A key element in achieving end-to-end revenue cycle success in any healthcare operation is proper dedication and maintenance of workflow tools, and those systems that support processes that help organizations meet net revenue expectations.
Workflow optimization and the deployment of tools should be viewed from four perspectives: People, process, technology and metrics/KPIs/reporting.
It is incumbent on healthcare organizations to explore each of these areas related to RCM workflow optimization and consider relevant questions before deploying a fresh approach to workflow processes and automation. First, they must recognize that a balance of concentration of these four components is needed when building operational effectiveness and for the success of workflow strategy, tools and support systems. Furthermore, it is critical for RCM workflows (front, middle and backend) to reflect the uniqueness (location, size, demographics, payer mix, etc.) of the organization.
While there are many benchmarks and strategies in the industry that an organization can follow, adapt to or adopt, the specific characteristics of the organization – whether it’s a rural versus urban facility, the size and makeup of its staff, budgets, effects of recent mergers and acquisitions, and more – must be inputs when building and maintaining effective workflow controls. Principally, dedication to establishing optimization in workflows within revenue cycle operations is a direct result of senior management’s objectives of lowering or maintaining organizational metrics involving departmental and organizational “cost to collect”.
Organizations’ achievement of desired “cost to collect” results comes from their empowerment of senior and middle management and line staff, adoption of sound strategies that are understood and embraced, provision of user-friendly processes and effective deployment of technology – as well as maintenance of technology in a manner that is adaptable and flexible to the user and the organization.
More importantly and in support the first three components, organizations pursuing workflow optimization must have a process in place for measuring and gauging the success of established RCM goals, as well as clear metrics. Metrics are where the rubber meets the road – they’re how organizations know whether the people, process and technology components are functioning efficiently and as intended.
As in any situation where there is a desire to get from one point to another effectively and efficiently, a sound understanding of how metrics support organizational expectations will inform the direction and strategy. It is also important to note that RCM workflow optimization is system agnostic. While each organization has different approaches to workflow support and automation, they need to look at this component relative to the system they have deployed as well as their own uniqueness.
With a dedicated, all-encompassing approach to workflow operations, organizations are better positioned to process patient access, improve eligibility/benefits verification administration processing, improve Point-of-Service (POS) collections, effectively manage claims loads, process appeals in a more timely manner and improve self-pay production and collections. They can also maintain proper coding requirements, improve overall processing, and possibly reduce denials or denial rates, all while improving overall aspects of the revenue cycle continuum to achieve organizational strategic and revenue goals.
While there is no off-the-shelf, cookie-cutter formula to deploy to achieve expected net revenues and RCM optimization, establishing and maintaining benchmarks consistent with the uniqueness of an organization is key to success.
Organizations must address many questions to understand whether workflow operations and technology are hitting the mark. While a holistic approach taking into account people, processes, technology, and metrics is fundamental for true system effectiveness and performance optimization, there are many considerations associated with each of these areas.
People/Resources:
Does your staff have the capacity to perform production requirements needed for organizational success? Additionally, in deploying resources, are team members in the right positions? Are there leaders who can enable others’ success?
Do all RCM staff fully understand their roles relative to the RCM end-to-end continuum? Are staff interchangeable or cross-trained to increase operational understanding or in preparation to fill unexpected gaps?
Does RCM management deploy outsource resources as a stopgap measure?
Are teams looking at “root cause” issues that will affect workflow production goals and objectives?
Processes
In the case of new RCM systems and upgrades to present systems, are workflow processes reviewed or challenged with respect to potential changes in technology?
Are RCM operational workflow processes interchangeable so that any new introducing effects do not create abnormalities, gaps, and workarounds?
Does the organization embrace outsourced help in achieving best practices in workflow processes?
Should the organization consider a central billing office if one does not exist?
While there are more questions organizations ought to consider in reviewing – and correcting – the effectiveness of the RCM continuum, the areas of people and process should guide the use of resources in the most efficient and effective manner. Furthermore, the structure of operations should allow for adaptable departments(s) and an environment that promotes the achievement of organizational goals and the ability to manage expected and unexpected changes.
