RCM Automation: Where to Focus or Further Refine

July 29, 2020 By: Quadax

COVID-19 continues to disrupt healthcare delivery, which will pose financial challenges to both large and small organizations. Now is the right time to investigate automation to keep revenue flowing and optimize reimbursements.

American healthcare delivery continues to be disrupted by COVID-19. According to the MGMA, 60% of practices have a decrease in patient volume and a closely-corresponding 55% drop in revenue. Organizations looking for ways to mitigate the financial fallout from reduced claim volume may want to focus on their RCM operations – specifically, the automation of manual systems that lead to denials. Refining labor-intensive claims processes and workflows improves revenue with efficient operations and allows staff to focus on more complex tasks.

Finding automation opportunities

The revenue cycle is filled with many parts and processes; automation can improve almost any part of the claims cycle. Where should you focus or further refine your RCM? There is one critical place to look to find the answer: denials.

Denial analysis

For some organizations, the method of denial analysis itself is a reliable indicator of an automation opportunity. If reporting is dependent on information retrieved from separate systems (which is then pieced together to see the 'big picture'), you may want to begin by focusing on the manual processes within each system.

Your denials can reveal where you would most benefit from automation, or where you may want to further refine the automation you already have. Find your top denial reasons on the list below to see the corresponding automation opportunity:

Reason Automation Opportunity
Duplicate claim Claims status checks
Not eligible for service Eligibility checks & insurance verification
Deductible hasn’t been met Eligibility checks & insurance verification
Bundled services Pre-submission claim scrubbing
Benefit has been exceeded Eligibility checks & insurance verification
Missing modifiers Pre-submission scrubbing
Inconsistent place of service Pre-submission scrubbing
Service not covered/lack of medical necessity Eligibility checks & insurance verification,
pre-submission scrubbing
Pre-authorization Eligibility checks & insurance verification,
pre-submission scrubbing
Error involving mismatched totals or mutually excluded codes  Pre-submission scrubbing
Coordination of benefits Eligibility checks & insurance verification
Timely filing Workflows
Patient demographic errors Eligibility checks & insurance verification


Criteria to evaluate automation solutions

After you have identified where automation would benefit your organization the most, the next step is to evaluate solutions to find the best fit. Essential questions to ask include:

1. Does the automation solution integrate with your systems? Or is additional software required to ‘hook’ the systems together?

Finding a solution that directly integrates with your EHR or practice management system is ideal. Software updates can be challenging exercises even if you are very familiar with your claims platform. Adding an additional system to get an automation solution to work puts your data and cash flow at risk every time there is an update because it opens the possibility that the systems will no longer operate together

2. How comprehensive and accurate are eligibility checks?

Automated insurance eligibility should provide insurance and benefit checks in real-time as well as supply information about copays, coinsurance and deductibles. The best solutions validate patient demographics, which not only reduces costs associated with finding missing patient information, but also avoids claim errors leading to denials and decreases the likelihood of creating duplicate accounts

3. Can the system confirm medical necessity?

Having a system that helps verify if a diagnosis/procedure combination supports commercial or government medical necessity can minimize denials and associated appeals. Additionally, the system should be able to produce and keep a record of Advance Beneficiary Notices (ABNs) for procedures that Medicare is not expected to cover.

4. What standard reporting comes with the system? How easy is it to customize reporting?

The key to reporting from any segment of the claims cycle is speed and accuracy. Data that needs to be downloaded onto spreadsheets is time-consuming, while manually interpreting data against goals and KPIs leaves room for error. The ideal system should produce detailed, real-time reporting that can identify cause-effect opportunities, measure results, forecast trends and predict cash flow.

5. What live support is available? If there is no live support, how long will it take to resolve a support ticket on average?

The revenue cycle is always moving and can shift quickly; that is why any issue with operations needs to be identified quickly and rectified. The ability to pick up the phone for live support can be the difference between an inconvenience and a drop in revenue due to delayed claims.

Now is the time to embrace automation opportunities because efficient operations can keep revenue on track and confirm you are paid every penny during these uncertain times. Quadax has the complete revenue cycle solution to ensure optimized billing productivity and profitability for your organization. Let’s take on the revenue cycle together!


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