Revenue Cycle 101 Archives – Spark Health Partners

Deep Dive: Is Your Practice in the Pre-Payment Review ‘Penalty Box’?

Stacie Sutter, AVP, Payer Strategy — Fri, 06 Sep 2024 18:41:23 +0000

Has a payer placed your facility on pre-payment review for certain services, such as emergency room visits for specific levels of care?

Pre-payment review means your facility must submit medical records with each affected claim before the payer will agree to pay or otherwise adjudicate the claim. This process:

Increases administrative costs in the form of developing alternate workflows to submit medical records with affected claims
Delays payment and increases days in accounts receivable
Insinuates there are concerns with a provider’s billing practices

The latter observation is critically important; however, despite the serious nature of what pre-payment review suggests, payers often provide little to no explanation or basis for placing a provider on pre-payment review.

There’s often no transparency as to why it happened or what’s needed to end it. Providers have engaged neutral third parties to evaluate their billing practices, and these reviews find them to be compliant and consistent with Medicare and industry requirements. Providers are left to wonder what’s going on, how to move forward, and how to avoid this situation in the future.

Pre-payment review can be a worrisome status for a provider to have. Here are some key steps to consider if your facility is facing pre-payment review:

1. Make sure you’re aligned with CMS standards

First, consider what the Centers for Medicare & Medicaid Services (CMS) require regarding facility coding for Emergency Department (ED) Evaluation and Management (E/M) services:

Unique Methodology:

CMS acknowledges that each hospital or ED may use its own unique system for assigning E/M levels.
However, this methodology must adhere to certain principles:
- It should be medically necessary.
- The coding process should be consistent, reproducible, and correlate with the institutional resources utilized in the facility.

E/M Guidelines:

CMS emphasizes that E/M guidelines should:
- Follow the intent of the CPT® code descriptor.
- Be designed to reasonably relate the intensity of hospital resources required to the different levels of effort represented by the code.

2. Assess the ask and your own resources

Next, consider what the payer’s pre-payment review asks of your facility or practice, and what challenges it may create to agree to it and comply. These may include:

Compliance risks:

Asking a provider to re-bill their claim under a different methodology to appease the payer would arguably place the facility or provider out of compliance with CMS requirements to have a consistent coding methodology which is uniformly applied to all patients. Non-compliance with CMS guidelines can result in False Claims Act exposure, fines and penalties and exclusion from Medicare and Medicaid programs.

Administrative burden:

Pre-payment reviews require providers to adjust routine workflows and submit extensive documentation before claims are paid. This is time-consuming and resource-intensive, and it unilaterally imposes significant administrative costs on the facility or provider — not the payer.

Impact on cash flow:

Because payments are delayed until the review is complete, hospitals and providers grappling with pre-payment reviews may experience cash flow issues. Delays in payment can lead to increased borrowing costs and financial strain on the provider. This can be particularly problematic for smaller facilities or practices that rely on timely reimbursement to maintain operations and standards for patient care.

3. Engage the payer using proven practices

Once you’ve confirmed your own compliance and assessed your resources, it’s time to take your concerns back to the payer. Consider these next steps in navigating this situation with the payer:

Ask questions: Given the serious nature of pre-payment review, which suggest there may be concerns with a facility or practice’s coding and billing practices, it’s critical that such activities be done in complete transparency and good faith to ensure the parties fully understand the issues and work collaboratively to resolve them. Ask the payer to describe in detail the criteria it used to conduct its review and the analysis it employed to determine pre-payment review was appropriate. This is also an opportunity to ask the payer to produce the criteria it plans to use in evaluating whether to continue or terminate the pre-payment review status.
Appeal: Facilities and providers have the right to appeal pre-payment review decisions. Understanding the appeal process and preparing comprehensive documentation can improve the chances of a successful appeal.
Enhance documentation practices: Ensure that all medical records are thorough, accurate and up to date. Proper documentation can reduce the likelihood of claim denials and expedite the review process.
Request a reconsideration: If the initial appeal is denied, hospitals and providers can request a reconsideration or a hearing, depending on the payer’s policies. This may involve presenting the case to an independent review board. Additionally, consider proposing a change in payment methodology to remove the payer’s incentive to downgrade claims. For example, a blended case rate for ER visits regardless of the E/M level can help ensure fair compensation and reduce disputes.
Maintain communication: Keep open lines of communication with the payer throughout the appeal process. Regular follow-ups can help ensure that the appeal is being processed and provide opportunities to address any additional questions or concerns.
Master your contract language: Understand your rights as a Contracted Entity and obligations to strictly adhere to CMS guidelines. If there are any uncertainties, consult legal counsel to ensure payers are not violating CMS guidelines when imposing their policies on hospitals and providers. In future contract negotiations, demand transparency and a robust appeal process should the payer wish to impose a pre-payment review status.
Consider dispute resolution or litigation: Review the terms of your contractual agreement with the payer to understand the dispute resolution or litigation options available. This may involve mediation, arbitration or legal action if necessary. Engaging legal counsel can help navigate this process and ensure your rights are protected.

The bottom line

Grappling with a pre-payment review status can be daunting and feel quite unfair to providers who find themselves in this situation. However, there’s every reason to push back on payers, and numerous avenues by which to do so.

The key steps listed above offer a good start, and an expert end-to-end RCM partner can help you navigate the entire process. Spark is on the provider’s side, not the payer’s — when navigating pre-payment review, make sure you also have an advocate in your corner.

Your revenue cycle is too important to be left to chance.

Download our actionable checklist for questions to keep your team on track when navigating pre-payment review with payers.

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A Closer Look at Coding the Social Determinants of Health Risk Assessment

Julie Appleton, VP, Coding Services — Mon, 10 Jun 2024 12:52:06 +0000

On January 1, 2024, Centers for Medicare and Medicaid Services (CMS) introduced the new HCPCS code G0136 – administration of a standardized, evidence based social determinants of health risk assessment tool, 5 to 15 minutes, referred to below as the Social Determinants of Health (SDoH) risk assessment.

This code is meant to reimburse a physician or other qualified healthcare professional for administration of an assessment of an individual’s social needs or identified social risk factors that may influence the diagnosis and treatment of their medical conditions.

The assessment may be rendered as a standalone service or in conjunction with another evaluation and management service. It is subject to a limitation of once every six months per provider per patient. The service will be subject to cost sharing (co-pay and deductible) unless it is performed at the same encounter as an Annual Wellness Visit.