By Joe Polaris, senior vice president of product and technology, R1 RCM.
Joe Polaris
This year promises many new opportunities to apply technology to improve the healthcare revenue cycle. The recent HIMSS conference, for instance, featured many exciting use cases for machine learning and artificial intelligence (AI). However, before rushing to implement any of the latest solutions, let’s step back for a moment.
While there is plenty of emerging revenue cycle technology, there is also still a fair amount of complexity when it comes to implementing these capabilities. Most organizations typically have a significant amount of disorganization to deal with on the back end of their billing processes, as well as disparate technology systems that don’t work together. Many organizational leaders also are growing tired of only achieving incremental improvements to the revenue cycle through stand-alone revenue cycle management (RCM) technology, especially with rising total administrative costs and cost to collect.
That means we simply cannot afford to implement “quick-fix” RCM technologies that fail to support future goals. In an industry known for emphasizing quarter-by-quarter financials, we must begin taking a longer view. Rather than trying to establish 2019 implementation priorities, think about using the rest of 2019 to set the foundation for a holistic RCM transformation.
Perhaps the question to ask this year is: “Where do we want to be in three years – in terms of process efficiency, cash flow and an experience that delights our patients?”
Map RCM to the patient journey
Answering that question requires a holistic assessment of the entire revenue cycle, especially as it relates to the patient journey. Although that’s not a small undertaking, it allows healthcare organizations to build a thoughtful, realistic roadmap for long-term RCM transformation. In turn, such planning helps organizations realize greater value from all their RCM technology investments. Consider these four steps:
Evaluate: Although some healthcare organizations are further along when it comes to more efficient and patient-centered RCM, most are just starting to explore due to a wide variety of situational limitations. Escaping such constraints will require you to map out the entire patient journey end-to-end. Then, look at the map to identify areas of potential revenue cycle satisfaction for patients, as well as their most significant pain points.
Plan: After evaluating your RCM strengths and weaknesses, prioritize those processes in which technology has the greatest potential to remove waste, create capacity or give back operational expense. When deciding which solutions to implement, remember to take a broader, longer-term focus. Your organization should avoid the temptation of “quick wins” and instead focus on a viable long-term path that will meet your holistic, collective objectives. By generating a long-term plan, you will also incrementally create business value and move toward a more well-defined end-state vision. The most impactful digital transformation might come from phasing in the adoption of a comprehensive platform, as well as combining digital self-service technology and other automation capabilities — some of which may take hold quickly, while others may require more time.
By Marvin Luz, senior director of revenue cycle management transformation, Greenway Health.
Marvin Luz
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.
One ageless trend emerging for 2018 is the quest of hospitals, larger carriers and clinics to identify new revenue streams; not just managing revenue cycles, but creating them. The healthcare industry is now looking at revenue which can be generated through the interoperability of annual wellness visits (AWV), chronic care and service care transitions between physical and behavioral health services. Hospital systems and other healthcare facilities that can connect these services with technologies such as bi-directional information flow will benefit by offering these services and creating a new profit centers of revenue through reimbursements by CMS and private insurers.
These types of market drivers are noted in The Global Healthcare Revenue Cycle Management (RCM) Software Market report for 2017-2021, issued a few months ago. The report predicts that the global healthcare revenue cycle management (RCM) software market will grow at a CAGR of 4.50 percent during the period through 2021.
Healthcare service providers deploy automated systems to address RCM processes and to fill the payment gap that arises from the processes of medical billing and collections. However, the report points out IT applications such as hospital information system and EHR have outdated technology platforms that lack advanced functionalities needed to address RCM issues, causing hospitals and health systems to prefer to outsource these services due to the lack of interoperability between revenue cycle processes and workflows. This type of outsourcing drains hospital revenue.
Meanwhile, global business researcher Radiant Insights issued a study in November reporting that the healthcare information technology market will have growth through 2022 of close to $50 billion. Factors such as increasing focus on improving quality of care and clinical outcomes, rising need to reduce healthcare costs and minimize errors in medical facilities, along with government support for healthcare IT solutions will drive the market. Increasing adoption of technologically advanced software solutions including EHR and EHR connectivity systems, e-prescribing and clinical trial management software and clinical decision support systems is helping to improve healthcare productivity.
