Revenue cycle management (RCM) is one area of healthcare operations that’s most in need of innovation and disruption, according to a recent survey of health system executives conducted by the Center for Connected Medicine and KLAS Research.
And it’s not hard to understand why. RCM can be an overly complex and manual process, resulting in unnecessary costs, overburdened staff, and delayed payments. The increase in value-based payment models increases the pressure because providers must assume greater financial risk and collect more from their patients, who are already shouldering a greater percentage of their medical costs.
But there are ways providers can reduce complexity, streamline workflows, and improve customer service without completely reimagining the revenue cycle process. Making process and technology improvements at each of the three key revenue cycle phases—pre-service, post-service, and post-adjudication—can make a big difference in day-to-day operations. Here’s how:
Pre-service: RCM starts long before a provider sees a patient, and many issues related to claim denials and patient payments can be traced back to the pre-service phase. Improving processes here should focus on obtaining the correct benefit information as well as the patient’s payment responsibility for the service.
While running an eligibility check with a payer is standard operating procedure, many practices assume patients are self-pay if they don’t have an insurance card or say they don’t have coverage. In reality, some patients may have coverage through a government payer—or even a commercial payer—and not realize it. In these cases, implementing a coverage identification tool can help practices find and bill the correct payer.
Post-service: The post-service phase takes place after the patient has been seen but before the payer has adjudicated the claim. Improvements here should focus on making sure claims are as clean as possible before they are submitted to the payer. While most RCM software systems run core edits, like HIPAA compliance and eligibility, practices may want to consider more sophisticated tools that can build edits based on a wide range of payer-specific criteria.
It’s also important for practices to regularly check the status of claims after they’ve been submitted, and not simply wait for the denial or remittance. By proactively checking, practices may be able to address and correct claims before they are denied, which can reduce delays in getting paid.
Post-adjudication: Once the claim has been paid, practices should ensure the remit matches back to the claim so there’s a full historical record of the claim. Some RCM solutions can automatically transfer remits to the practice management system, which eliminates staff members having to do this manually.
When claims are denied, the most important thing practices should do is start working them as soon as possible. Appealing denials can take time, and practices want to make sure to meet any appeal deadline and not leave money on the table. If resources are tight, practices should focus on tackling high dollar claims and assigning those to their most experienced staff members.
The post-adjudication phase is also a good time to analyze performance and identify ways to improve. Ideally, insights captured here will be used to improve process during all three revenue cycle phases.
Healthcare is complex, but there are ways to streamline processes, deliver superior patient care and receiving fair compensation for their services. Tackling some or all the pre-service, post-service, and post-adjudication – help ensure that providers receive accurate reimbursements.
MicroMD offers Integrated end-to-end RCM with Availity
MicroMD works with Availity to deliver an integrated Revenue Cycle Management solution that helps you keep your profitability healthy, reduce costly denials, and minimize days in accounts receivable. Producing cleaner claims reduces calls to the health plans and expedites payments. MicroMD and Availity RCM work seamlessly together to provide maximum convenience and flexibility by incorporating processes direction into your practice’s workflow:
- Secure, automated file transfers
- Professional and institutional claims submission (electronic and drop-to-paper)
- Auto-posting of remittance advice (835s) back to MicroMD
- Claim status (277U) posting with plain-language error messages
- Real-time eligibility and benefit verification from within MicroMD
- Edit/Error Management
- Analytics and Reporting
In addition, several additional modules are available to help you take results even further. Denial Prevention, EOB to ERA Conversion, Auto-Secondary Claim Generation, and Drop-to-Paper, are just a few examples of the powerful, integrated revenue cycle functions available from MicroMD, working with Availity.
Katrina Mack is a channel relationship manager with Availity. Availity is the place where healthcare finds the answers needed to shift focus back to patient care. As one of the nation’s largest health information network, Availity facilitates billions of clinical, administrative, and financial transactions annually. The company’s suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment.