The SDoH risk assessment can be performed by the treating physician or other practitioner (NPs, CNSs, CNMs, PAs), or by auxiliary personnel under the general supervision of the billing practitioner incident to their professional services.

The SDoH risk assessment refers to a review of the individual’s SDoH needs or identified social risk factors influencing the diagnosis and treatment of medical conditions. Use of a standardized, evidence-based SDoH risk assessment tool helps to assess for:

Housing insecurity
Food insecurity
Transportation needs
Utility difficulty

Any SDoH needs identified through the risk assessment (HCPCS Level II code G0136) must be documented in the patient’s medical record and may be documented using one of the ICD-10-CM, “Z codes” (Z55–Z65) which are used to document SDoH data to facilitate high-quality communication between providers.

It is important to note that this is not a screening service that would be performed on every patient. This is an assessment service to be performed when the provider has reason to believe that there are unmet SDoH needs that are interfering with the diagnosis and treatment of a condition or illness or will influence choice of treatment plan or plan of care.

There is some confusion with providers that G0136 can be reported with most Medicare patients. However, the assessment is only to be completed when the provider has reason to believe there are SDOH needs. Medicare has provided limited information on this new code and we may expect additional information as the year progresses and usage increases.

Provider reimbursement for G0136 is $18.97 nationally and can be negotiated into commercial contracts.

Our recommendation for operationalizing this new code is for providers to understand what the potential health hazards related to socioeconomic and psychosocial circumstances are, and to make sure they are aware this new code is available when an assessment is required.

Reference: Detailed information on the use of this code can be found in the CMS publication MLN booklet Health Equity Services in the 2024 Physician Fee Schedule Final Rule.

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Why Revenue Cycle Data Is a Key Differentiator

Devdatta Halbe, SVP, Engineering — Wed, 29 May 2024 13:44:00 +0000

What you need to know

Aggregating and normalizing data is time-consuming and costly for health systems — it requires preprocessing, mapping and translating millions of data points, which is resource intensive. The effort is worth it, however; in revenue cycle management, as in other areas, the efficacy of analytic models lies in data diversity — more variables and broader data sources enhance model completeness. By mapping to outcomes, RCM models can yield swift, precise insights precisely when decisions matter most.

Data is the lifeblood of artificial intelligence (AI), and high-quality, unbiased data is essential for building fair and ethical AI systems. But with the average person likely to generate more than one million gigabytes of health-related data in their lifetime, equivalent to 300 million books, this kind of massive amount of information can be difficult for health systems to analyze on their own.

In healthcare, 80% of data is unstructured, meaning that it traditionally needed to be manipulated or processed in order to be readable by machines. In today’s industry, AI and other technologies exist that can ingest this data and make meaning of it, but these advancements come at a cost. Hospitals, which in recent years have been working with narrow operating margins and focusing their energies on standing up EHRs to meet federal specifications, are left with a ton of rich, beneficial data that many can’t fully tap into without support.

What is the value of data for analysis?

In machine learning, models ingest a large volume of data from thousands of data points to detect patterns so that computers can make decisions without a person intervening.

Data is critical for many other functions, including deep learning, the subset of machine learning that spawned generative AI like ChatGPT. Deep learning is essentially machine learning at warp speed; relying on more data input, millions of data points to assess, and the use of neural networks, which provide layers of processing to support more complex representations of data.

Diversity is critical here; models that draw on diverse expertise, geographies and perspectives help to ensure a diversity of contexts and patterns within datasets. This will help to support robust LLMs that can prevent overfitting a model to a limited set of instances, while also incorporating a diversity of contexts and patterns through a broader range of data and insights.

The more variables that inform models, the more valuable their insights become. Historical data can and should be codified within artificial intelligence, drawing upon multi-system or facility perspectives. This helps to avoid an N=1 bias in model development during the training or evaluation of a model.

Hosting and analyzing this data can take so much processing power and translation that many hospitals usually can’t do it alone. But the energy to access this data is worth the effort, as valuable insights can be gleaned across the revenue cycle.

Where are the sources of revenue cycle data in RCM + how are they used?

To train and run these models, there must first be data for them to ingest. Structured data is explicit and can be readily processed by machines. It is easier to ingest but limited in nature. These data sources include:

Demographic information (e.g., age, gender)
Vital signs (e.g., height, weight, blood pressure, blood glucose)
Diagnostic, procedures and/or billing codes, medications and laboratory test results generally available in host system
Financial data elements such as billing, payments, denials and adjustments

Unstructured data sources require extensive tools to extract relevant information. Examples of unstructured revenue cycle data include:

Clinical data, including medical images, scanned labs and ECGs
Treatment data, including clinical notes and discharge summaries

The benefits of this data in RCM are massive. These datasets can be used to guide decisioning across various stages throughout the revenue cycle and improve reimbursement accuracy.

Front office:

Streamlined appointment scheduling, taking into consideration which providers are credentialed for which payers
Automated and optimized scheduling to boost utilization
Automated insurance verification and prior authorization retrieval prior to service
Virtual assistants managing patient communications regarding financial inquiries, payment plans and insurance-related questions to enhance the patient experience

Mid-office:

Thorough clinical documentation based on natural language processing during patient encounters
Automated coding and charge entry based on clinical data
Automated coding and charge audit for all accounts to ensure accurate reimbursement for services provided

Back office:

Denial prediction and prevention based on historical data for proactive interventions to prevent revenue loss
Automated billing and payment posting to reduce errors and accelerate reimbursements
Contract management and analytics to support underpayment recovery, improve reimbursement and support payer contract negotiations
Payer portfolio management to analyze and predict payer-specific trends, behaviors and patterns associated with reimbursement

What are key challenges in compiling revenue cycle data?

Gathering and harmonizing data from many different systems is a difficult ask across industries. Healthcare revenue cycle data, in particular, has unique barriers that make the creation of a centralized, holistic dataset a challenge.

Data heterogeneity and inconsistency

Challenge: Healthcare data comes from various systems, each with its own format, terminology and structure. Aggregating these disparate data sources can be like assembling a puzzle with mismatched pieces.
Solution: Implement robust data normalization techniques. Standardize terminology, map data elements to common ontologies and ensure consistent representation across systems. For true interoperability, the industry must align on standard data definitions. This means not just consistent terminology, data formats or exchange standards but a single set of these that can inform an industry-wide patient health dataset.

