Top 5 Revenue Cycle Management Challenges in Specialty Healthcare
2021 E&M Changes
Efficient Revenue Cycle Management plays a pivotal role in assuring the profitability and sustenance of healthcare organizations. The ability to collect revenue and utilize it to improve the quality of care provided by clinicians enhances the trust and brand of the healthcare entity. Successful revenue cycle management involves establishing clear communication among payers, providers, and patients, and of course, your revenue cycle team.
In today's digital era, the healthcare industry is now beginning to utilize robotic process automation and artificial intelligence to manage its revenue cycle. The shift to automated workflows is leading to fewer errors, increased collections, and overall profitability. However, despite these advancements, there is always a gap in some of the RCM processes, especially in specialty healthcare.
As healthcare delivered is specific to the specialty, your revenue cycle processes required specialized resources with specialty-specific competencies. RCM for Specialty healthcare can be daunting to most healthcare organizations, considering the frequent changes in regulations. In addition, it can be complex as it requires attention to financial & administrative challenges that usually have a hyperbolic effect on its financial stability.
This article brings you a few revenue cycle management challenges in Specialty Healthcare and a few tools & strategies to overcome them.
Prior Authorization is the process of obtaining approval from the payers before a provider offers any service to a patient. Prior Authorization helps in controlling cost and allows providers to provide evidence-based treatment to the patients.
In specialty healthcare, prior authorizations are essential as the specialists can arrive at a proper treatment plan that adheres to the distinctive requirements of various payers. Therefore, outsourcing your prior authorization process to an RCM company that understands specialty-specific prior authorization requirements can improve the clean claim rate, reduce denials, and improve reimbursements.,
Revenue Integrity – Capturing the right charges
Charge entry is one of the most crucial processes in medical billing. In this process, a patient account is involved the correct $ value as per the medical codes and the fee schedule. The charge entry process determines the reimbursement a physician receives for the services rendered. Apart from this, all cost accounting methodologies and financial benchmarking depend on the practice's ability to get reimbursed effectively, thereby relying immensely on charge entry.
The charge entry process becomes more complex in the specialty ecosystem as it includes many specialists participating in a value-based care program or bundled payment programs. The complexity is due to multiple systems to generate various information that helps diagnose & treat patients with highly complex diseases. Therefore, Healthcare organizations should begin to move towards data interoperability to overcome issues in the charge entry process. Charge entry outsourcing can help you achieve >98% charge capture accuracy and reduce charge entry lag.
Coding for a specialty healthcare provider is one of the complex processes in revenue cycle management. The evolution of ICD-10 guidelines for specialty healthcare is rapid and demands the coders to stay updated with every nuance of the correct practices. Improper knowledge and incorrect coding might result in revenue leakage. Confronting payment challenges due to such frequent changes in guidelines can be done by outsourcing their specialty coding needs to an offshore revenue cycle management company.
Accounts receivable benchmarks for the specific specialty must be adhered to while managing the A/R. A team of focused accounts receivable and denial management professionals can keep days in A/R less than 30 days. Creating an iterative feedback look to coders and clinicians based on claim denials can shift the focus to denial prevention and eliminate situations of huge backlogs. CFOs should work with COOs and revenue cycle operations managers to define A/R and collections standard operating procedures to eliminate situations of claims not being addressed due to lack of clarity on the guidelines.
Physicians/providers must credential themselves with the Payer's network and be authorized to provide services to patients who are members of the Payer's plans. The credentialing process validates that a physician meets standards for delivering clinical care. The Payer verifies the physician's education, license, and specialty accreditations. Payers may delay or refuse payments to physicians who are not credentialed and enrolled with them. These impact the financials of the practice negatively.
Providers in specialty healthcare must ensure that they are credentialed appropriately as per their skills. Providers who have been credentialed already should provide up-to-date information on acquiring any new specialty certification. Allowing external credentialing specialists to handle your credentialing requirements will help avoid mishaps in terms of reimbursements.
Conclusion
As specialty healthcare providers continue to adopt the latest in clinical technologies, patient engagement tools, and reimbursement strategies, they should keep in mind that those solutions will predominantly depend on the financial strength of their organization. The financial stability is directly proportional to the quality and capabilities of your RCM service provider. An RCM service provider with specialty-specific expertise can be your partner in improving the financial health of your healthcare organization.
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