Once a patient has been seen, a complex process begins as the provider’s position for reimbursement. This elaborate series of actions is mandated by outside entities, both governmental agencies, and commercial insurance payers, that stipulate the various parameters and requirements to secure payment.
The process has evolved in a piece-meal fashion for decades and is being challenged again by a value-based care payment model that focuses more on quality and less on quantity. For radiology groups, the revenue cycle management (RCM) workflow continues to evolve. Still, there are some specific areas that can be enhanced regardless of how the system develops in the future.
Solutions to Improve the Radiology RCM Workflow
Regardless of the payment models used now or in the future, two things are certain — insurance payers will continue to define the process, including pre-approval requirements and submission criteria, and costs will continue to be shifted to the patient through higher deductibles and cost-sharing schemes.
It will remain the providers’ responsibility to ensure a smooth RCM workflow that is efficient and adaptable, including:
- Use Payment Estimation Tools and Processes — Patients are much savvier about their own healthcare costs, and many now want an accurate estimate upfront – plain and simple. The providers job is to provide an estimate and educate their patients further on ways to pay for the upcoming obligation. An estimation tool is an invaluable way to improve practice collections and increase patient ownership in their care and outcome.
- Offer Electronic Payment Options — Patients should be provided with the means to pay electronically prior to their visit. Patient portals, electronic payments, and e-statements are ways that patients can utilize advanced automation to pay their portions.
- Ensure Approvals are in Place — Prior authorizations, ordering provider referrals, and, for Medicare patients, Appropriate Use Criteria Compliance Certificates, from a CMS-approved vendor for CDSM, are all examples of insurance stipulated approvals and requirements that can negatively impact reimbursement if not in place. Consider using electronic solutions and advanced automation, including artificial intelligence (AI) driven software, to streamline the workflow and enhance revenue capture.
- Reduce Lag Time in Documentation/Submission — As part of a team effort, providers and APP should all make the cooperative push to ensure documentation and charge information is submitted timely (ideally within 24 hours) while procedure, diagnostic review, or patient interaction is all still clear. The sooner the data enters the RCM phase, the quicker the reimbursement can be collected. And, without a doubt, timely filing requirements are generally more than adequate to get claims submitted.
- Ensure Accurate Coding — Whether this is done in-house or by a 3rd-party partner, ensure proactive coding for the procedures performed during the patient’s visit to eliminate missing or invalid information, including:
Codes that are not specific enough when each diagnosis must be coded to the highest level (maximum number of digits allowed),
Unbundled charges being charged separately when they are designated as part of a diagnosis bundle,
Use of outdated superbills or coding books, either CPT, ICD-10, or HCPCS, which lead to inaccurate information being submitted and rejected.
- Manage the Denials Process — According to the Medical Group Management Association (MGMA), the cost to rework a claim that has been denied by insurance is $25.00 for each occurrence. And even more impactful is the fact that between 50% and 65% of denied claims go unchallenged due to lack of time and/or understanding on how to proceed and the revenue is lost completely. The message is to avoid denied claims by strengthening upfront processes, but, if they occur, manage them quickly and accurately to maximize reimbursement.
- Discover Undisclosed Insurance Coverage as a Final Step — With ARs, there always seems to be uncollectible amounts once the rework has been done. But what if those accounts could be processed electronically to ascertain if there are undisclosed insurance coverages available before they are sent to collections. Using AI-driven software with machine learning capabilities, it’s possible to glean data from vast insurance clearinghouses so that a claim can be resubmitted and collected from coverage that the patient didn’t disclose or wasn’t clear about.
Future solvency in healthcare will rely, in part, on managing the RCM workflow to the highest standards. Today, radiology groups should consider their overall investment in technology, paying considerable attention to operational improvements that reduce administrative RCM workflow and increase revenue capture.
Contact us to learn more about radiology RCM workflow solutions to enhance your revenue collection throughout the patient encounter.