Revenue Cycle Management (RCM) is like a one of those huge Lego sculptures. From the outside it looks one thing, but upon further inspection there are a million tiny little pieces that fit together to create the whole. Having a well executed RCM strategy is crucial to keep your organization running because it impacts everything. When things are simple and easy to pay for, patients are happy, the staff is happy, and you are most definitely happy. But if any part is misaligned, the whole sculpture can be disformed or even fall apart. So how do we improve? How do we make our sculpture be more realistic? The key lies in optimization. We need to be looking for areas that we can simplify to make everyone’s life easier.
But equally important to keep in mind as we optimize our RCM sculpture, as we optimize old practices, we need to prepare to adjust to the new changes. For example, for Legos any curves needed to be built using rectangles, because that was all that was available. To simplify this, Lego found ways to create arched pieces. But in optimizing the process, the old instruction manuals were now outdated and adjustments needed to be made.
To better understand ways that RCM can be optimized and how to best prepare for any needed adjustments, we reached out to our incredibly talented Healthcare IT Today Community for their insights. Below is what they had to share on this topic!
Kyle Sherseth, Vice President, Revenue Cycle Solutions at Savista
Revenue integrity programs aid in the identification and correction of process inefficiencies, thereby improving the overall revenue cycle. When done right, revenue integrity management supports the delivery of high-quality care, enabling providers to reinvest in staff, infrastructure, and technology, and ultimately improve patient outcomes. A successful revenue integrity program requires a multidisciplinary approach with the involvement of executive leadership and the establishment of a culture of transparency and accountability.
Ron Wince, Founder & CEO at Myndshft Technologies
Addressing inefficient prior authorization processes remain a crucial aspect of effectively managing the revenue cycle. Barriers to patient care lead to delayed procedures and denials that negatively impact healthcare providers’ bottom lines. Automating the process enables timely care while reducing operational costs creating a win-win for providers and patients alike.
Jordan Miller, Senior Medical Director of Dermatology at ModMed
U.S. doctors lose an estimated $125 billion in revenue each year to avoidable errors, such as incorrect patient or provider information, invalid or missing codes, duplicate billing and missing documentation. Integrated EHR and practice management systems with AI capabilities mitigate those mistakes because they can automatically suggest relevant ICD-10, CPT, and modifier codes. Automating coding and billing can also expedite the billing process and reduce administrative burden on clinic staff.
Huntley McNabb, Vice President at Nordis Technologies
Revenue cycle management communications can play a key role in rebuilding patient trust in healthcare, which fell sharply during the pandemic. Trust in information from doctors declined 23%, 21% for hospitals and 16% for nurses, according to Trilliant Health’s 2022 Trends Shaping the Health Economy. Just 23% of consumers completely trust the healthcare industry, according to Salesforce. To restore consumer confidence, providers need to leverage communications along the patient financial journey, from appointments to billing and payments. Consumers who trust healthcare organizations are 6X more likely to receive timely communications than consumers who don’t trust these organizations, Salesforce found. Using cloud-based communications platforms that enable mail, email and text messaging, providers and their RCM partners can personalize timely communications to increase engagement, improve patient financial experience and speed payments.
Clara Lambert, Director of Financial Navigation & Product Subject Matter Expert at TailorMed
Affordability is a major challenge for patients and healthcare organizations alike, and should be addressed as early in the revenue cycle as possible. Often, a patient’s financial distress is not recognized until it results in unpaid claims, which negatively impacts not just the patient, but also the wider healthcare system. For example, total patient statements with balances of $7.5K+ tripled between 2018 and 2021, while statements with balances of $14K+ nearly quadrupled in that time. These higher balances have created new challenges for providers and health systems, often resulting in dramatically lower collection rates. Providers must assess patients’ need for financial support on the front end of their intake process. With the help of technology, healthcare organizations can flag at-risk patients early on and help them locate and leverage financial resources before they receive a bill they cannot afford. Proactively addressing affordability ensures that bad debt and uncompensated care are avoided. This means more captured reimbursement for providers to bolster their financial health, as well as enhanced patient financial experiences.
Patrick Murphy, General Manager, TruBridge at CPSI
Leveraging advanced revenue cycle management software and analytics brings tremendous benefits to hospitals and health systems. By automating and streamlining billing, coding, and claims processes, healthcare providers significantly reduce administrative burdens, minimize errors, and accelerate reimbursement timelines. This not only improves cash flow, but also reduces costs associated with manual labor and inefficiencies. Adopting a patient-centric mindset is also crucial as organizations automate their revenue cycles. Healthcare providers should prioritize transparency and patient communications to ensure patients fully understand their financial responsibilities and are actively engaged in the billing process. The patient’s financial experience is remarkably enhanced with a streamlined revenue cycle process including clear and concise explanations of charges, available payment options, and personalized financial counseling. The two sides of revenue cycle automation (internal operations and patient engagement) work together to minimize confusion and potential disputes on the back-end for all stakeholders.
Shannon White, Chief Operating Officer at Ensemble Health Partners
It is critical to look at the RCM process holistically – too often provider organizations bring in technology partners that only address individual friction points within the revenue cycle, often leading to more fragmentation. One of the most fundamental ways that providers can optimize their revenue cycle for reliability of results and predictability of costs is by proactively conducting a comprehensive situational analysis of the challenges they may experience and the tools, partners and options they have if needed. Whether it is denial prevention measures, ensuring accuracy in capturing the complexity of services rendered or by improving utilization management – knowing the right actions to take and when to take them is critical to keeping the revenue cycle functioning efficiently. As far as technology and specifically AI’s role in improving revenue cycle management, it is certainly a critical component that can help analyze large quantities of data, identify patterns and predict payor behavior – but its most important value is in accelerating the human expertise, an element that remains a critical piece of an effective revenue cycle.
