential as a business activity as any other; hence requires serious analysis. This will help to modify previous activities so as to collect more money and streamline the revenue cycle of a business.

What is the difference between RCM and FMEA?

RCM as a tool is used to ensure that a process such as the revenue cycle of a practice is reliable. This is done by designing the inherent software functions, functional process failures such as the coding and billing process, modes of failures, as well as the impact of the failure (for a medical practice this is likely revenue loss.)On the other hand, FMEA is mainly used to reduce risks before a process is implemented.
In addressing equipment functions, RCM addresses performance standards as well as asset functions while FMEA functions are higher and do not, therefore, address performance standards.
These are the most frequently asked questions concerning revenue cycle management processes and best practices. Understanding them will help your practice to navigate the revenue cycle efficiently and reduce revenue leakage points and denial of claims.
A medical practice that addresses these questions correctly will eventually enjoy a streamlined RCM process and increase its income flow.
Medical Billing Statement

FAQs On Medical Coding

What is medical coding

Medical coding is defined as the transformation of healthcare services such as diagnosis, medical procedures, and equipment into a universally known alphanumeric code. The diagnosis, as well as medical procedure codes, are extracted from documented medical records. These include physician’s notes transcription, radiological and laboratory results, among others.
Medical coding is applied correctly through the billing process by professionals. This process relates to the abstraction of documented information, assigning of appropriate codes, and the creation of a claim for reimbursement purposes.
Medical coding is a continuous process that is undertaken in every instance of patient interaction. Whatever information the physician records during this interaction forms part and parcel of the medical coding process. Besides, it’s a critical record for ensuring the physician gets paid.
Medical coding requires the ability to understand anatomy, physiology, and details of the services, and the rules and regulations of the payers to succeed.

Why is medical coding important

The revenue flow of a healthcare organization relies upon the documented records of what was decided and performed. The documentation of a patient’s visit is, therefore, very critical with regards to payments and improving future service delivery. Once a patient’s record is opened, it will follow them through all the subsequent complaints and treatments and hence should be clearly understood.
The healthcare revenue stream is based on the documentation of what was learned, decided, and performed.
Medical coding is important because it simplifies the identification and categorization of the many conditions, diseases, injuries and causes of death for the purpose of payment.
Medical coding also helps to standardize the medical language, which uses multiple descriptions, names, eponyms and synonyms for diseases, tools and procedures. This makes it easy for anyone who is medically informed with these terms to understand and refer to them, especially in the case of insurance companies.
Medical coding is a common language mandated by the senior medical authorizing body in the nation. It allows hospitals, healthcare providers and payers to have seamless and consistent communication with each other. Most of the private health information is digitally stored and rests on the assigned codes.

What is medical billing and coding

Medical billing and coding form the backbone of the revenue cycle in the healthcare industry. It is a system that ensures both payers and patients reimburse healthcare providers for the services delivered.
Medical billing and coding transform a patient interaction into the common languages used inthe submission of claims and reimbursement by insurers.
Although the two sound like separate processes, they’re equally crucial in receiving payment for healthcare services.
Medical coding involves retrieving billable information from medical records and clinical documentation, while medical billing, on the other hand, utilizes those codes to create insurance claims and bills.
The two intersect at the point of claim generation to form the backbone of the healthcare revenue cycle.
Medical billing and coding commences with patient registration and winds up at the full reimbursement of the provider. Depending on the complexity of the services provided, medical billing and coding can take days or even months.
The fundamentals of medical billing and coding should be well understood by healthcare organizations. It will ensure providers and general staff operate a smooth revenue cycle and recoup all of the reimbursement allowable for the delivery of quality care.

How medical coding works

A trained and certified medical coder undertakes medical coding. A medical coder starts the process of medical coding by reviewing the physician’s notes of the previous day’s batch of patients.
Reviewing the patient’s documentation helps the coder to understand the diagnosis that was assigned and the medical service that was offered to that patient. Medical coders get vital information such as the name of the physician, time and date of the procedure.
Medical coding professionals rely on ICD-10 and CPT code books for the translation of the physician’s notes into some more useful medical codes.
For a professional coder, the process is simple, but occasionally some cases require in-depth research and take more time to complete the coding. Complex cases bring up confusion, especially in the coding guidelines,and thus the coder will have to consult their peers.
The final step in the medical coding process involves completing the chart and picking on the next patient’s record. The cycle of reading, taking notes, assigning codes, and computer entry is repeated for each chart. Medical coders will spend their day in the office sitting at the computer reading notes and entering data into a computer billing system.

