In history, COVID-19 was perhaps one of the most serious issues confronting the United States healthcare system, but it was only one of several. That's right; there has been a slew of concerns plaguing healthcare for years, resulting in patient safety mishaps, income losses, and more. However, due to the consequences of COVID-19, these losses skyrocketed, with estimates of $323 billion in 2020. While the pandemic is gradually fading, things are improving as providers open their doors to in-person appointments.
While hospitals, relatively small practices, and significantly bigger healthcare systems are known for saving lives and treating patients, every public health care organization must develop successful financial processes and policies. That's where revenue cycle management in healthcare comes in.
Healthcare revenue cycle management is the financial operation that establishments use to manage the administrative and clinical elements associated with claims processing, payment, and revenue generation. The procedure entails identifying, managing, and collecting revenue from patient services.
Americans are currently confronted with an irony that may apply to healthcare revenue cycle management solutions in 2021. Even in a decent year, norms and standards change quickly, but the pandemic decided to throw healthcare RCM into a whirlwind. It's critical to keep up with these developments, or you'll fall behind. Following COVID, new legislation and shifts to work from home will significantly impact healthcare RCM procedures and cybersecurity requirements. These trends will have an impact on your workflow in the coming year, as shown below.
At the onset of the pandemic, health system and hospital revenue cycle teams were confronted with many challenges, many of which are still impacting today. The closure and the transition to largely virtual treatment created substantial disruption and problems that revenue cycle staff had never encountered before. Simultaneously, revenue cycle workforces went from almost 100% remote to nearly 100% remote; medical coding software process and claims procedures are turned upside down in the face of payer and government reforms, and budgets were slashed as elective surgeries came to a standstill due to the COVID-19 problem.
Impact of Automation on the Healthcare Revenue Cycle Management:
After the COVID- 19 pandemic, new legislation and shifts to work from home will significantly impact healthcare RCM procedures and cybersecurity requirements. Here's how these tendencies are manifesting themselves to support Revenue Cycle Management in Healthcare Industry:
Increase in Remote Work:
Medical Billing and accounting teams in healthcare are close to the front lines. The billing and accounts teams were quickly forced to switch to remote work, although the work never stopped. The resulting increase in security and compliance controls isn't expected to go away anytime soon.
Around 75% of large hospitals and health systems have traditional instructional staffing changes that include work from home. As a result, your RCM procedures must be able to function just as well at home as they do in the hospital.
Increase of Patient as Payer:
With insurance companies' increased denials following COVID, individual patients will be forced to shoulder responsibility for their procedures. Healthcare organizations have struggled to collect payments on time due to the change, as they are only experienced with the behavior of significant payers, not individual consumers. This step slows down the entire RCM process, and it's starting to become a real revenue issue for about two-thirds of healthcare firms.
Since these Patients have quite different payment cycles than typical payers, it will be critical to pay attention to the data to discover new best practices for engaging the customer and ensuring that the payment is made.
Increase in Consumer Collection Laws:
Surprising billing methods will be restricted by this regulation, which will demand greater attention on compliance. Because billing cycles and standards change, it's critical to keep the RCM practice up to date so that one won't miss out on any compensation due to a clerical error.
Increase in Cyber Security Issues:
Security breaches in the healthcare industry are rising, and sensitive patient information is always a target. The cost of a security rupture is higher than the cost of protection. These standards may appear to be working right now, but it's all too easy to become complacent. As a result, it is necessary to ensure that RCM practices are compliant with industry-standard cybersecurity protocols.
Increase in RCM Automation:
The healthcare revenue management team and the transaction data team will save time due to automation, which will result in more timely compilations from payers and patients. These automation systems will need to be intelligent and scalable to handle multiple care approaches, such as telehealth, to maintain pace with the enormously complex public insurance rules. Conventionally, rules-based technologies have driven automation in patient billing. However, as medical reimbursement becomes more complicated, a shift to intelligent automation powered by machine learning can help maintain productivity.
Furthermore, while healthcare revenue cycle management solutions are complicated due to the numerous technical processes, it is simple to comprehend.
In a word, revenue cycle management healthcare is used by hospitals and health systems to track the "revenue" they earn from treating patients. RCM has several processes, but it begins with the initial encounter with the patient, such as booking an appointment, and continues until caregivers receive the final payment.
The revenue cycle of a healthcare facility typically has seven components:
Preregistration:
The primary and most crucial step in the revenue cycle process is preregistration. Pre Registration allows the medical practice to capture demographic information, insurance information, and eligibility in real-time through a clearinghouse. The data is sent to the patient's protection company and then passed through the provider's practice management system, informing the provider of coverage, deductible, co-insurance, and copayment.