Amy Brown, Founder & CEO at Authenticx
The good news is that improving patient experience often has a compounding positive impact on improving cash flow and more efficient processes—thankfully, these business objectives are not mutually exclusive. The first step is to understand with a high degree of confidence the current customer experience and the root causes of negative experiences as well as the root causes of inefficient processes and barriers to cash flow. The best way to increase confidence is to collect statistically relevant data that is inclusive of leading indicators. We find that conversational data (call center conversations, including voice, text, chat, patient portal messages) is one of the best sources for leading indicators. It also provides a wealth of context that can be used to determine root cause analysis. For revenue cycle clients, listening to conversational data sources has been able to shed a light on the root causes of:
- Patient confusion on bills driving up inbound call volume
- User challenges with payment portals creating hurdles for customers trying to make payments
- Agent confusion and inconsistency in delivering instructions for payment or payment plans
Brooke LeVasseur, CEO at AristaMD
Value-based care shifts the focus of RCM strategies from charge capture to utilization. These models require providers to eliminate: Fragmented care that drives up costs. Requests for unnecessary or duplicate imaging lab work and tests. Delayed care that delivers poor outcomes for the patient. Technology can help. Referral management tools verify insurance, identify in-network specialists, and improve care coordination. Physician-to-physician consultations – or eConsults – enable primary care physicians to quickly treat lower acuity issues themselves. That means less care fragmentation, fewer unnecessary tests and faster diagnosis and treatment.
In an environment where specialists are in short supply, these tools prioritize face-to-face referrals while offering specialty care advice in the primary care setting. RCM data can identify areas where errors are made, like referring to an out-of-network specialist and opportunities to lower expenses, like accessing electronic consultations. PCPs can eliminate errors by verifying insurance before referring a patient, identifying in-network specialists and transferring patient information to avoid duplicate imaging and lab work – keeping costs low for the patient and the overall healthcare system. PCPs can lower costs and improve outcomes by leveraging eConsults to expedite specialty care access without the time and expense of referring the patient.
Laxmi Patel, Chief Strategy Officer at Savista
Given the financial and staffing challenges healthcare is facing today, globalization is here, and it’s here to stay. As healthcare organizations review their financial health and balance the scarcity of resources against their mission to deliver quality patient care, they must consider the utilization of global resources. A globalization strategy can reduce costs and help overcome staffing shortages, allowing for critical jobs to be made more meaningful and be retained domestically while more technical work is offloaded to expertly trained global teams.
Branden Barkema, Chief Revenue Cycle Officer at MedEvolve
Running an effective revenue cycle ultimately comes down to empowering your staff with the right tools/training and trusting them to execute. It’s important to consider the type of value you are creating for your organization. In other words, it’s not an RCM leaders’ job to do everything — it’s their job to see that it all is getting done. Technology is constantly evolving and change is part of everyday life as a leader. Effective leaders use their credibility to influence how their teams come to understand how technology and resources can be leveraged as effective tools to enhance process rather than viewing these things as a burden. If you have knowledgeable, skilled, and motivated employees who are placed in the best situation to succeed, your patients are sure to have a good experience. By effectively managing change, revenue cycle leaders can ultimately enhance the financial performance of their organization.
Lynn Carroll, Chief Operating Officer at HSBlox
The shift from fee-for-service to value-based programs requires a shift from the traditional claims-based revenue cycle to a whole-health model. In a more holistic health approach, where the emphasis is on the patient outcome, providers need to look for efficient allocation of resources, ensuring referrals are high-value and reducing the churn in getting the patient on the right care path.
Clarissa Riggins, Chief Product Officer at Experian Health
Changing payment models, such as value-based care, have a significant impact on revenue cycle management. In value-based care, reimbursement is based on patient outcomes and the quality of care provided, rather than the traditional fee-for-service model which incentivized cost reduction and increased utilization to improve margin. This shift requires healthcare providers to focus on preventive care, care coordination, and population health management. To adapt to these changes, providers can implement strategies like investing in data analytics to gain a better understanding of their patients to motivate wellness behavior, target community outreach, and track patient outcomes and performance metrics.
Understanding their community can help providers better target care and services to best meet those needs. By using data on consumers, providers can leverage insights for targeting preventative care and education making sure care coordination and limited population health resources are focused on the patients most likely to need and benefit from it. This can inform strategic focus for the services and specialties offered and will be in higher demand for the population providers service.
Also, insights help form more individualized and positive patient financial experiences. This part of the patient journey is vital because data shows a negative financial experience correlates to worse health outcomes. By reducing “no show” rates, implementing adaptive reminders, or identifying barriers to transportation providers can help ensure patients receive the care they need.
Additionally, another strategy is by partnering with employers to form a more collaborative and mutually beneficial approach to employee care and services, and a stronger united population health front. They can customize coverage and services, especially when they layer population health insights, in collaboration with the employers to create centers of excellence to best service their population needs.
So much to consider here!! Thank you to everyone that submitted a quote for us and thank you to everyone reading this article. We would love to hear from all of you as well! Comment down below or on social media with your thoughts on RCM optimizations and what adjustments you think need to be made.