The study also cited the growth of cloud computing in the healthcare industry is improving real-time communication and data exchange. Interoperable systems and cloud computing are integrating healthcare systems at a rapid pace and are identifying infectious diseases and tracking the incidence as well as occurrence rates of chronic diseases.
Radiant Insights points to up-and-coming organizations such as Zoeticx, Inc., a provider of medical software, that has introduced a cloud app called ProVizion Wellness. This software can be beneficial for streamlining data integration for annual wellness visits by offering interoperability through bi-directional data flow. Hospitals and other healthcare facilities are benefiting by providing this service through private and government insurers. This system provides management capabilities for supporting tracking ability on population progress for AWVs. The report also mentioned prominent players operating in the healthcare information technology (IT) market include 3M Health Information Systems, Lexmark Healthcare, Conifer Health Solutions, and CSI Healthcare.
The Chemistry of Linking Unrelated Hospital IT Landscapes to Revenue
As the hospital revenue trend for 2018 looks promising, we are still facing the same old interoperability issues despite the advances in technology pointed out in the previously mentioned research. What can hospitals and clinics do to be a revenue leader? As we move into 2018, it might be a good time to examine what is necessary to solve a complex problem like the ability of hospitals to link interoperability and the benefits that arise from adopting tools, technologies and concepts from unrelated landscapes.
When we look at the value generated in healthcare, we remain enamored with acute care administration to address patients’ concerns with a new illness or exacerbation of a chronic condition. One of the stated goals of widespread EHR adoption was to assist in this aspect of care. EHRs are being used to capture patient data, as well as to label and extract detailed metrics in an attempt to quantify the amount and quality of the care delivered, irrespective of the geographic and temporal boundaries of where the data was captured. The design of EHR’s is to allow for capture and subsequent analysis and billing for the care delivered.
However, the value of health IT lies in the robustness of applications. This might seem obvious since most of the technology we have direct experience with relies on the applications which drive value such as cloud based assets. For hospitals, investing in an application seems more prudent then investing in a protocol. However, by looking at the problems faced in healthcare, changing the perspective of the problem from an application-centric one to that of a protocol-centric view brings new revenue possibilities.
The revenue cycle management (RCM) process is one of the most vital parts of an efficient and functional healthcare entity. The vitality of this process to the healthcare industry as a whole cannot be understated, and it continues to grow with each passing year. In fact, it is predicted that the RCM market will reach more than $43 billion by 2022, underlining the increasing importance RCM has for healthcare providers. By offering the process by which healthcare providers receive reimbursement for their services from insurance providers, proper RCM can be the difference between sinking and swimming for healthcare facilities.
In understanding the facets that go into an effective RCM process, it’s important to note the key factors that successful RCM processes tend to share. These fundamentals all contribute toward creating an RCM process that brings the best results for healthcare facilities while minimizing their pain points and streamlining the experience for patients. Healthcare providers would do well to examine their RCM processes closely and determine whether or not these key fundamentals exist within their systems. If not, they may need to take a stark look at their processes and make significant changes if they are to have any hope of functioning at optimal efficacy.
For example, high accuracy is one of the most vital features of a successful RCM process. Without high accuracy, the data healthcare providers use to optimize their processes may be lacking, leaving them open to making serious errors in judgment. In turn, creating a domino effect that can have catastrophic effects on the rest of their RCM framework. Successful RCM processes also must incorporate a physician advisory module or component that can provide physicians with the resources from which they can navigate the regulatory environment with better success and ease. This can reduce obstacles that are encountered commonly with regards to legal requirements — in effect, streamlining the entire RCM process.
The below infographic from R1 RCM outlines these and the many other aspects that go into creating a successful RCM process for healthcare providers. Understanding these key components only becomes more important all the time. Meaning, there’s no excuse for not getting started on building a better RCM process today.