Lack of meta-information and quality for unstructured data

Challenge: Unstructured data (such as clinical notes, radiology reports, and free-text entries) lacks essential meta-information (context, source details) and also suffers from inaccuracies, missing values and biases. Extracting meaningful insights from unstructured data becomes challenging without proper context. The vast volume of clinical data is unstructured, requiring processing before any value can be extracted. This means that fundamentally valuable revenue cycle data is often inaccessible to the health systems that might benefit from it.
Solution: Generative AI can make sense of unstructured data to create content that can then be analyzed for patterns and other valuable insights. Develop tools for capturing relevant metadata during data entry. Leverage natural language processing (NLP) to extract context and enrich unstructured data. At the same time, implement data validation checks, address missing data and assess bias systematically. Regularly audit data quality and correct discrepancies. Each of these steps helps ensure that the datasets being used are not only accessible but accurate.

Lack of systems interoperability

Challenge: Standards such as HL7 and FHIR exist but lack of adherence is an issue. Without consistently enforced standards in place for technological systems — like electronic health records or pharmacy and lab databases — to easily share healthcare data electronically, the effort that it takes for a health system to be interoperable can create a barrier to information exchange.
Solution: Providers can overcome challenges of interoperability by integrating large language models (LLMs) with host/legacy systems and other systems of record, not only at a facility level, but across all locations and across all instances of EHRs. This will allow for system-wide datasets that follow industry standards and vendor-specific requirements for data management.

Regulatory compliance and privacy

Challenge: The Health Insurance Portability and Accountability Act (HIPAA) regulates the use of sensitive patient health information and prohibits its broad disclosure to those who do not need to access it. Any dataset containing protected health information (PHI) therefore must be built to align to these federal restrictions. Aggregating data while adhering to HIPAA regulations and ensuring patient privacy is critical.
Solution: Understand HIPAA’s permitted uses and disclosures. Obtain patient consent when necessary. Regularly review privacy policies and practices. Regarding data usage, ensure proper de-identification of patient data to protect privacy, and adhere to the minimum necessary standard, sharing only relevant information. Implement robust access controls, encryption and audit trails to secure patient data.

The bottom line

Robust AI models are informed by thousands of variables and consume billions of transactions. The more variables provided to inform models, and the greater the volume and variety of data available for consumption, the more complete and valuable models become — providing better and faster insights at the point of decision.

For many health systems, however, this type of processing power can be difficult to support in house; in these situations, a revenue cycle data partner can be an invaluable asset, not only to assist in processing the data but also to provide insight into normalized, holistic analyses from other organizations.

Revenue cycle data is only as valuable as the access an organization has to it. Data analysis requires persistent efforts from a diverse team of problem solvers as well as a robust, diverse dataset — ensure your organization has both available to it.

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What Is a Reference-Based Pricing Plan?

Stacie Sutter, AVP, Payer Strategy — Wed, 01 May 2024 13:28:15 +0000

What you need to know

Reference-Based Pricing (RBP) plans: RBP plans pay providers, labs, clinics and hospitals based on an established benchmark set by a third-party administrator, rather than rates based on services rendered or value derived, like traditional private health plans. RBP plans do not offer in- or out-of-network tiers. Providers may choose not to accept these plans for scheduled non-emergency services or elective services.

What's the difference between Reference-Based Pricing plans and other commercial health plans?

Reference-Based Pricing removes the economic predictability that a contracted fee schedule provides. The model also upsets the existing economic structure of health plans, which relies on:

Network involvement: The discount provided to the payer or third-party administrator through a managed care agreement is provided in exchange for network participation.
Benefits from participation: The network then channels patient volume to the provider. In other words, the provider is discounting their rates and agreeing to payment and Utilization Management protocols in exchange for patient volume.

Under the RBP process, however, the provider’s reimbursement is unilaterally discounted by the RBP administrator, and the provider receives no volume increase in exchange.

Who's driving the adoption of these plans?

Adoption of RBP plans has been driven by employers. According to 2019 data, less than 2% of employers were using an RBP plan but 10% were actively considering it for future use. As employer-sponsored health plan costs continue to rise, more employers will be looking at alternatives like RBP plans.

Why might employers choose this type of plan?

Employers want financial savings and less expensive options while also meeting their obligations to provide health coverage under the Affordable Care Act (ACA). RBP plans meet that need, and often reduce an employer’s healthcare claims spending by 20% to 30%.

These savings, however, are accomplished by shifting the cost of care away from the employer to the employee and the employee’s providers. Employers adopting RBP plans arguably prioritize financial savings over service or employee experience.

How should providers go about accepting RBP plans?

If you choose to accept RBP plans for scheduled non-emergency services or elective services, then consider the following:

Providers: Be sure to think through your out-of-network billing policies for scheduled non-emergency services. RBP plans often increase bad debt for providers. You may consider seeking a Single Case Agreement from the RBP plan in advance of rendering the service.
Patients: Providers have a responsibility to educate patients on these types of plans so patients may understand how RBP will impact their own financial responsibility for the non-emergency services sought.

FAQ

When can providers choose not to accept a Reference-Based Pricing plan?

Providers have the option not to accept these plans for scheduled non-emergency services or elective services. For emergency services, patients with private or commercial health coverage, including employment-based group health plan coverage, are protected from balance billing under the No Surprises Act (NSA) and sometimes state law. Any decision not to accept RBP plans should include review by your legal and compliance advisors.

Who sets the rates? How is the benchmark defined?

Employers engage third-party administrators (TPA) who develop pricing according to a reference or benchmark, like Medicare, and often use provider cost reports to do so. The TPA will develop rates in reference to that benchmark and which they think is fair, but without the provider’s agreement or consent.

What sort of agency do providers have for recouping payment for non-emergency services or elective services?

There are two possibilities when it comes to provider involvement:

Dispute the rates: This is specifically relevant to elective procedures, educating patients regarding what their plan does not cover. Alternatively, providers can still bill patients, but must notify them that they’ll be billed. The patient then contacts the plan, so that the plan negotiates with the provider. Essentially, the Reference-Based Pricing model uses the patient as the AR follow up person rather than staff. Without the plan’s intervention, the patient may be “balance billed” for the remainder of the provider’s fee.
Work out additional payment: Providers don’t know what the rate will be — the standard notice under NSA simply states that this provider doesn’t participate with the insurance plan. This then gives the provider an opportunity to work out additional payment, since the patient has to go to their health plan, and then the plan goes back to the provider to address any remaining differences.

