When it comes to your patients, the focus is on the continuum of care. But when it comes to the business of practice management, your focus should be on the continuum of revenue. In this blog, we examine the importance of a stable, functional revenue management system process which includes, workflow automation, patient pay, insurance verification, prior authorization, medical coding, and billing.
The main question any healthcare organization should ask itself is whether it has one continuous process in place that connects patient scheduling to successful claims. Depending upon the systems integrated into practice workflow, the process is either a rock solid highway to revenue or a shaky rope bridge with gaping holes through which revenue is lost. Only one will serve your practice well.
Automated systems improve cash flow
The foundation of all excellent revenue generating systems is when your workflow is automated for real-time decision making. When one solution and one platform is in place, workflow is streamlined and cash flow will follow. The system reduces claim rejections, speeds prior authorization approvals, and reduces staff time. Secure, HIPAA-compliant cloud data storage and electronic documents should interface data seamlessly across RCM and EHR platforms. When a system like that is behind your practice, complete, timely, successful claims, and increased revenue are the results.
A revenue process that leads to high performance
Highly functioning components make up the best revenue cycle management systems. When you assess the capabilities of your current backend functions, determine whether it includes the following elements that create efficiencies and economy of scale. If you are experiencing lost revenue, it may be due to the lack of one of these revenue linchpins.
Patient pay: The patient pay process should begin when the appointment is scheduled. Patient pay makes up 30% of accounts receivables for physician practices — that’s why it matters. Patients need to fully understand their payment responsibility and be prepared to pay at the time of visit. A good process sets that in motion. Statistics show that 90% of patients are likely to pay before they see the physician but only 40% will pay after they leave the practice.
Insurance Verification: Verifying insurance at the time of the appointment being scheduled is the most optimal because it puts in motion a discovery process for your staff and education for your patient. It saves time, money, and the scramble for information when your patient appears at the door of your practice. You need coverage details, network information and details on deductibles to inform your patient and prepare for accurate and timely patient pay.
By automating your insurance verification and eligibility processes, you can increase your payment velocity. Real-time results increases payment velocity and moves you from coverage unknowns to insurance verification in seconds. You have actionable information and the details necessary to arrange payment schedules with patients. A knowledgeable patient is a happier patient and a reimbursed practice is a more profitable one.
Prior authorization: Prior authorizations can interrupt patient care if your system doesn’t prompt staff to handle the details of each patient’s coverage before the test, medication or procedure is ordered. Better information leads to more revenue. The only way to survive onerous prior authorization burdens is to optimize accuracy and maximize revenue through electronic, automated prior authorizations. Best practices in prior authorization are built on software that delivers the following benefits:
- Timely prior authorizations conducted at the time of patient scheduling
- Accurate prior authorization details obtained for accurate claim submissions
- Automated prior authorization tasks, reducing physician admin time
- Cloud-based tools that provide real-time data to make good decisions about patient payment and scheduling
Medical coding: There is no way around it, coding is complex. The intricacies and nuances of coding can make or break the success of claims. With 144,000 code sets, medical coding requires speed, accuracy, and expertise. Industry error rates are averaging 5%, which translates to massive losses in revenue. When a code is wrong, it guarantees denial and stops the payment lifecycle.
Medical billing: It’s so much more than paperwork; billing is the lifeblood of practice revenue. When you review your billing function, look at these factors and gauge their efficiency.
- Charge entry should post patient demographic data, medical codes, and insurance information.
- Payment posting should be regular and staff should be proportionate to the number of providers in the practice.
- Accounts receivable days should be firmly in control to maximize revenue with timely payment posting and accurate aging reports.
- Denials management should wring every dollar out of every denial with timely appeals. (50-60% of denials are unresolved)
- Credit balances are regulated by law. Ensure you are in compliance with balance resolution and 3rd party overpayments. If not, you may pay hefty fines to payors.
- Contract management — are you getting paid your contracted amount, every time?
Review your revenue cycle management process
Luckily the continuum of revenue isn’t a mystery; it’s a precise equation of well-oiled functions. Assess your process and if you find gaps and inefficiencies call in experts to repair them. If you don’t have an efficient process in place to ensure your patient scheduling leads to reimbursements, that’s the very place to start.
It’s critical to examine your entire RCM process: workflow automation, patient pay, insurance verification, prior authorization, coding, and billing. Everything needs to add up to a well-oiled system that tracks patients and care received to billing, denials management, and resubmissions. The work you put in will pay off in spades.