The CMS (Centers for Medicare and Medicaid Services) employs HCC (Hierarchical Condition Category) for determining payment level for Medicare Advantage Plans. The difference in diagnosis of patients and outcome of their health makes for the risk- adjusted payment. Patients suffering multiple chronic conditions are prone to greater risk scores. For physicians practice accurate HCC coding becomes an important element for managing the revenue cycle.
These risk scores are derived by HCC which are annually assigned to the members. HCCs are completely based on claims data which is collected from the providers. This information further gets annually validated through an audit, which is referred as RADV audit (risk adjustment data validation).
For tackling this situation in a better manner, many payers have started education initiatives for guiding their medical staff and physicians to document complete and accurate medical records. Your medical records determine risk scores of all the members. Here we will tell you how professional support can be a holistic approach for reaping greatest benefits and further upgrading your HCC revenue cycle management:
Let’s begin with have a brief insight into HCC codes:
Under HCC codes, your reimbursement depends on diagnosis of the patients. The risk score is higher with the patient having severe diagnosis. HCC codes are also referred as “payment multipliers” by CMS. All the guidelines are to choose a primary diagnosis under risk adjustment.
Describing the main reason for the encounter.
Adding codes which describes coexisting conditions.
Now, let’s start with the importance of professional support in order to upgrade our HCC Revenue Cycle Management:
Staying Updated with Guidelines
We recommend you to look for a partner who have expertise working in the HCC risk adjustment, encounter data submission, preparation of audits(RADV) and can have a retrospective review of records. Regulations which are implemented by ACA can change anytime and that too abruptly. For staying up-to-date, many vendors have established a body of governance, guidance and memoranda. As soon as the changes are announced, this body of governance informs and updates the affected department.
This governance body is liable for evaluating new requirements. Any single department or an individual can’t anticipate the impacts of modified conditions. Expert of each department collectively takes the decision of selecting the best way for responding the new guidelines.
A professional support have its own body of governance for dealing with new guidelines in a better way.
Implementing Audit and Quality Assurance Program
A quality assurance program will lead you to meet RADV audits and improve the accuracy of your data. For reaping the benefits of this you need to hire a third party. Your third party will substantiate the HCCs which are documented and are based on medical records.
The IVA (initial validation audit) has to verify the enrollment which is included in the sample of the member. After this whole process gets completed, a second validation of audit (SVA) is conducted by HCC. This focuses on the sub sample of the member whose evaluation of record is done in the IVA.
In case SVA finds huge amount of errors, HHS will confirm that whether payer is having an effective program for quality assurance. This program focuses to ensure that the data is complete, accurate and formatted properly. A solid assurance quality program is an important defense in the cases of False Claim Act.
Even with electronic decision-support technology and responsive, knowledge-based medical software built into modern electronic health care record (EHR) systems, it is critical for physicians and clinicians to recognize the primary focus is still treating the patient. In an effort to survive escalating costs of care and declining reimbursements, modern health care delivery models shifted from a patient-centric care model toward a financially motivated business model.
With the push toward value-based reimbursements and rigorous quality measurement reporting mandates, hospitals and medical organizations today must balance the need to remain financially solvent with improving patient outcomes and experiences throughout the health care journey.
Business Process Outsourcing: Revenue Cycle Management (RCM) and Value-Based Care
End-to-end RCM in the healthcare industry explores cost per transaction beyond salaries and benefit packages. Administrators examine productivity volumes, idle time, workforce utilization ratios and patient flow as key factors that directly influence revenue potential.
Business process outsourcing (BPO) has gained popularity in recent years as a way for hospitals and practices to control operating costs without compromising patient care or satisfaction levels. It is a win-win proposition for all stakeholders. The RCM software and services market, which includes BPO, now garners more than $12 million, annually. There are many reasons to consider BPO, including streamlining internal efficiency, expediting third-party payer reimbursements, and reducing data entry errors that stifle cash flow and frustrate consumers.