Get in touch with one of our experts to learn more about Reference-Based Pricing plans and how they may impact your revenue cycle.

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Tips for Providers Thinking of Going Out of Network

Brad Gingerich, VP, Payer Strategy — Mon, 17 Jul 2023 20:56:42 +0000

Considering the decision to go out of network with a payer? Understanding the implications and implementing a well-thought-out strategy is crucial. Discover how to navigate the process of debating going out of network effectively to optimize your healthcare organization’s financial stability and patient care.

Why Consider Going Out of Network?

One common reason for health systems to exit a payer’s network is the inability to reach mutually agreed-upon reimbursement rates and terms during contract negotiations. Years of challenges with timeliness, accuracy and costs of pursuing full reimbursement from an insurance company often lead to this last-ditch effort.

Impact on Providers

Two of our clients recently leveraged an out-of-network strategy that ultimately resulted in contract rates double the standard annual increase of 2%-3% for each year of their agreement. One of the organizations only went out of network for a matter of hours before settling on a higher rate with the payer. The other merely threatened to exit the network, leveraging social media and community news outlets to make their position public and put pressure on the payer to come to the table with more reasonable rates.

Impact on Payers

The impact of going out of network varies based on the size of the health system. It can challenge network adequacy for government-sponsored plans, disrupt network access for commercial patients and their sponsoring employers and increase payment for out-of-network services.

Tips for Considering + Implementing an Out-of-Network Strategy With Major Payers

Assess Current + Prospective Out-of-Network Patient Volume

Review patient volume metrics such as primary care attribution by plan type, elective procedures by plan type and patient referral patterns. If the emergency department is a primary access point for patients, the non-participating status will have a lesser impact to patient volume since all emergency services qualify for in-network benefits regardless of participation status.

Be Selective About In-Network Services

Consider keeping primary care, OB/GYN and pediatricians in-network to maintain HMO patient attribution. This is especially important for temporary out-of-network periods. It also mitigates disruption of PPO member attribution to the primary care physicians, allowing patients with out-of-network benefits to still be referred to the out-of-network facility for elective procedures.

Educate Physicians About the Out-of-Network Experience

Reassure primary care physicians and staff about the implications of being out of network and its impact on access to care. Provide a clear roadmap of expectations and reinforce the need to have privileges at a participating facility.

Connect With Impacted Self-Funded Employers

Rank and engage the top 10 self-funded employers utilizing the out-of-network plan. Consider offering direct-to-employer network rates or alternative insurance carriers. Consider petitioning the payer for renegotiation to restore your organization to the network.

Keep Patients Informed + Engaged

Educate patients about the implications of being out of network for each service and plan type, including the distinctions between medical emergencies and elective procedures, whether they have secondary coverage and different plan types. Utilize existing communication channels such as patient portals and targeted outreach via mail or phone. Ensure staff are available and equipped to address specific patient questions through a centralized call center.

Make Your Position Public

As payer/provider contract negotiations become more public, consider sharing your stance with community media outlets to shed light on your position. Clearly state your position and support it with available data to demonstrate the gap between reimbursement and cost, supporting your rationale for a higher negotiated rate.

Prepare Your Operators for a Smooth Transition

Ensure your Patient Access team is prepared to accurately schedule and register patients and answer coverage-related questions. Update processes and tools to identify at-risk accounts and ensure compliance with the No Surprises Act and any applicable state surprise billing laws. Evaluate utilization management procedures as well as billing and collections processes to effectively manage out-of-network claims.

In Summary

When healthcare organizations consider the decision to go out of network with a payer, it requires careful analysis and planning.

Whether it’s a temporary tactic to strengthen negotiations or a permanent decision, assessing patient volume, providing comprehensive education to staff and patients, and engaging employers are critical components for a smooth transition. By proactively managing these factors, organizations can navigate this shift successfully to strengthen financial performance and continue delivering high-quality care to their communities.

Spark Health Partners offers comprehensive revenue cycle managed services to clients, including strategic guidance for health system executives and managed care departments to improve payer relationships. We support our clients with out-of-network strategy analysis and operationalization. Our payer strategy experts have more than 15 years of experience leading payer negotiations, educating managed care teams and effectively addressing and resolving payer challenges.

Brad Gingerich has 16 years of experience in managed care and revenue cycle operations, designing and implementing national payer strategies for large health systems.

Get the latest insights

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What Is Healthcare Revenue Cycle Management?

Amy Summers, SVP, Marketing + Commercial Operations — Fri, 07 Jul 2023 21:15:30 +0000

Hospitals and healthcare providers are critical pillars in their communities, delivering much-needed care and wellness resources to the people they serve.

But just like any other business, healthcare organizations must fund the care they deliver. They rely on various sources of revenue to keep their facilities open and up to date, buy necessary medical supplies, invest in advanced equipment and compensate their clinical and administrative staff for the work they do each day.

Healthcare revenue cycle management (RCM) covers the business side of healthcare and includes all tasks associated with the management and collection of revenue generated by healthcare organizations from patient care episodes, from initial patient intake through complete payment collection.

Healthcare Revenue Cycle Basics

The healthcare revenue cycle starts as soon as the patient’s care journey begins with scheduling an appointment or hospital visit. It concludes once the healthcare provider receives complete payment from insurance companies, the patient or both, for the care they delivered.

There are four Ps in the revenue cycle ecosystem:

- Patient (which you’ve likely been at one point).
- Provider is a term used for healthcare organizations and their practitioners across all types of care settings, from physician offices to hospitals to long-term care facilities.
- Payor typically refers to one of the more than 1,600 insurance companies responsible for reimbursing providers for the care delivered to their members. This includes government entities like Medicare and Medicaid and commercial insurance companies like Blue Cross Blue Shield and Cigna.
- Payment can be structured in a variety of ways based on the types of contracts established between the payors and providers, including traditional fee-for-service contracts, where providers collect payment based on the services they deliver, and value-based care contracts where payment depends on the quality of care delivered and the sustained health of the covered patients.

What is Revenue Cycle Management?

Healthcare revenue cycle management involves the orchestration of thousands of tasks that occur throughout the four main stages of the patient’s care journey:

Scheduling
Registration
Care Delivery + Documentation
Billing + Collections

Successful revenue cycle management provides a positive experience for patients and ensures providers get paid exactly what they are owed for the services they deliver.

