Industry-wide, hospitals, and healthcare systems are impacted by an onslaught of changing governmental regulations, insurance payer modifications, and transitioning patient expectations. Our evaluation of the revenue cycle management (RCM) process points to four areas where significant revenue is at risk when not performed efficiently: 1) medical coding, 2) medical billing, 3) A/R management, and 4) bad debt/collections. While hospitals may opt to handle these functions in-house with a mix of automated and manual systems, we outline a far superior structure that brings artificial intelligence (AI) and machine learning capabilities through an integrated and secure HL7 technology, supported by highlytrained billing specialists, as a comprehensive solution to today’s RCM process.
Exceeding Industry-Accepted Norms for RCM
While generating healthcare revenue gets a lot of the spotlight, medical billing, and collecting that revenue can be the real workhorse. Hospitals and healthcare systems are facing real challenges as we enter the 2020s, and headwinds are everywhere. Changing and expanding requirements from government entities and insurance companies, new payment models, and RCM issues like rising bad debt and uncollectible amounts leave hospitals searching for a way forward.
From the macro perspective, maximizing revenue in the healthcare industry’s complex third-party payer system continues to be a challenge. With increasingly elaborate payment models and fee schedules, and escalating payer scrutiny for advanced technology used in most hospital departments, it’s never been more critical to stay current with new AI-driven advances in the revenue payment lifecycle.
To add to the complexities, according to the Healthcare Financial Management Association (HFMA), the CDC has released findings showing that 47% of commercially-insured consumers were choosing a High Deductible Health Plan (HDHP), hoping to reduce household health insurance costs by lowering premiums. This shift in financial responsibility from government and private insurance payers to consumers has made it imperative for hospitals to embrace new technology or risk precious margin on the accelerated growth of bad debt.
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or these purposes, let’s define the lifecycle as twofold: 1) patient access, including prior authorization and insurance verification, coupled with 2) RCM—medical coding, medical billing, A/R management, and insurance discovery. By examining RCM’s key functions, we can determine where maximum efficiency could be gained, and previously lost or delayed revenue could be captured.
Let’s look at four RCM components and their inherent issues: