The biggest challenge in RCM is developing internal processes that work well with other stakeholders to increase the chances of reimbursement. This firstly requires a strong knowledge of different reimbursement models (payments from insurers, direct from patients, from Medicare, etc.) as well as the nuances involved in seeing revenue flow from each. In other words, you need to know your payers. Secondly, practices need to be aware of the origins of misinformation or communication breakdowns that lead to denied claims or patient bills ending up in collections – i.e., “Know Thyself”, or, at least, know your practice.
If you can better understand your payer's expectations and adjust your internal workflows to more efficiently meet them, then greater efficiencies on the revenue-side are sure to follow.
From the insurer's point of view, the priority is to make sure that every reimbursement claim is justified. With this knowledge, practices should prioritize creating the cleanest possible claims to reduce the chances of denial. This starts with insurance eligibility verification and pre-authorizations. There are many types of health insurance plans on the market, and it's important to make sure you're billing the insurer for something they actually cover.
Creating clean claims also requires an Electronic Health Record (EHR) that simplifies coding and robustly documents encounters, and one that ideally integrates well with your practice manager (PM) system. This is important for reducing friction as information moves from the examination room into an insurance claim form. It also curbs the risk of over-coding that could lead to compliance issues and denied claims, and it helps prevent down-coding, which could precipitate lost revenue opportunities that actually earned.
Once claims are developed, they must be carefully scrubbed to ensure that:
Proactively scrubbing claims will help catch errors that might otherwise lead to denials. Every year, billions of dollars of claims are rejected, and according to MGMA, 65 percent of those rejections are never followed up on. This tells us two things. The first is that far too many claims are being denied. The second is that once denied, the majority of those claims are left to be written off. That's literal lost revenue that should have positively impacted your bottom line.
Give insurers as few excuses as possible to reject claims by double-checking your medical-billing codes and submitting accurate patient data. And for those they still reject, make sure you have a formal and effective process in place to follow-up, and take preventative action to avoid making the same mistake twice.
Patients are the second of the three high-level stakeholders involved in RCM. Most of them realize they can't barter down the cost of healthcare, but they rightfully crave transparency regarding their payment obligation. This is truer now than ever before. High-deductible health plans and co-insurance can muddle the amount owed out of pocket for the patient. It's risky to assume patients understand how their plans function, when they become effective and the amount they'll cover. Most Americans don't understand basic healthcare plans, according to UnitedHealth, let alone HDHPs.
Practices must therefore adjust their workflows to ensure that patients are aware of their payment obligation before services are rendered. This can prevent sticker shock and feelings of misplaced frustration toward your practice. It also helps you and the patient work together to prioritize treatments in order of importance. This sets a more congenial, transparent tone from the outset of the relationship. It also reduced the chances that a patient will be unable to cover his or her portion of the bill down the road, which would ultimately lead to uncollected revenue.
In this same vein, your RCM cycle can benefit from making it as easy as possible for patients to pay their portion of the bill. People crave convenience in most aspects of life, whether they're shopping online or covering their portion of a medical bill. Practices can improve their point-of-service collection rates by turning to digital patient engagement tools, such online portals. For one, this gives patients the ability to cover their co-payments online, which is now a standard expectation for web-savvy consumers. Alternatively, patients may opt to keep a credit card on record, setting up what amounts to an automatic payment plan. A third option is to implement custom repayment plans to help patients settle their accounts in a specified timeframe. It's always preferable to collect the patient's portion of the bill upfront, but if the alternative is sending bills to collections or never getting paid at all, then why not work with patients to get them to pay you back on their terms?
The bottom line is that the patient's stake in your revenue is increasing. Implementing patient-centric workflows can facilitate transparency and convenience, and ultimately improve your point-of-service collection rates.
Any number of workflow inefficiencies can inhibit your practice's revenue, and break down the chain of communication between you and your payers and patients. Oftentimes, practices don't even realize those problems exist, let alone that they're hurting their revenue.
In other words, the least predictable sources of lost revenue are the ones that dwell right under your nose, within your own workflows. Whether they're related to claims scrubbing, patient engagement failures, poor technology integrations or something else entirely, it's important to actively seek out and remediate the problems that could be harming your practice's revenue.