Here’s a summary of what’s going on in the revenue cycle during an episode of care:

Step 1: Scheduling an Appointment.

In the revenue cycle, this is known as pre-arrival services.

Unless it’s an emergency, patients usually schedule appointments themselves or respond to appointment requests initiated by their physician. For example, you may call a provider to schedule an annual physical, or a provider may contact you to schedule the knee CT scan that your doctor ordered as a follow-up from your last visit.

During this step, key information is collected from the patient and documented in the provider’s electronic health record system. This information includes details about the appointment, the patient’s identification, and health insurance coverage and is critical to building an accurate final bill. We’ll dive into that more during the billing and collections phase.

Behind the scenes, coordination occurs to ensure the patient receives the most appropriate care and that the patient’s health insurance company will cover the scheduled services. This authorization process, or agreement from the payor to reimburse the provider for the scheduled services, is critical but cumbersome. Failure to receive authorization from the payor could mean the services rendered won’t be reimbursed. The process can also significantly delay care, with some insurance plans requiring 48-hour prior approval for services or taking more than seven days to provide the necessary authorization.

Specific revenue cycle functions in Pre-Arrival Services include:

Digital Patient Engagement
Scheduling + Appointment Management
Pre-registration + Financial Clearance

Step 2: Arrival + Intake

Referring to a patient's initial encounter with the healthcare organization, this is called Patient Access.

When the patient arrives for their visit, their identity and health insurance coverage are reviewed and verified. Ideally, there is also a review to determine if the patient qualifies for any financial programs, if needed, to ensure all available avenues for financial assistance are provided to the patient.

Most healthcare organizations also offer an estimate of a patient’s financial responsibility, or what they will owe for their visit. They can also provide financial counseling to help patients understand their health insurance coverage and provide the opportunity to make an upfront payment or establish payment plans before they leave to help streamline the billing process and eliminate financial uncertainty.

Specific revenue cycle functions in Patient Access include:

Registration
Financial Clearance
Point-of-service Patient Collections
Financial Counseling (for uninsured + underinsured patients)

Step 3: Care Delivery + Documentation

This is known as "the critical middle" or the revenue integrity function.

When the patient receives care, the clinical staff document the visit, including procedure and diagnosis details. This documentation is translated into standard alpha-numeric codes, which are then associated with charges defined in the provider’s charge description master (CDM) – a database of costs associated with every item, service and supply available within the facility.

The specificity of procedure and diagnosis codes, substantiated by thorough clinical documentation, significantly impacts what the provider will ultimately be paid – hence the RCM moniker “critical middle.”

During patient care delivery, teams continually monitor the patient’s status and treatment plan to ensure they receive the right amount of care at the right time in the right setting. Just as failure to obtain required prior authorization can result in lack of payment, so can delivering care that’s not deemed medically necessary by the health insurance plan. For example, if a patient stays longer than three days in the hospital for a knee replacement surgery that has no additional complications that would medically require a longer stay, the payor could deny the bill because the standard of care for knee replacements dictates that a patient should only stay for three days or less.

Specific revenue cycle functions in Revenue Integrity or Mid-Revenue Cycle include:

Health Information Management (HIM)
Coding
Clinical Documentation Improvement (CDI)
Utilization Review
Charge Description Master (CDM) Management
Charge Capture

Step 4: Medical Billing + Collections

The final phase of the revenue cycle management process is known as "the back end" or business office.

This phase covers all activity related to claims management and collecting payments from both health insurance companies and patients based on their financial responsibility.

A medical bill begins as a claim, which contains all information necessary to receive payment for the services rendered by a healthcare organization, including patient demographics, medical codes and charges. The claims management function involves reviewing each claim for accuracy and submitting claims to the appropriate payors for reimbursement.

Revenue cycle teams monitor the status of submitted claims to ensure they collect the money owed for accounts receivable (AR) in a timely manner. The accuracy of the claim, effectiveness of AR follow-up and scrutiny of remittance (or payment received) all impact the speed and accuracy of insurance reimbursement.

Payment delays can occur because of issues like claim denials and underpayments, which cause costly rework to be resolved. Claim rejections and denials occur when the payor disagrees with the charges or requires more information or different submission specifications to process the claim.

Underpayments occur when payors don’t reimburse the full amount owed for services rendered or when providers commit coding or documentation errors that lead to incomplete or incorrect billing for the delivered care.

Once insurance has paid its portion of the claim, remaining patient balances are routed to teams that specialize in collecting patient payments. If patient collections are unsuccessful after a certain period, they are often referred to a debt collection agency, and the balance is considered bad debt.

Specific revenue cycle functions in the Medical Billing and Collections process include:

Claims Management
Billing
Insurance Accounts Receivable
Patient Financial Services
Denials Managemen
Underpayment Recovery
Bad Debt Collections

Common Revenue Cycle Management Challenges

Unfortunately, the healthcare revenue cycle is an error-prone process with hundreds of data handoffs and complex rules, making it incredibly challenging to capture proper reimbursement while ensuring a positive patient experience.

Complications that arise in the revenue cycle can result in costly setbacks for healthcare organizations, including decreased patient satisfaction, and therefore, patient volume, regulatory audits and fines due to non-compliant practices and delayed or lost revenue due to denials, underpayments, uncollected AR and bad debt.

Common revenue cycle management challenges for healthcare organizations include:

Overwhelming Complexity

Effective revenue cycle management requires in-depth knowledge of more than 70,000 medical codes used to document care, thousands of line-item charges in CDMs and thousands of pages of payor policies.

According to the American Hospital Association, there are more than 130,000 pages of Medicare rules and regulations, most of which cover how to submit claims for payment. Payor rules can change by the day, with tens of thousands of policy updates issued each year. Healthcare providers must understand every rule, monitor and interpret changes, then adjust systems and amend processes as needed to accommodate payor requirements.

Lack of Experienced Resources

Labor shortages and the global talent pool of a remote workforce have made it difficult for healthcare providers to fill even entry-level positions in revenue cycle departments, let alone highly specialized senior positions.

A lack of adequate, accessible and up-to-date training limits the ability of providers to up-skill staff or train new hires to manage complex RCM tasks.

When short-staffed, employees often wear multiple hats, which diminishes performance and prevents functions from being managed to the level of specificity required to avoid revenue loss.