What is remote medical coding

Some medical facilities hire coders who work from home instead of the in-house offices. This form of outsourcing lets you pay for only what you need when you need it. Remote medical coders work away from the health institution they are paid to code for.
Some medical coders remotely work for giant medical coding companies while others work as freelancers at the comfort of their homes or personal offices.
For remote medical coding, the medical facility sends patient’s documents, charts and physician notes to the remote coder through fax. The coder then commences the general medical coding process.
After completion of the coding process, the remote medical coder forwards them to the insurance company and health facility.

What is ancillary medical coding

Ancillary coding is where the physician who makes the first patient encounter refers the patient to another trusted professional. Ancillary services are described as any supportive or diagnostic measures that help to treat a patient’s condition. For instance, these services may include anything else except room and board or direct medical care by a nurse or physician.
Ancillary coders identify a patient’s diagnosis and match the subsequent services offered by the physician to the right code. Ancillary coding requires extensive research and knowledge of medical terminologies. An ancillary coder must possess the ability to communicate effectively with physicians and other health care professionals.

Why is coding for procedures so important for a medical office

Medical coding is performed as part of the health facility’s compliance with regulatory and contractual needs. Health Insurance Portability and Accountability Act (HIPAA) requires that medical practice protect patient information. The HIPAA guidelines also contain the ICD-10, which provides uniform diagnostic codes.
Accurate coding ensures medical practices comply with insurance contracts. Contracts with insurance companies outline the negotiated reimbursement rates for medical services.
Medical coding provides a comparison chart for the administrative functions. It expedites the payment of services for physicians.
Moreover,a medical organization needs to consider medical coding to plan for the understaffed health areas.
Finally, coding helps you identify symptoms that must be addressed by other physicians.

How can technology reduce errors in medical coding

Technology continues to disrupt the healthcare industry. This is bound to change how medical coding is performed. The features of medical billing found in HER systems help independent physicians to check for any errors automatically.
Maintenance of accurate patient data in the Electronic Health Records system also prevents errors in the patient’s information provided in the claims. Medical coding has reduced errors and claim rejection greatly because of the use of technology.

What is an advantage of using medical coding

There are several benefits of using medical coding. These include:

What is the process of medical coding

The process of Medical coding is where medical coders assign internationally recognized numerical codes to medical diagnoses and procedures to bill insurance companies and facilitate reimbursement for healthcare services.

What is a diagnostic phrase in medical coding

In medical coding, a diagnostic phrase is defined as the identification of a patient’s condition that requires medical care. A diagnosis comes after a physical examination.
Clinical codes are also used if that is the only patient information available to the physician concerning the patient’s condition.
If a patient is suffering from a chronic condition, the medical coder must identify, in the Alphabetic Index, if there are separate entries at the same indentation level.
Diagnosis coding captures the state of illness of the patient as well as chronic disease during outpatient care and inpatient admission. This important information relays the patient’s health record to other healthcare specialists, insurance payers,and data registries.

What certifications are needed for medical billing and coding

Medical coding certification is not a legal requirement; however, individuals with this certification are likely to get employed quicker and earn higher salaries. The medical coding certification shows that you have acquired fundamental foundational coding knowledge. Certified medical coders are more efficient and offer more value.
Different medical coding certifications exist. They include:
Different organizations issue each of these 3 certifications.

What is a v code in medical coding

The ICD guidelines,as noted in the sections I-IV, specify that unless otherwise indicated, V codes apply to all healthcare settings. Specific use of V codes is provided for in section I C.18 for codes in category V01 up to V91.
Section I C.18, titled “Classification of Factors Influencing Health Status and Contact with Health Service,” provides specific coding guidelines for the use of V-code categories V01–V91.
V codes in section II, “Selection of Principal Diagnosis,” and section III, “Reporting Additional Diagnoses,” apply to inpatients in acute care, short-term, long-term care, and psychiatric hospital settings.
Section IV, “Diagnostic Coding and Reporting Guidelines for Outpatient Services,” provides V-code instructions for the outpatient and physician office setting. The outpatient setting includes reporting by home health agencies.

