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360 Degrees of Revenue Cycle Management (RCM) Process

360 Degrees of Revenue Cycle Management (RCM) Process

Author: Palak Jethva

The Three Pillars of Healthcare Revenue Cycle Management (RCM) are People, Process, and Technology. There is a symbiotic relationship between financial issues and patient health. Today patients are responsible for more of their healthcare spending than ever before, and many are delaying treatment because they are concerned about the expense. People who regularly save money for a nest egg show that they value their future selves and are more inclined to make sound choices now for better health in the future. So naturally, the number of high-deductible health plans has increased in the insurance market. As a result of the COVID-19 pandemic, including the current labour crisis, there has been a shift away from commercial plans toward financial assistance plans. Providers are having trouble in maintaining profitability as more and more patients switch to Medicare, Medicaid, and financial assistance plans – all of which offer lower reimbursement amounts.

Health care expands in size and complexity each year. Consequently, it is necessary to improve the efficiency, flexibility, measurement, and reliability of healthcare IT infrastructure. Providers are under pressure to increase profits as high market fragmentation and a complex revenue cycle have increased costs and friction. Providers can no longer rely solely on point solutions to manage revenue challenges. They need a customizable, end-to-end revenue cycle solution from a single trusted partner. For instance, efficient quality assurance programs are vital to performance in this sector. Instead of developing the solutions themselves, providers can access solutions that promote profitability and have a higher ROI by using an RCM service vendor’s network and scale.

Revenue Cycle Management (RCM) spans the entire revenue cycle, connecting patient experience and the dots between providers, patients, and payers to drive revenue excellence and patient experience. It is a digital, retail-like experience that improves access and transparency, allowing patients to search for local providers, compare reviews and costs, and schedule and pay for treatment all on a single application. It is about how RCM addresses consumerism, helps recruit and retain patients, reduces leakage, and grows revenue.

Healthcare revenue cycle management must adapt as the industry shifts from fee-for-service to value-based reimbursement. In healthcare, RCM performance is critical. Advanced technology solutions help improve the revenue cycle by using data to understand common patterns. Advanced solutions can guide the next recommended step and their prioritization from this analysis by selecting the right tasks that will first streamline the procedure and assist in capturing higher revenue (cash-collecting tasks).

Throughout the revenue cycle, automation offers possibilities for improvement, but patient access is one of the key areas. Improving patient access is among the top healthcare predictions, and for good reason – a frictionless and positive first impression can have a significant, long-lasting impact. As revenue cycle technology continues to advance in 2023 and beyond, providers need to ensure they are capitalizing on the latest software to boost their bottom line, deliver on patients’ service expectations, and keep pace with healthcare predictions.

Several companies have an RCM model, and a few of them are highlighted over here. A US-based technology company called Inovalon offers cloud-based software for data-driven healthcare. They introduced their RCM intelligence, which offers medical professionals a thorough understanding of important revenue cycle management performance metrics including payer performance, denial rates, and claims. This system also displays earlier payment trends and cash flow projections to spur quick action that boosts financial performance and enables providers to concentrate on providing care to patients.

With worldwide capabilities and tailored solutions for clients, Coronis Health is a developing revenue cycle management (RCM) firm. They assist organizations of all sizes in maximizing revenue and preserving their financial independence because they are solely focused on the healthcare sector. At Coronis Health, they collaborate with experts in RCM and use their technology to help develop your abilities and hit new professional milestones.

JKTech‘s End-to-End Solution for RCM recognizes and eliminates administrative inefficiencies in healthcare operations, which lowers costs while boosting revenue and enhancing processes. By working with the best-in-class solution partners in the ecosystem, they supply the most innovative solutions in the hyper automation-enabled RCM space. They aid in addressing essential queries about Availability, Accessibility, and Affordability. To decrease administrative labour and boost the availability of healthcare professionals, they have developed a 3A method that makes use of automation-driven technologies. The next factor is accessibility, which enables healthcare providers to give the best possible patient care. This factor includes telehealth, online consultations, virtual clinical trials, and real-time monitoring. Along with value-based care, health risk assessment, and drug development optimization, the method also addresses affordability.