Disjointed Systems + Error-prone Processes

The average healthcare organization’s revenue cycle is often fraught with disconnected systems, data silos and manual processes. This disconnect and inefficiency make it difficult to cohesively manage operations, accurately pinpoint systemic issues and effectively manage costs associated with collecting revenue.

Processing errors or inaccurate data at any point throughout the revenue cycle can lead to delayed reimbursement, lost revenue or regulatory compliance risk for providers. Unnecessary rework to fix errors and reprocess claims requires valuable resources and decreases productivity.

Disparate systems and information silos make it difficult to gather, normalize and analyze data. This data helps to assess financial and operational performance, identify trends and patterns to strengthen rule sets or fuel machine learning algorithms and ensure accurate reimbursement.

What Are the Key Components of a Successful Revenue Cycle Management Program?

The most successful healthcare revenue cycle management programs focus on expert revenue orchestration with the proper technique, talent and technology, underscored by a constant focus on patient connectivity.

Technique

Tried and true best practices are critical to a well-run RCM operation. A clear understanding of the revenue cycle as a system allows expert operators to break down traditional silos and streamline processes, taking lessons learned from trillions of transactions to bridge data gaps across departments and eliminate inefficiency.

Talent

Experienced and capable talent is at the core of every good RCM program. Staying ahead of the pace of change and adapting to the complex RCM environment requires competent leadership, specialized experts, well-trained staff and a highly collaborative work environment. Best practices must be well documented and hardwired into evergreen training tools and resources to ensure everyone is operating at the top of their license.

Technology

Working smarter by leveraging modern technology and true business intelligence is essential for a successful RCM function. The right RCM technology can help automate repetitive manual tasks, prioritize exception-based workflows and continually learn from patterns to detect anomalies and prevent errors. In addition, the right technology can provide robust business intelligence to guide strategic decision-making and reveal insights into performance.

In Summary

While expert revenue cycle management may be outside most healthcare organizations’ core competency, it’s critical to their missions, nonetheless. They often lack the capabilities to efficiently manage and optimize their revenue cycle operations because the complexity requires a degree of operational expertise and scaled investments in talent and technology that many health systems struggle to prioritize. Luckily, healthcare providers have a range of options to drive successful revenue cycle management, from low-commitment operational assessments to end-to-end revenue cycle management with an experienced partner.

According to one healthcare organization CEO, “There’s only so many levers of opportunity for improvement in margin right now, so if you’re not focusing on your revenue cycle, you’re really missing one of the biggest opportunities out there to make an impact on your system.”

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The post What Is Healthcare Revenue Cycle Management? appeared first on Spark Health Partners.

6 Tips to Ensure Your RCM Partnership Will Go the Distance

Andrew Bess, Chief Client Officer — Wed, 28 Jun 2023 17:00:00 +0000

Expert revenue cycle management (RCM) has become crucial for healthcare organizations to maintain financial stability and optimize revenue streams. Many of these organizations are turning to RCM partnerships to streamline their revenue cycle processes and achieve sustainable financial growth. However, choosing the right RCM partner and establishing a successful long-term partnership can be challenging.

Odds are you’re one of the 93% of hospital leaders considering strategic RCM partnership to combat margin pressure. Healthcare RCM is a high-impact area that’s prime for support and capable of delivering much-needed financial relief to cash-strapped hospitals.

But entering a committed relationship can be daunting. It requires vulnerability, trust, communication, compatibility and respect (just ask any marriage counselor). You have to find someone who really gets you. Because just like any significant relationship, it takes a lot more than chemistry to make a partnership successful.

Choose the right partner, and you may go the distance together. This will be the company providing complete oversight of all processes throughout your revenue cycle from patient engagement to account resolution. The right RCM partnership can reduce operating costs, streamline vendor management, substantially increase revenue and ultimately allow you to devote maximum focus to patient care and engagement.

Choose the wrong partner, and you may be stuck with them. If done incorrectly, there can be a significant negative impact to your staff, community and your bottom line. But these contracts are typically long, and the integration is extensive. So, like many relationships gone wrong, people often choose to stay in them instead of spending the time and resources required to unwind from the failed partnership. Who wants to go through terminating a contract, finding a new partner and implementing another solution?

Bottom line: It pays to be thoughtful about who you partner with.

6 RCM Tips to Consider When Looking for a Compatible Match

1. Make Sure They’re Who They Say They Are (Don’t Get Catfished)

Talk to the company’s current clients to determine if their results matched the sales pitch. It’s critical to check references and hear directly from your peers who’ve gone through the process. Evaluate their experience and expertise in the healthcare industry. An RCM partner should have a deep understanding of industry trends. Choosing a partner with a proven track record with organizations similar to yours will ensure you feel more confident they will be better equipped to meet your needs and drive positive outcomes. Don’t just take the vendor’s word regarding what they will potentially do for you.

2. Ensure They Share Your Values + You’re Both on the Same Page

Professional partnerships that are built to last have mutually inclusive priorities and shared values. Make sure your mission and cultures are aligned. Maybe you won’t be introducing them to mom and dad, but is this a partnership you’d be proud to announce to your community? Would your employees assimilate well into their organization? Does the vendor have the infrastructure and processes in place to smoothly transition, train and grow your employees?

It’s important to be very clear about what’s expected from each side, what the relationship deal breakers are and what vision everyone is working towards. Discuss your challenges, objectives and goals for the partnership up front. A strong partner will be invested in your vision for the long term and will work collaboratively to ensure your goals and incentives are aligned with theirs.

Ask about their approach to technology. Will they be able to work with your existing systems and tools or require certain technology to be decommissioned? What IT support will your resources require and what training will be provided to your end users?

3. Evaluate Their Technology + Infrastructure

Efficient RCM is reliant on sustaining robust technology and infrastructure. A potential partner should offer robust technological capabilities, including the RCM software, data security measures and integration capabilities. They should have the necessary infrastructure to handle your organization’s volume and complexity, but should also be adaptable and able to upgrade their technology to keep pace as industry requirements shift.

4. Make Sure It’s Not One-sided

Ask your potential partner how they will work to ensure that decision-making about policies and procedures is inclusive of leadership and aligned with your organization’s goals. Will a joint steering committee be established with equal representation by your organization and the vendor? If so, how early in the process? What other cross-functional communication channels will be established?

