The Revenue Cycle

As patients are increasingly responsible for a share of their healthcare costs, revenue cycle management has become an increasing priority for health systems. This shift in reimbursement is forcing many organizations to invest more resources in working with patients to recoup payment for delivered care. Leaders are seeking solutions that allow them to ease the payment process for consumers, better manage accounts and ultimately increase revenue.

The complex pre-authorization process along with claims denials are common challenges providers face as they search to secure their revenue cycles. In the wake of COVID-19, providers must also work with patients experiencing unemployment who may be between insurance, as well as create sustainable business strategies to ensure their revenue cycle is prepared for a potential future crisis.

In a discussion with Modern Healthcare Custom Media on this critical topic, two industry experts offered insights into how their organizations are finding innovative ways to reform, maintain and secure revenue.

Panelists:

Matt Hawkins is the chief executive officer of Waystar, a cloud-based platform that simplifies and unifies healthcare payments. Matt is passionate about technology’s ability to transform healthcare and is ranked a top 50 healthcare CEO.

Michael Ford is the chief development officer at Revecore and has been a licensed healthcare attorney for over 20 years with extensive knowledge of healthcare revenue cycle. He has assisted in driving Revecore's expansion to more than 1,000 hospital clients across the U.S.

MH: Over the past 10 years, healthcare providers and organizations have faced growing financial pressure, making an efficient revenue cycle crucial to the success and sustainability of any organization. Providers are therefore embracing technology to automate formerly manual financial and administrative processes. They are also looking to AI and predictive analytics for insights that can drive strategic and effective decision-making.

MF: Providers have greatly increased their selection of vendors who have technological advances. This has especially been the case within the specialized portion of their billing population (auto, workers’ compensation, underpaid and denied claims). Providers are selecting partners that have both specialized knowledge and technology that can increase speed-to-pay through automation, customizable work flow rules and insurance identification.

MH: Many providers have fragmented technology, with staff managing multiple systems that aren’t talking to each other. Providers should look to implement a unified platform for all healthcare payments so that, in the case of a future crisis, there is less room for revenue to fall through the cracks. Additionally, AI and automation can take keep things running smoothly and efficiently, so that providers are able to focus on whatever crises may arise.

MF: COVID has taught providers the criticality of redundancy and flexibility. Simply moving billing staff to a remote workforce setup has greatly minimized a number of potential future concerns. This, combined with implementing vendor solutions which can help to act as a backstop for both specialized/complex claims, allows for greater responsiveness to expansion and reduction in overall claim volume by choosing to focus on their core claim population.

MH: Forward-thinking providers are implementing technology that gives patients an accurate estimate of what they’ll owe before the point of care so that they can make informed choices without sticker shock after the fact. It’s also important to generate easy-to-understand bills, communicate with patients through their channels of choice, such as email and text, and offer consumer-friendly, electronic ways to pay.

MF: With patient out-of-pocket costs rising steeply, providers have had no choice but to shift their focus to the overall patient experience. Providers should be hyper-focused on education, assisting with unknown insurance identification, providing accurate bill estimates and creating patient-friendly payment options to not only improve loyalty, but to increase a patients’ likelihood to pay.

MH: Providers should invest in the technology, data and expertise that can simplify healthcare payments. Technology that automates formerly time-consuming payments processes will reduce the time it takes to collect. Patient engagement is also key to this strategy. Generating easy-to-understand bills, communicating clearly with patients and offering convenient ways to pay will result in faster, fuller payment.

MF: The best revenue cycle operations in the country are choosing to focus primarily on the core of their revenue cycle and subsequently selecting which areas make more sense to outsource. Bringing in third-party assistance for their most complex claims allows for the greatest possible opportunity to ensure these claims get the attention and technology applications they need to pay quickly and at the best possible rate.

MH: Providers can implement coverage detection technology that can identify insurance patients may not even know they have. Additionally, not-for-profit health systems and hospitals can leverage automated charity screening solutions to proactively connect eligible patients with financial assistance. Most importantly, providers can communicate clearly and compassionately with patients about their financial options and offer flexible payment plans.

MF: The best offense is to first ensure they are collecting on every dollar owed from traditional insurance. Focusing on these dollars is actually something they can control. Greater insurance collections allow for greater charity care, minimizing the impact of self-pay reimbursement rates. Additionally, tech-enabled insurance identification, particularly within the P and C space, is a great way to help patients who may be unaware of insurance available to them.

MH: Prior authorization has long remained a highly manual, time-consuming process for payers and providers. But there is now technology that can automate this process, from verifying whether an authorization is needed through submitting the required data to the payer, checking status and then automatically publishing the authorization details directly in a provider’s HIS or PM system.

MF: The most efficient way to streamline PAs is through tech-enabled processes, including EHR integration to enable instant PA decision making and real-time access to data to improve UM programs to prevent delays in quality of care. This is especially true in the workers’ comp patient population. Maintaining accurate, up-to-date clinical criteria & real-time accessibility of payer & clinical specialists for medical necessity discussions is essential.

MH: Insurance ineligibility is the leading cause of denials, so choosing the right eligibility and coverage detection solutions is key to preventing denials before they happen. Denial management technology can analyze denials that do occur, determining those that have the best chance of being overturned and prioritizing the order in which they should be worked. Finally, the right technology can automate appeal packages, reducing the burden on staff.

MF: Leveraging data in order to track, trend, and perform statistical data analysis is key to uncovering trends, root causes, and gaps in processes. Conducting monthly reviews of detailed denials data and originating cause will help to prevent future denials. We can’t emphasize enough how crucial interdepartmental collaboration and improved real-time provider-payer communication is for streamlining data sharing and preventing silos in processes.