We can utilize data analysis to shed light on patient trends and frequent in-house errors. We can track data sets to keep an eye on the overall RCM performance. To begin with, patient preferences. The RCM approach should put the well-being of your patients first. Because of this, it’s critical to give patients’ preferences priority when it comes to communication and payment methods. Track the responsiveness of the patient using a variety of communication channels, such as text, email, and phone calls. This will assist you in deciding how to educate patients about important information and remind them to make payments or keep appointments.

Second is claims denials which are denied for a variety of reasons, including inaccurate coding, insufficient patient data, and late filing. Watch out for any patterns in the most recent claim denials that could indicate recurring mistakes. This data may assist you in reducing future errors by teaching employees how to prevent typical errors. Finally, your accounts receivable balance is another piece of data to keep a watch on. The unpaid balances from insurance companies and clients are represented by accounts receivable. Take special attention to the portion of your AR balance that is older than three months. This will show how well you are obtaining money for the services you have provided.

Medical billing and claims processing are two healthcare processes that can be fully automated. With faults present in 40% of insurance claims and 80% of bills, there is startling space for error in this situation. The worst effects may be seen on the bottom line for healthcare providers, notwithstanding the terrible patient and payer experience that results from this. The percentage of claims that are denied has been increasing, with hospitals reporting a 23 percent rise in claim denials between 2016 and 2020. Denial management costs hospitals roughly $262 billion annually, creating significant cash-flow issues due to errors or inefficiencies with their revenue cycle management. Sometimes exceeding the filling time limit, authorization and referral issues, medical coding issues or coding denials are some reasons for the denial of claims.

Up to 65% of denied claims are not resubmitted, and a substantial portion of that may be avoided with effective RCM management. As a result, more and more hospitals and medical practices are choosing to hyper automate their RCM. They use disruptive technologies to accelerate reimbursement and create an efficient exception-based workflow.  By embracing hyper-automation, humans are given the opportunity to focus on more creative endeavors while leaving the menial and repetitive tasks to cutting-edge technology like robotic process automation, artificial intelligence (AI), machine learning (ML), APIs, process discovery, and analytics (RPA). These innovations contribute to saving time, improving productivity, and increasing revenue.

It can be challenging for organizations to keep their revenue cycle management policies consistent considering the constantly evolving healthcare regulations. For healthcare organizations, the biggest revenue cycle management difficulty is collecting payments from patients at or before the point of service. While it might save time and effort, it could be more difficult stated than done to collect money before a patient leaves the office. Due to high deductibles and financial difficulties, many patients are unable to pay medical bills in full upfront. Healthcare firms must strike a balance between timely payment collection success and patient retention. The issues of revenue cycle management also include coding and charge capture. Staff members’ mistakes in coding might cause problems with claims reimbursement.

To ensure compliance with financial policies and procedures, healthcare organizations should provide regular employee training programs that promote proper coding techniques and comprehensive chart documentation. The training sessions are associated with better ROI, such as reduced turnover rates and medical errors.

“Whether it’s matching a patient with the right provider, estimating out-of-pocket costs, or coding the claim, those are things that have long lists of variables associated with them, and AI is pretty uniquely good at evaluating those variables and coming up with an ever-improving success rate of getting to the right outcome against any of those process steps,” said by Joe Polaris, senior vice president of product and technology at R1 RCM, a revenue cycle management vendor.

It can be concluded that healthcare organizations can fully automate their revenue cycle management processes by using intelligent document processing, cognitive search, analytics, and end-to-end automation, thereby reducing the time and effort required to manage these processes and improving their efficiency and accuracy. In the past several years, AI has advanced in a variety of administrative and clinical domains as healthcare institutions leverage technology to improve workflow processes and reduce human error rates. It makes sense for businesses to fully embrace AI in revenue cycle management (RCM). The year 2023 is ideal to explore integrating AI to help the team as healthcare organizations look for strategies to enhance revenue amid the devastating financial impact of the pandemic.