Revenue cycle management 2.0: The key to successful healthcare finance

The impact of COVID-19 means that it has never been more important for those in healthcare to manage their revenues effectively. As a result of the pandemic and several supplementary factors posed by the market changes, there are increasing pressures on healthcare providers to deliver better customer experiences and for more efficient administration.

This has, in turn, put greater emphasis on the need for Revenue Cycle Management (RCM) systems to enable a healthcare provider to better manage transactions between payer, provider and patients. It can, through the use of various software platforms, boost revenues, reduce denials and enhance the patient experience. According to a survey published by health technology company AKASA, nearly three-quarters of health systems surveyed, reported using active technology in RCM operations during the pandemic.

However, RCM systems are often fragmented and uncoordinated. A survey by Unified Automation, an RCM consultancy, revealed that 30 percent of health systems and hospitals are unable to manage their revenue cycle automation efforts without at least two vendors. Calculations by the University of Pennsylvania School of Medicine reveal that the US healthcare system wastes $265.6 billion a year on administrative complexity, including billing and coding waste.

Even when they are implemented, the risk is that a focus on regulatory issues and administrative requirements means that patients’ needs are not always taken into account. The revenue cycle includes a variety of components, each of which, if not managed well can result in a suboptimal experience for the patient.

In a recent report titled “A dozen facts about the economics of the US health-care system,” the Brookings Institution noted: “Surprise billing is associated with high health-care costs. In a well-functioning market, consumers are able to observe price and quality differences between different options. Health-care markets often fail to meet this standard.”

Many systems fail to provide an estimate and an outline of the claimable expenses before the medical treatment starts. This means that the patients discover, way too late in the process, on what they are and are not covered for. They may well find themselves bearing unexpected costs. In some cases, previous costs that a patient was liable for were not brought to their attention led to unhappy patients who were less willing to settle bills for historic amounts.

The reimbursement landscape is evolving with a move towards reimbursements based less on fee-for-service and more on pay-for-performance. To produce better the clinical outcomes required to meet these performance targets, healthcare providers will need to optimize their RCM operations by adding technological capabilities to collect data and drive analytics. Payer scrutiny of compliance and charges by both government and commercial operators is becoming increasingly stringent. Meeting this challenge requires enhanced tracking and management capabilities in the RCM function, with interested parties embracing value-based reimbursement structures.

To achieve this RCM systems must be automated. However, healthcare providers also need to know how to incorporate the human touch, something that is especially important given the nature of the sector. It’s essential during the design, implementation and execution stages to include input from all stakeholders, especially, as the Northwell Health writers argue, patients. This involves a clear explanation to patients of issues such as the difference between estimates and final costs. RCM systems and other administration need also to ensure that patients are made aware of the risk of insurance denials and opportunities for accessing the Affordable Care Act provisions, as well as navigating Medicaid provisions and charitable support options.

In fact, healthcare providers frequently discover that many of the considerations are related less to the design of RCM architecture and are more related to its implementation on a day-to-day basis. Staff training is essential to deliver a high-quality patient experience, supported by RCM systems.

One particularly important issue here is the possible change in revenue management brought about by the introduction of remote physiologic monitoring, in the wake of COVID-19. Already expanding rapidly before the COVID-19, it has grown by a remarkable 38 times its pre-COVID-19 rate, according to McKinsey.

Meanwhile, many patients and healthcare workers still do not fully understand the new codes introduced by the American Medical Association (AMA). Healthcare providers need to ensure that their RCM systems are capable of managing them.

Practitioners need RCM that provides visual data representation and dashboards to make receiving meaningful information drawn from data easy to read and act on. Systems should also be ready to provide more information for patients directly, alleviating the need for them to speak to hospital and insurance representatives, improving transparency and giving them a greater sense of empowerment.

Healthcare providers should also ensure that their RCM systems are ready to incorporate and exploit technologies such as Artificial Intelligence (AI), Machine Learning and the use of bots. AI can be used to predict additional health treatments and cost for patients as well as the risk of denial by an insurer among other issues.

As it evolves and integrates these rapidly emerging technologies RCM has the potential to transform the management of hospital revenues. Trends such as aging populations and new, more complex treatments mean that existing health services infrastructure is facing new kind of challenges. The next-generation RCM, blended with traditional human care, presents healthcare providers with a means of not only meeting these challenges but of delivering the efficient administered, high-quality healthcare that patients are increasingly demanding.

Dr. Gauri Puri is Business Unit Head for Life Sciences and Healthcare Practice at WNS.