The preregistration method allows a practice to establish the financial tone from the start and eliminates payment-related questions. Many categories are usually missed if a practice does not have a strict pre registration procedure.
Registration:
From start to finish, registrations ensure that the patient's health information is 100 % accurate. Upon registration, the provider verifies the patient's address, phone number, date of birth, guarantors, and insurance information, and they must safeguard this information every time a patient is treated.
During registration, the provider collects copayments and ensures that a referral or authorization to treat the patient is in place if the patient is a specialist. If that stage is skipped in a specialist's office, it's unlikely that they will be reimbursed for the service. Financial paperwork is signed, and insurance benefits are allocated during registration.
Charge capture:
Charge capture, the third phase in the revenue cycle process, can be accomplished in various ways.
It is automated, so the provider's paperwork is automatically fed into the practice management system. The other alternative is to do things the old-fashioned way, with front-desk workers manually entering information or sending it to top billing.
Consulting an expert to assess the charge capture process if the patient is concerned about accounting for all expenses. An experienced advisor can track a charge from beginning to end as part of a revenue cycle audit, uncovering missing charges and identifying miscoded charges. Making sure clients' charges are properly captured is an integral part of the revenue cycle process.
Claim submission:
After the charges have been submitted, claim submission comprises sending information to the insurance provider. The revenue cycle team routinely examines the charges, CPT code, and diagnostic code. They'll inquire as to whether the diagnostic supports the procedure. If two services are offered, they must be differentiated and categorized correctly.
Scrubbing claims is the process of ensuring that they are clean and enter the system correctly. A claim is settled much faster if it arrives at the insurance provider in good condition. The claims are sent from your practice management system to a clearinghouse, which works as a mailroom, receiving and distributing the claims to the various payers.
As a result, the sooner errors are found, the faster they are corrected, and the faster reimbursement of claimed reimbursement.
Remittance processing:
Remittance processing is the fifth step in the revenue cycle management in healthcare. Remittances are received once a practice's claims have been sent out. The benefit of explanation shows the practice of how much they were compensated for the services they supplied. Allowable is determined during this process.
Fee schedules, which are the quantities providers charge for each of their services, are a part of remittances. Annually, providers should examine their fee schedules to comply with changing rates, contracts, and allowable. Examine your costs frequently to ensure you're not wasting money.
Write-offs, both contractual and non-contractual, are the final step in the remittance process. Because contractual write-offs include contracted prices with carriers and payers, they are unavoidable.
Insurance follow-up:
Insurance follow-up is the following phase in the revenue cycle process. Practices examine not only what has been paid but also what has not been paid at this time.
Faster reimbursements accounts receivable (A/R) report displays all of the items sitting in the insurance and patient buckets for a long time. This analysis will reveal whether or not insurance follow-up is broken and claims are taking so long to receive payment.
Determining the structure is a crucial part of insurance follow-up. The following are some good questions to ask:
Is it true that people are assigned to specific carriers?
Is your billing staff multi-skilled?
Do you have many billing personnel who are capable of working with Medicare?
Is this insurance being handled by the practice management team?
Are you noticing any visible aging changes every month?
Are there any claims that are being appealed or that are being resubmitted?
Patient collections:
Patient collections are the most problematic aspect of the revenue cycle procedure. When a patient is in the office, the optimum time to get money from them is there. As a result, front desk workers should be educated to collect at the moment of service. To avoid a collections backlog from building up, make sure you have a uniform policy in place for collecting copayments and deductibles that outlines the practice's financial expectations.
Making sure that routine patient statements are sent out is just as crucial. A daily statement cycle is ideal; your patients will receive one statement every 30 days, but statements will be sent out more often, faster reimbursement pinging you to improve revenue cycle and cash flow.
The revenue cycle begins with the initial engagement with the patient engagement and ends with receiving the whole amount due for delivering healthcare services to the patient, as shown in this list.
CONCLUSION:
Regulations, reimbursement models, and technology in healthcare are all changing at a breakneck speed. The financial viability of healthcare organizations faces significant challenges as a result of these factors. A well-thought-out and well-implemented medical revenue cycle management strategy can mean the difference between struggling practices and those that thrive.
Practices that automate where appropriate and streamline when necessary gain an advantage over those mired in tedious and time-consuming tasks that fail to deliver the desired result—maximum payment for rendered services as soon as possible.