What does CMS stand for in medical coding

In medical coding, CMS stands for Centers for Medicare & Medicaid Services. This is a federal agency within the U.S Department of Health and Human Services. CMS administers the Medicare program while also working in partnership with state governments in the provision of the Medicaid program.

CMS also collaborates with the states to administer the Children’s Health Insurance Program and health insurance portability standards.

CMS is also mandated with other responsibilities such as simplification of administrative standards from HIPAA 1996 standards in long terms health care facilities. It also standardizes clinical laboratory standards while also playing the oversight role for the

Previously, CMS was known as Health Care Financing Administration HCFA.

What does NOS mean in medical coding

NOS stands for Not Otherwise Specified. It refers to codes that don’t have quite sufficient information that allows the use of a specific code. To put it simply, NOS means there is little information in the documentation of a patient encounter, and this deficiency is preventing you from coding to a higher specificity.
NOS codes are rarely favored. They are a common reason for the denial of most claims because they lack specificity.

What are e codes in medical coding

E codes in medical coding are described as Supplemental Classification of External Causes of Injury and Poisoning. E codes are used to add more information to a claim. Payers use the supplemental information to research and evaluate the appropriate injury prevention methods.
E codes are varied, but they all describe different aspects of injuries. They include;
Medical coders are free to use more than just one E code in a claim. This helps provide as much information as possible about the injury of the patient.
Hospitals utilize E-codes to ensure timely reimbursement from payers. In case E-codes are not used, payers request supplemental information about the injury that could otherwise have been readily supplied by an E-code. If E-codes are absent, payment can delay until the payer obtains the necessary information. This information may be obtained from the patient or through additional record requests.

What is av code in medical coding

V codes are used to identify circumstances of patient encounters besides injuries or disease. They’re also used to report factors that are likely to cause a future health issue.
It is important to assign V codes correctly to avoid inaccurate claim denial and to report medical necessity.
While certain V codes can be used as the primary diagnosis, others are only assigned as additional codes. The V code table is included in the official coding guidelines. It indicates code sequencing rules for out patient cases.

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What does NCD stand for in medical coding

In medical coding, the NCD provides the extents to which Medicare covers services and procedures. It is a legal requirement for Medicare contractors to follow the NCD guidelines.
In cases where NCD fails to exclude a circumstance, the Medicare contractor is allowed to decide on the coverage.
Before NCD takes effect, the CMS is expected to issue a manual transmittal CMS ruling or a Federal Register Notice, which gives specific guidelines to the contractor processing the claims.
The issuance with effective and implementation dates is the NCD. An NCD becomes effective on the date listed in the transmittalannouncing the manual revision.

What is RHIT in medical coding

RHITs work in hospitals as well as office-based physician practices, mental homes, nursing homes and other public health agencies. Any organization using patient data such as pharmaceutical companies, insurance and law firms can employ the services of RHITs.
RHITs are important assets in medical coding because they guarantee quality health records by verifying their accuracy, proper entry and completeness.
They use computer systems to assemble and analyze the patient data to improve patient care and also to control costs.
RHITs specialize in coding diagnoses and procedures of patient records for research and reimbursement.

What is APC in medical

Ambulatory Payment Classifications APC in medical coding refers to the US government’s method of paying the outpatient services of a facility for the Medicare program. APCs only applicable to hospitals as an outpatient prospective payment. Reimbursement for the physician is done through other methods, such as Current Procedural Terminology(CPTs).
The APC payment is made after discharge of a Medicare outpatient from the ED(Emergency Department) or when the same patient is transferred to a different facility not affiliated to the previous one.
APC may not be payable where a patient is admitted from an Emergency Department of the clinic. In such a case, the physician will be paid by Medicare under the inpatient diagnosis-related DRG methodology.

What are the duties of medical billing and coding

Medical billing and coding take care of a range of duties,including:
While the majority of medical billers and coders work on-site in hospitals and clinics, they’re generally far-removed from where patient care is taking place.

