There are more technology-driven opportunities to ‘fix’ your RCM than ever before. With all the solutions out there, why aren’t healthcare organizations getting better results?
For many organizations, the operational ramifications of claims processing have led to significant investments in software and applications to fix issues that cause denials and impact reimbursement. Up through 2019, the primary aim was to efficiently handle an increase in claims volume. The emergence of the coronavirus in 2020 has upended the revenue cycle in myriad ways. Elective procedures have dropped dramatically and may never be performed, but rapidly evolving rules around treating COVID-19 patients, remote work for revenue cycle staff and new payment rules around telehealth for Medicare beneficiaries are only underlining the need for effective revenue cycle automation even in cases where overall claim volume has decreased.
Installing EMRs and workflow solutions is intended to help organizations work efficiently and keep administrative costs down.
Despite all these efforts, a benchmark survey showed some unsettling trends:
- On average, 350-bed hospitals lost $3.5 million to increased denial write-offs over four years
- Successful denial appeals for hospitals fell from 56% to 45% over two years
- Hospital write-offs increased 90% over six years
Executives at over 90 hospitals and health systems and nearly 300 organizations participated in the survey. The authors concluded, "…benchmarks indicate a reduction in (the) centralization of revenue cycle functions…"
An explanation of this decentralization may come from a study by HIMSS Analytics. The study found that “72.5% of respondents polled… were using their electronic health record alongside three or more other RCM systems to manage their revenue cycle.” Sixty-seven percent of respondents said a main problem was siloed information in their RCM.
Where things have gone wrong: the lack of meaningful automation
Creating efficiency in the revenue cycle is the surest way to ensure you save labor costs and improve revenue. Many organizations have installed 'automated' solutions for eligibility, denial management and other essential RCM functions. However, unless the automation can clear these four hurdles, they may be contributing to the problem, rather than helping.
Hurdle #1: Information must feed back into the host system’s patient accounts
Many clearinghouse systems silo claim correction information, which means that the cause of the rejection, error or denial is not rectified in the ‘host’ EHR and will happen again. To correct the host system, often manual entry is required, which is time-consuming. Productivity targets usually focus billers’ attention to the next claim rather than preventing claims problems in the future.
Ideally, clearinghouse functions should integrate and communicate directly with the host system. Problem areas should be flagged, and up-front edits fed back into the host so missing and incorrect data is corrected before submitting the claim. In addition to avoiding future rejections and denials, an automated clearinghouse system should produce a clean claims rate of at least 95%.
Hurdle #2: Automated work queues need to do more than sort claims
Work queues need to be more than places to sort and store problem claims; they need to have ways to resolve claims and prioritize work automatically.
Automated workflow, conditional claim correction and other efficiency features should reduce the manual work required to process claims and free your staff to take care of more complicated denial resolutions. The right solution should quickly route claims according to customized criteria and provide an automated process that triggers appropriate actions such as appeals, corrected claims or write-offs that help increase staff productivity and improve net revenue
Hurdle #3: Automation must be customizable
One size does not fit all when it comes to automating RCM. Payer requirements and behaviors change, as well as the needs of the organization using the technology.
The right automation tool should be flexible but still have robust controls and integrity. It should possess both standard and customized edits, adapt for custom data conversions, and incorporate user-defined rules to streamline workflows, saving labor and reducing days in accounts receivable (A/R).
Hurdle #4: Automation needs to provide a macro view
Separate RCM systems designed to focus on one part of the revenue cycle not only keep information siloed from other billing activities, but they also make it challenging to forecast and report holistically on the revenue cycle. Exporting data from every system to manually compare and calculate performance is onerous and leaves room for human error. Organizations should centralize on one tool to centrally generate reports, dashboard displays and summary spotlights for real-time analytics into claims performance against industry KPIs and forecasting.
The goal of automation: an integrated system that optimizes productivity and improves revenue
As increasing patient volume, changing reimbursement models and pressures to contain cost increase, organizations will be driven to find better technological solutions to overcome the four automation hurdles.
The right RCM partner integrates claims systems for maximum efficiency and revenue capture. Quadax has the complete revenue cycle solution to ensure optimized billing productivity and profitability for your organization. Find out how Quadax can work for you!
Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.