5. Set Clear Expectations From the Start

Ask them how they get started and how they ensure project success. These types of engagements are incredibly complex and require diligent project management and execution. Ensure the vendor has a process in place to get intimately acquainted with your processes, staff, workflows, systems and areas of opportunity. Make sure you feel comfortable with their ability to create and manage complex project plans and report out on key metrics before and after project go-live to ensure there is no productivity loss or dip in performance during the transition.

6. Look for the “Whole Package”

Ask what they bring to the table outside of day-to-day operational management. The best partnerships are the ones that bring ongoing value to the relationship beyond fulfilling day-to-day obligations.

Will your partner identify issues and help you resolve them, even if it’s not exactly what they signed up for? Will you be able to rely on them for insights and action plans related to payer policy changes to help you stay compliant and avoid preventable audits, claim rejections and denials?

Finding a partner who “completes you” can be difficult, but so worth it. The right RCM partner should provide support when you need it most and should grow beside you, helping you reach your full potential and deliver on your mission, through sickness and health, through good times and bad.

Moving Forward with an RCM Partnership

When you’re ready to optimize your healthcare organization’s revenue cycle and achieve financial stability, it’s important to establish a successful, long-term RCM partnership. Considering each of these factors will help you rest assured your RCM partnership will be well-aligned and drive financial success in addition to enabling your organization to focus on delivering high-quality patient care.

What Is a Revenue Cycle Assessment + Why Is It Important to Healthcare Providers?

Amy Summers, SVP, Marketing + Commercial Operations — Fri, 16 Jun 2023 14:50:02 +0000

For healthcare organizations, ensuring financial stability is crucial to providing high-quality care to patients. One key aspect of financial management in healthcare is the revenue cycle, which encompasses all aspects of the patient billing process, from insurance verification and pre-authorization to claims submission and payment posting. Effective revenue cycle management is essential to ensure accurate and timely reimbursement for services rendered.

However, the healthcare revenue cycle process is complex and can be impacted by a range of factors. These include changes in regulations, complex reimbursement requirements, rapid shifts in payor policies, and evolving revenue cycle management and payment integrity technology. As a result, healthcare providers may face revenue cycle challenges that diminish their financial health and put their operations at risk.

Conducting a revenue cycle assessment can help healthcare organizations identify these challenges and develop a plan to address them. By improving the revenue cycle process, healthcare providers can optimize revenue and reduce costs to improve their financial health as well as their ability to deliver high-quality care to their communities.

What Is a Revenue Cycle Assessment?

A revenue cycle assessment is a comprehensive review of a healthcare organization’s revenue cycle process, from patient registration to billing and collections. Revenue cycle assessments are relatively popular with healthcare organizations, particularly those that are looking to improve their financial performance and streamline their revenue management processes. These assessments are designed to evaluate the effectiveness of an organization’s revenue cycle, identify areas for improvement and develop strategies for optimizing revenue collection and management.

The goal of a revenue cycle assessment is to identify strengths and weaknesses in the revenue cycle process and recommend improvements that can optimize revenue, reduce costs and improve the overall financial health of the hospital or health system. The assessment typically includes a review of policies and procedures, technology systems, staffing and training.

Assessments can be conducted internally by a healthcare organization’s finance or revenue cycle team, or they can be outsourced to a third-party firm that specializes in revenue cycle management. Teams should consist of experts with specialized knowledge of healthcare finance, revenue cycle management and regulatory compliance.

Benefits of a Revenue Cycle Assessment

Increased Revenue: A revenue cycle assessment can identify opportunities to improve revenue by streamlining processes and reducing errors. This can lead to increased cash flow, improved collections and a reduction in accounts receivable.
Improved Efficiency: An assessment can also identify opportunities to improve efficiency by streamlining processes and reducing waste. This can result in a more effective use of resources, reduced costs and improved overall financial health.
Enhanced Compliance: An assessment can help ensure hospitals and health systems are in compliance with regulatory requirements, such as HIPAA and Medicare billing rules. This can reduce the risk of audits, fines and penalties, which can have a significant impact on financial health.
Better Patient Experience: An efficient revenue cycle process can also improve the patient experience by reducing wait times, improving communication and ensuring accurate billing.

Key Components of a Revenue Cycle Assessment

A revenue cycle assessment typically includes the following components:

Patient Access: The assessment will review the patient registration process to ensure patient data is accurate and complete, and insurance information is verified and entered correctly.
Coding + Clinical Documentation: The assessment will review the coding and clinical documentation processes to ensure the medical claim accurately reflects the care delivered. This includes ensuring all necessary codes are included on claims and all required documentation is present to prevent claims rejections and denials.
Billing + Collections: The assessment will review the billing process to ensure claims are submitted accurately and in a timely manner. It will also examine the accounts receivable process to ensure payments are received on time and posted accurately. This includes identifying any outstanding balances, denials or underpayments and effectively addressing them.
Technology: The assessment will review the technology systems used in the revenue cycle process to ensure they are up to date and functioning properly. This includes reviewing electronic health record systems, billing software and other technology used throughout the claim life cycle.
Staffing + Training: The assessment will review staffing levels and training programs to ensure departments are appropriately staffed and staff members have the necessary skills and knowledge to perform their jobs effectively. This includes identifying areas where additional training may be needed.

Signs a Healthcare Organization Needs a Revenue Cycle Assessment

There are several signs a hospital may need a revenue cycle assessment, including:

Decreased Revenue: If a hospital’s revenue has decreased over time, despite maintaining the same level of patient volume, it may be a sign there are issues with the revenue cycle management process.
High Volume of Claim Denials: If a hospital is experiencing a high volume of insurance claim denials, it may be an indication there are issues with coding accuracy or other billing processes.
Billing + Coding Errors: If there are frequent billing and coding errors, it may be a sign the revenue cycle management process isn’t functioning optimally.
Long Accounts Receivable Cycle: If a hospital has a long accounts receivable cycle, it may be an indication there are issues with the revenue cycle management process, such as inefficient billing processes or poor collections practices.
Inefficient Processes: If the revenue cycle management process is inefficient and requires a lot of manual intervention, it may be a sign there is room for improvement. This can result in higher costs and decreased revenue.
Lack of Compliance: If a hospital isn’t in compliance with industry standards or regulations related to revenue cycle management, it may be at risk of incurring penalties or fines.

How Often Should Healthcare Organizations Consider a Revenue Cycle Assessment?