What is j code in medical coding

J codes are subsets of the HCPCS level II codes. J codes are used by hospitals and physicians to bill for the Medicare program. They are primarily used for non-orally administered drugs, inhalation solutions, chemotherapy and immunosuppressive drugs.

What is an encoder for medical coding

An encoder is defined as a software program that uses a tree of terms to assist in selecting appropriate codes. The tree starts with a main level and then branches off, where each selection is displayed on subsequent screens. This is done to help you choose the most correct code for a set of diagnoses.
There are several variations of encoders, with some having a computer-assisted coding CAC. This element suggests the codes associated with each diagnosis in case it was previously overlooked. Encoders in medical coding play a crucial role in delivering efficient work and speeding upreimbursement.

What is AAPC in medical coding

AAPC stands for American Academy of Professional Coders. The AAPC was founded in 1988 with the aim of training and providing certification for medical coders. This would help elevate the standards of the medical coding profession through education, certification, networking and employment opportunities.
To date, the AAPC has well over 190,000 memberships with more than different types of 28 certifications that cut across the entire business side of the healthcare industry. Some of these certifications include CPC, CPMA for medical auditing, CDEO for medical documentation, physician practice management (CPPM) and Medical compliance CPCO, among others.
The AAPC certifications illustrate that a medical coding professional has working knowledge required to support neater claim submission, quicker reimbursement, lesser claims denied, and improved healthcare practices.

What does NEC mean in medical coding

In the medical coding profession, NEC stands for Not Elsewhere Classifiable. These codes are selected when information for documented diagnosis is specific, but the ICD CM code doesn’t exist to classify it. Such cases lack additional specificity in the ICD-9-CM manual but not in the actual documentation.
There are codes titled ‘Other Specified’ in the Tabulated List. They don’t always have a number 8 or 9 in the 4th/6th or 5th character, respectively. This provision allows the coder to understand that a particular code could likely be an NEC code.

What does ICD stand for in medical coding

In medical coding, the term ICD stands for the International Classification of Diseases. It provides the classification methodology for injuries, diseases and causes of death. The World Health Organization has the mandate of publishing ICDs to standardize recording and tracing methods for instances of diagnosed medical conditions globally.
This makes it possible for a universally accepted approach of conducting medical research on illnesses, what is causing them and appropriate treatments.
Although WHO publishes the base versions of ICD, member states are permitted to modify them to suit their healthcare industry needs. The ICD base classification has a code set of over 14,000 codes that enable tracking of a wide range of new diagnostic cases.
ICD-10 has an option for sub-classification, which provides for a higher level of specificity with regards to the cause, severity, manifestation and location of disease or injury. There are many ways in which the adapted versions differ – some member countries even expand the set codes further.
Any information regarding the ICD can be found on the WHO’s website. WHO also includes an online browser for ICD-10. They also provide a training resource center for ICD, which includes a self-learning tool, user guide and support forum.
These are the frequently asked medical coding questions. Healthcare organization’s CEOs should be well placed to comprehend all that pertains to medical coding to lead a successful revenue cycle management process in their facility.
An in-depth understanding of the medical coding professions helps one understand how to recruit coders and best medical coding practices that would eliminate errors and reduce the number of denied claims. This will eventually improve the provider’s bottom line with regard to their revenue flow.
EHR Integration Remain a Pain Point for Healthcare EPM-2

EHR Integration Remains a Pain Point for Healthcare

According to the HIPAA Journal, 41.2M healthcare data records were breached in the year 2019. December alone saw an upsurge in this healthcare nightmare with over 500 breaches of patient data – reported by just 28 healthcare providers. Even worse, these attacks are prone to happen over and over again, primarily due to little expenditure on data protection infrastructure. EHR integration, therefore, remains a pain point for healthcare providers as further alluded by a survey by Navigant in collaboration with the Healthcare Financial Management Association. According to the study on 108 revenue recycle executives, hospital health systems chiefs and financial officers, it was determined that healthcare providers are;

What are the implications of EHR Integration on RCM

EHR is a systemized collection of the electronically stored health data of patients and population. This digital format information facilitates an inter-system sharing of healthcare data.
EHR and Billing Processes Integration
The capability of EHR integration remains your best bet at driving up RCM benefits. However, today, healthcare providers continue to face challenges when it comes to integrating electronic health records with billing processes.
Lack of EHR systems procurement knowledge
In addition to the integration challenges, there has been a general lack of knowledge and professional input towards the procurement of the right EHR solutions. Most healthcare providers according to an Olive/Sage Growth Partners survey do not have an in-depth understanding of their EHR systems specifications. This makes procuring the correct solution a serious issue.

