The changing healthcare landscape makes revenue cycle management rather illusive, as new laws and reforms have forced the sector to change. It has left many hospitals trying to maintain their revenue in a value-based care reimbursement model.
Technology platforms today may help providers, payers, and consumers interact and communicate more effectively. This will result in a plan for revenue cycle management that is more enduring. For a medical facility to maximize reimbursement, revenue cycle managers should concentrate on a few important areas.
A healthy revenue cycle is essential for the path to financial recovery following the pandemic. Hospitals cannot afford inefficient workflow and out-of-date manual processes that result in denied claims and postponed payment. Top Revenue Cycle Management Companies can address these problems by narrowing their strategic focus to four important areas.
Ways To Improve RCM Performance
Submitting clean claims
The concept of GIGO (garbage in, garbage out) is a concern in very few fields more than claims processing workflows. However, the health of cash flow and the bottom line depends on submitting claims that are accurate and complete the first time.
The following are the principal causes of claim rejections and denials:
- Invalid or absent claim dates
- Issues with prior permission and precertification
- Information about eligibility or registration that is not accurate
More than half of all denials are the result of just these three problems, and they are all brought on by ineffective workflows.
There are various things that providers can take to increase clean claim rates and decrease denials. First, use claim scrubbing tools to find and highlight potential problems before a claim enters the payer’s adjudication system. This will allow staff to address the problem before the claim is rejected.
Setting a priority for payer changes is also crucial. Maintaining awareness of the ongoing changes in payer criteria can be difficult for workers. However, failure to do so may result in denials due to things like incomplete or missing documentation, missed deadlines for submitting, and more.
Making ensuring coding staff receives regular training on correct and full coding is another strategy to reduce rejected and refused claims. Additionally, it is important to let them know how their performance affects the financial health of the hospital. It may be helpful to use rewards for error-free labor. It might also assist in lowering turnover.
Industry insiders advise providers to aim for a clean claims record of more than 90%.
One out of every ten claims that are submitted is now being denied by the payer. Health systems may have to pay up to 2% of net income.
Payers’ three acts have led to this increase:
- Utilizing more advanced algorithms to automate reviews
- Use of more stringent standards for determining medical necessity and claim submission
- Adding extra parameters to their contracts, like technological requirements and standards for medical necessity
Providers should manage denials using a three-pronged strategy: prevention, recovery, and escalation. These approaches include Prevention, Recovery, and Escalation.
Focusing on industry best practices and a dedication to continual improvement are necessary for achieving the best revenue cycle results. Providers must use end-to-end revenue cycle analytics with standardized reporting that enables them to do comparison analyses with peer organizations to show their dedication and focus.
To spot troubling tendencies in both payer behavior and internal revenue cycle processes, providers should adopt a cutting-edge strategy that makes use of artificial intelligence (AI) and predictive analytics. The improvement of the entire claim journey is made possible by measuring quality at each step and subprocess level, which also benefits the hospital’s financial performance.
Providers can more efficiently allocate limited resources thanks to predictive analytics when paired with business intelligence and artificial intelligence.
Hospitals can gain from outsourcing all or a portion of the revenue cycle while they deal with continuing workforce issues. In particular today, in the post-COVID context, outsourcers may have a larger pool of highly skilled revenue cycle professionals than a hospital can locate in its local community. Revenue cycle leaders can concentrate on more systemic projects and process improvements by outsourcing the recruiting, onboarding, and training of inexperienced revenue cycle workers.
The finest outsourcers will have in-depth knowledge of front-end, mid-cycle, and back-end revenue cycle processes. They should be adaptable to the particular needs of the hospital while also being able to scale up and down fast to meet changing demands.
According to a recent survey, 92% of healthcare companies reported having trouble hiring and keeping support employees. Also in the survey nearly as many said they had to raise base pay to remain competitive. By lowering expenses and improving revenue cycle performance, outsourcing can help to offset these problems.
One of the most crucial elements of a successful medical practice is revenue cycle management. Top revenue cycle management companies can offer guidance on creating a revenue cycle committee, hiring a qualified outsider to do revenue cycle claims to trace analysis, or putting revenue cycle best practices in place.