Analytics, Document Management and BPO
Improving document management is critical. Leading technology enables collecting vast amounts of data, data that can be used to improve patient outcomes, and financial performance. However, data is only valuable if it can be rapidly accessed, analyzed, organized and converted into actionable information. Digital Documents, which is a company that provides outsourced document management services, says document processing services essentially convert information to digital assets.
Those assets may translate into higher profit margins. One study showed hospitals that outsourced most of their RCM operations in 2014 saw an average revenue increase of 5 percent to slightly more than 6 percent. Revenue increases are expected to continue to grow over the next few years, especially in the health IT outsourcing area, which according to Reportstack should see an annual compounded growth rate of almost 9 percent through 2019.
In the following conversation, Jim Lacy, CFO and general counsel of ZirMed, discusses the company’s mission, goals and growth; his passion for healthcare and serving those who work in it; ZirMed’s transition from a clearinghouse to a revenue cycle management, population health and predictive analytics firm; why privacy has become the biggest issue very few are seriously talking about; and the changing face of healthcare as a whole.
Tell me more about ZirMed, the brand, its solutions, and your mission for it.
Our core mission is to help healthcare providers, hospitals and health systems get paid. It sounds simple, but efficiently and effectively getting providers paid for their services and supporting their mission in an ever-evolving technological, regulatory, and clinical environment is incredibly complex.
ZirMed is uniquely positioned to deliver a comprehensive end-to-end platform of cloud-based financial and clinical performance management solutions. That means that at every point in the revenue cycle, we have solutions that support healthcare providers in collecting monies from payers and patients, and do it as quickly, efficiently, and cost-effectively as possible. Our solutions address the challenges of the current fee-for-service and consumer-driven payment systems, and also support fee-for-value reimbursement, broadly defined as population health management.
ZirMed’s solutions are logically oriented to address the revenue cycle needs of providers ranging from small physician practices and durable medical equipment providers to the largest hospitals and health systems. At the front end, we offer Patient Access solutions focused on registration and check-in to streamline pre-registration, estimate patient responsibility, accurately verify eligibility, and more.
Core to our mission of getting hospitals and health systems paid for services provided is our Charge Integrity solution. We use big-data and predictive analytics to identify and capture charges, resolve process inefficiencies, improve coding compliance, and ensure the complete integrity of all inpatient and outpatient billing.
Our claims and A/R management solutions include robust edits and rules aggregating claims across an entire system, and provide highly efficient claims and receivables workflows, reduce preventable denials, and deliver insights into financial performance for critical decision support.
With the ability to process vast amounts of data and provider metrics across an organization, our cost and utilization solutions benchmark provider performance, stratify risk, and support fee-for-value reimbursement programs.
Population health management has come to hold very different meanings across different organizations. Our population risk management solutions combine clinical and financial information, enabling insights into patient populations while identifying risk, analyzing discharges for readmission risks, and managing referrals across an integrated system.
And, of course, healthcare is always about the patients. We offer a comprehensive suite of Patient Engagement solutions including consumer-friendly billing and payment options and a patient portal offering online payment, statement management, and two-way messaging between the patient and provider.
What about you? What keeps your passion for this mission, and organization, alive? Tell me more about what excites you about your work and why you love what you do?
I love what I do, and couldn’t design a better job for myself than this one: I get to be a CFO, counsel and influence product design, all within the course of a normal day.
My roles are seemingly very different and one person holding them is rather non-traditional; however, there is logic to the fit. ZirMed develops financially focused software solutions in a highly regulated healthcare environment. We deal with billions of transactions and hundreds of billions of dollars annually with an extreme focus on privacy, security and compliancy. My background from the provider side of healthcare prior to joining ZirMed directly influences the types of solutions we build and how we deploy them to positively impact provider organizations.
Ric Sinclair, our VP of product, and his team excel at designing and delivering great software that’s beautiful, powerful, and easy to use. Their role is to take all this complexity and make it as simple and easy as possible for users and managers in client organizations. My role is to weave my experiences into the design of our products and support the role of the client in everything we build.
So I’m doing what I love and working with incredibly smart, talented people every day. That makes it easy to stay passionate and excited about my work and about ZirMed.
