Revenue cycle management has gone from being a "back office" function to an "end-to-end" system that begins at patient intake or even before, claims specialists say. Advanced technologies, in tandem with improved workflows and better data have resulted in RCM systems that encompass the entire healthcare enterprise.
With the right automation tools and revenue cycle support, experts say healthcare providers should be able to improve their cash flows by collecting patient payments up front, determining precise eligibilities and filing clean claims to payers.
With the fee-for-service business model changing to prospective payment and value-based care, healthcare organizations are undergoing a cultural shift that dramatically alters their approaches to patient intake, eligibility verification and claims processing. These are issues that providers will have to understand and adjust to accordingly, says Jose' Rivera, vice president of physician solutions development at Santa Rosa, Calif.-based Visiquate.
"Fee-for-service is going away and bundled payments will come to fruition," he said. "We will see a resurgence of capitation because it puts the risk back on the provider. Organizations were able to overcome ICD-10, but as the model moves toward quality I think we'll see another resurgence of value proposition payer mixes."
As a result, Rivera believes it will be a lot more difficult to get paid. Meeting the challenge means physicians must become educated on tracking quality metrics and reporting them to payers, he says.
"This is a formidable task because different payers with different contracts all want slightly different quality metrics," Rivera said. "It's a big question mark in the back of my mind."
RCM specialists agree that patient intake is a critical part of the revenue cycle process and that if they aren't emphasizing it, they need to do so immediately. Collecting patient deductibles, co-payments and eligibility authorizations is paramount for boosting the organization's cash flow as well as for ensuring clean claims, Rivera said.
"That is the front line – they need to capture that information correctly and guide it to the right places," he said. "When it comes to authorizations, we are still in a prehistoric environment where a payer has to be called on the phone and it's a half-hour wait to get the authorization. This process definitely needs to be upgraded."
Patient registration is undergoing dramatic change, with intake clerks "being asked to do more and more," says Colleen Wood, vice president for the Eastern U.S. at Jacksonville, Fla.-based Availity.
RCM technology at the point of intake should be leveraging technology for patient data capture as well as having credit and debit card readers for upfront payments, she said. And while some providers – especially physicians – have been reluctant to ask for payment upfront, collecting deductibles and co-payments at intake fosters cash flow while informing patients of their obligations.
"As patients, they should want to know how much it will cost," she said. "This is an opportunity for them to ask about costs and manage their dollars, which they couldn't do previously."
Receiving deductibles and co-payments not only improves cash flow, it also creates a more comprehensive patient profile, Wood said.
"It goes deeper than just getting deductibles and co-insurance," she said. "It is the total dollar for the patient and provider experience. Deductibles are part of the equation, but the challenge is that there is a ton of data about patients being eligible for services, but also the benefit level each payer covers and how it is going to be covered. Providers need to realize they need to get the total dollar and understanding of the benefit level for every patient, whether it is in the physician or hospital setting."
Illuminating the buckets
Although the emphasis is on intake, the back end of the revenue cycle continues to be as vital as always and clean claims remain the key to prompt payment. Still, there are stumbling blocks in the claims filing system, says Jay Deady, CEO of Greenwood Village, Colo.-based Recondo.
"On the back end, we need to identify the buckets and reasons why claims aren't adjudicated cleanly," he said. "When we illuminate those buckets, patient ineligibility and lack of authorization are still the main reasons for denials."
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Electronic data interchange transactions with payers is still the standard for eligibility and authorization data, but Deady's research shows that the information can be wrong up to 25 percent of the time. On the whole, however, the process has improved immensely in the past few years, he said.
"We're getting more information earlier, getting more information cleared earlier and more is being done earlier," he said.
Many moving parts
While the end-to-end revenue cycle system has become more automated, there are "still a lot of moving parts" within the process, noted Mike Nissenbaum, CEO of Dallas-based billing contractor Aprima.
"There are so many changes just on what is covered and how much will be paid," he said. "There are constant changes in plans and the payers can modify formularies and delay them up to six months. That is very stressful. If we don't pay attention to all these rules changes, our clients suffer."