This is further compounded by the inadequate information of what IT vendors offer you as a healthcare provider.
Violation of Patient Privacy
One major implication of providers’ failure to adopt EHR integration is the violation of patient privacy down the line. EHR systems are designed with robust security features, which we’ll look at further in this article. These features help to protect the privacy of your patients’ data. In an attempt to address the aspect of EHR integration, most healthcare providers attempt to collaborate with external entities, which include outsourcing and vendor partnerships to improve RCP (Revenue Cycle Performance). Additionally, healthcare providers should be considering consumer-faced IT solutions. Such solutions include online portals for price estimates, payment plans, and financial counseling. This will help improve revenue cycle management.

EHR integration continues to give healthcare providers serious challenges. More so, due to the privacy matters it is meant to address.
Privacy Matters
The privacy of your patient’s data is a big deal considering the impact of serious breaches. In many instances, patients have failed to disclose their information fearing its breach could result in identity theft.

Healthcare providers who delay the crucial integration of EHR are essentially courting disaster in the form of risking violation of HIPAA. You can avoid similar violations through the integration of certified EHRs. The integrated EHRs must conform automatically to the protocol for safeguarding users against any common mistakes.

Most EHR systems come with standard features. Fortunately, the government mandates that all EHR IT solutions have features that will enable you to enjoy their intrinsic ability to safeguard your health records from breaches.

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Primary Features of Integrated EHRs

All EHR solutions should have the following integral features to ease the health provider’s heartache.

  • ONC-ATCB Certification
  • Data Encryption
  • Audit Trials
  • Password Protection
ONC-ATCB Certification

While evaluating your EHR IT solutions, check to ensure that it is approved by an ONC (Office of National Coordinator) recognized Authorized Testing and Certification Body. When evaluating EHR systems, ATCB checks for;

  • Interoperability- the EHR should be able to communicate with other systems.
  • Functionality- ability to create and manage health records
  • Security- ability to safeguard patient information.
Data Encryption
EHR integration systems solutions must provide a safety net against lackluster passwords. To implement this, information is coded in such a way that it is only deciphered or decrypted by someone with access codes or authorized programs. This should make patient data transfer a lot safer.
Audit Trials
The audit trials feature keeps track of access to patients’ records. This enables flagging of any risks such as suspicious activities that could lead to the violation of HIPAA. Audit trials will also enable you to carry out system reviews. This helps to tighten security measures by preventing and correcting human errors.
Password Protection
Password Protection With EHR continuing to be a major pain point for healthcare providers, adopting a system that is password protected can offer controlled access to patient’s information. Look out for the following password security features that make EHR systems hack-proof;
  • Lookout capability which prevents unwarranted access into the system containing patient data using wrong login credentials
  • Complex and robust password requirements that make the EHRs password difficult to guess
  • Validation of password with further security questions
  • Additional security layer provided by 2-factor authentication.
These features make EHR systems a sound solution to the breach of healthcare records and a boost for providers looking to avoid HIPAA violations.


Due to the intrinsic value of EHR integration, it was projected that EHRs would be the primary drivers for extensive performance improvements. Unfortunately, this has not been entirely true in most cases. Budget constraints continue to encumber integration of EHRs which leaves most healthcare organizations prone to breaches. According to a survey by Black Book Matters, hospitals systems protection IT budgets rose by 6% only, while physician cyber security has been on the decline since 2018. Even worse, 92% of these providers don’t even have a fulltime system security staff. However, healthcare provider’s management, it might seem, are now more intent on using an expanded IT budget to solve the data breach issues. Currently, nearly seven in 10 (69 percent) are predicting their IT budgets will rise in the coming years. In the meantime, providers are looking to leverage advanced technology to address their lack of integrated EHR systems. This is a pain point they have struggled to shake off simply because they’re finding it increasingly difficult source to invest in an area that does not produce revenue.