Electronic Health Reporter

By Marvin Luz, senior director of revenue cycle management transformation, Greenway Health.

The move to value-based care not only impacts the approach providers take to serving their patients, but it also changes the way they document, account for, and bill patients — quickening billing cycles and creating a need for better cost containment.

Timely revenue cycle management (RCM) is essential for success in this new healthcare realm, but many practices still handle billing as if they were in the fee-for-service age. This leads to critical mistakes that cost them in the long run, including:

#1 – Lack of a defined process

Billing glitches originate in several areas of practice operations, especially during busy times. With many patients coming in and out of the office, important information may be miscommunicated, overlooked, or even lost. Practices must standardize their billing processes as a “cycle” that is clinically driven and embraced by staff.

#2 – Neglecting critical information

While managing every type of information contained in documents that practices require may seem overwhelming, providers must embrace this task to optimize revenue opportunities. For example, when organizations understand the nuances of payer contracts, they are in a better position to fully leverage payment and negotiations. Equally important is staying on top of edit reports, explanation of benefits forms, and other claims issues, while also making sure denied claims are reworked and resubmitted in a timely manner.

#3 – Failing to follow up

Providers employ a variety of strategies to improve collections, including appeals, tracers, collections letters, and payment plans. While these tactics are a good first step, many fall short due to lack of follow-up. Research conducted by Greenway Health found that only 62 percent of practices review delinquent claims, while just 59 percent of secondary claims are filed due to back office time constraints. Often, by the time a practice realizes a patient or payer has not responded, it’s too late to collect the money owed.

#4 Drowning in detail

Details are important, but when billing practices become all about them, organizations can neglect the bigger picture revenue opportunities. For example, if practices look for trends, such as repeated claims denials for the same services or claims that are denied for registration errors, processes can be reworked to avoid those common errors to occur in the future.

RCM – a practice-wide responsibility

While front office, back office, and clinical roles within a practice have traditionally been segregated, it’s becoming more important that all staff engage equally to rectify these common mistakes. A holistic approach will help practices successfully implement a complete RCM strategy, since the duties of all three groups contribute in one way or another to the bottom line.

Effective RCM strategies begin with the initial staff and patient encounter, which is typically before a patient enters the office. At this time, front office staff should collect insurance information and confirm eligibility prior to the appointment. This enables the practice to reconcile any inconsistencies before treatment and billing and inquire about both primary and secondary coverage. Practices also should gather demographic and medical information from the patient before the appointment, using an online patient portal or emailed registration packet a patient can fill out in advance.

Once a patient arrives at the appointment, the front office should also collect co-pays and be prepared to discuss the cost of treatments and procedures, since many patients now have elected for high-deductible health plans or pay directly for services.

Clinicians then are responsible for the next steps in the RCM cycle. Even though their primary responsibility is treating and helping patients, they also play a critical role in generating revenue and cannot be blind to the finances of the practice. With ICD-10 coding rules and value-based reimbursement requirements, clinicians must document their interactions with patients and capture details about the care they provide.

Having more complete and accurate information from the first two stages of the cycle, the billing department will be able to submit cleaner claims with less likelihood of rejection. This should free their time to focus on collecting delinquent fees or resubmitting previously denied claims.

Improved RCM involving your whole team is required for practices to succeed, particularly in the value-based care environment. Team members must work together to ensure patient information is complete and accurate from the point of registration through clinical documentation because a single gap in data can delay payment or detract from revenue streams and negatively impact practices’ bottom lines.