A comprehensive approach to improving the end-to-end revenue cycle management process

Revenue cycle management (RCM) is an area of healthcare operations in need of significant innovation and disruption, according to a recent survey of health system executives conducted by the Center for Connected Medicine and KLAS Research. 

It’s not hard to understand why. RCM can be an overly complex and manual process, resulting in unnecessary costs, unpredictable outcomes, overburdened staff and delayed payments. The movement toward value-based payment models increases pressure on providers because they 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 patient satisfaction without completely reinventing 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. 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 before the patient is seen.

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 know it. In these cases, implementing a coverage identification tool can help practices find and bill the correct payer.

Providers can also ease the challenges within the payment process and improve their chances of collecting payment by offering patients an online payment option for credit card transactions. If expenses are expected to be significant, providers should talk to patients about setting up payment plans.

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 clean before they are submitted to the payer. While most RCM software systems run core edits, such as 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, rather than 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 payment delays. 

Post-adjudication

Once the claim has been paid, practices should ensure the remit matches back to the original claim so there’s a full historical record of the transaction. Some RCM solutions can automatically transfer remits to the practice management system, which eliminates staff having to do this manually. 

When claims are denied, practices should start working the denials 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. 

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 processes during all three revenue cycle phases. 

Healthcare is complex, but there are ways to streamline processes, deliver superior patient care and receive the correct compensation for the services provided. Tackling pre-service, post-service and post-adjudication processes helps ensure that providers receive accurate reimbursements.