In general, it is recommended healthcare providers perform a revenue cycle assessment at least once every three to five years to ensure their revenue cycle processes are up to date and functioning effectively. However, some providers may choose to perform assessments more frequently, particularly if they have experienced significant changes in their revenue cycle processes or have identified specific areas of concern that require further analysis.

Additionally, it is important for healthcare providers to continually monitor and evaluate their revenue cycle processes on an ongoing basis, through routine reporting and analysis of key performance indicators (KPIs) such as point-of-service collections, denial rates and days in accounts receivable. By regularly tracking these metrics, providers can identify potential issues early on and take proactive steps to address them, which can help to minimize revenue loss and improve financial performance over time.

Key Considerations Before Committing to an Assessment

Before committing to a revenue cycle assessment, healthcare leaders should consider several factors to ensure the assessment is successful and provides value to their organization. Some of the key factors to consider include:

Objectives + Scope: Healthcare leaders should clearly define the objectives of the revenue cycle assessment, including the specific departments, processes and systems they want to evaluate and the outcomes they hope to achieve. This will help guide the assessment process and ensure it is aligned with the organization’s overall goals and strategic plan.
Budget: Healthcare leaders should also determine the budget for the assessment, including any consulting or technology costs. The budget should be realistic and aligned with the organization’s overall financial resources and goals. The cost of implementing any recommended changes identified during the assessment should also be considered.
Resources: Understand the resources that will be required to conduct the assessment, including personnel, data and technology. They should ensure they have the necessary resources in place to support the assessment and they will be available when needed.
Assessment Approach: Consider the approach that will be used to conduct the assessment, whether it will be done in-house or with the help of a third-party. The assessment approach should be aligned with the organizations’ goals, budget and available resources.
Communication: Healthcare leaders should ensure they have a plan in place for communicating with staff about the assessment goals, process and timeline. Results of the assessment should be clearly communicated to stakeholders, including staff, patients and board members. Consider how assessment results will be used to drive improvements and achieve revenue cycle goals.

In Summary

Revenue cycle assessments are an important tool for healthcare organizations that are looking to optimize their revenue cycle management processes and improve their financial performance so they can deliver exceptional care to people in their communities. By addressing these opportunities, healthcare providers can improve cash flow, increase efficiency, ensure compliance and enhance the patient experience.

Learn more about how a revenue cycle assessment could impact your organization and your financial health.

Spark Health Partners is a full-service revenue cycle management company, delivering holistic financial health for more than 250 healthcare providers across the country. Our partnerships begin with an operator-led assessment of end-to-end revenue operations, which typically uncovers 5% or more in net revenue improvement opportunity. Engage our RCM experts today to build your revenue optimization playbook.

The post What Is a Revenue Cycle Assessment + Why Is It Important to Healthcare Providers? appeared first on Spark Health Partners.

RCM Outsourcing Guide: Choosing the Right Partner Is Vital to Your Bottom Line

Andrew Bess, Chief Client Officer — Wed, 14 Jun 2023 16:36:29 +0000

When it comes to revenue cycle management (RCM) outsourcing, the process of selecting the right partner for your organization’s financial success is crucial. In the ever-evolving healthcare landscape, managing revenue cycles efficiently has become more challenging than ever. Thanks to increasing complexities, stringent regulations and mounting administrative burdens, many healthcare providers are turning to outsourcing as a strategic solution. However, the key to reaping the benefits of RCM outsourcing lies in selecting the right partner. In this revenue cycle outsourcing guide, we’ll delve into the significance of choosing the right RCM outsourcing partner and how it can significantly impact your bottom line, ensuring optimized revenue streams and streamlined operations for your healthcare organization.

What is Revenue Cycle Management Outsourcing?

RCM outsourcing is the practice of entrusting the management of revenue cycles to external service providers. It involves delegating critical financial tasks and responsibilities to specialized professionals who possess expertise in handling billing, coding, claims processing and other revenue-related functions. RCM outsourcing holds particular significance in the healthcare industry as dedicated firms or vendors can help handle tasks such as patient registration, insurance verification, coding, billing, collections and payment posting. By leveraging the knowledge and resources of an outsourced partner, healthcare organizations can streamline their revenue cycles, enhance financial performance, reduce operational costs and ensure compliance with complex billing and regulatory requirements.

RCM outsourcing enables healthcare providers to focus on delivering quality care while entrusting the intricate financial aspects to experienced professionals, ultimately leading to improved efficiency, increased revenue and enhanced patient satisfaction.

What Are the Benefits of Outsourcing Your RCM?

Outsourcing RCM offers numerous advantages that significantly benefit healthcare organizations.

Ensuring the accurate transmission of data across disparate systems and different departments, without losing anything in translation, is crucial for precise reimbursement and a positive patient experience. RCM leaders must adapt to constant changes and nuanced requirements for how data should be shared, through which systems, and at what time to comply with thousands of intricate rules that vary between payors and service types.

Bringing in individual vendors and systems to manage different aspects of the RCM process demands meticulous orchestration and oversight to prevent gaps between steps or vendors. This task becomes particularly challenging due to the multitude of ways information and performance are captured and shared. Each vendor introduces their own reporting variation, calculating metrics differently or utilizing specific subsets of data. This leads to discrepancies between vendor reports and the provider’s host system, making it exceedingly difficult to obtain a comprehensive overview of RCM performance and verify it through transparent access to the data and calculations.

“Revenue cycle has its own black box,” explains Marty Bonick, president and CEO of Ardent Health Services, a 30-hospital system in the southeast. “There wasn’t visibility at an executive level to see underlying subcategories within the revenue cycle where we were leaving dollars on the table or what was really happening with denials or underpayments or recoveries. I would ask our vendors to provide an overview of our performance I would get spreadsheets with a bunch of data but no insights.”

RCM outsourcing is a holistic solution that offers a comprehensive approach to revenue management, eliminating the challenges associated with coordinating multiple vendors and ensuring a unified, streamlined process.

Through RCM outsourcing, you can unlock benefits including improving your revenue cycle performance, reducing the burden on administration, cost-effectiveness, enhancing the patient experience and achieving better financial forecasting and management.

Improved Revenue Cycle Performance

By partnering with experienced outsourcing providers, healthcare providers can tap into a wealth of industry knowledge, specialized expertise and advanced technological resources. These partners can implement accurate coding practices, effective claims management strategies and efficient billing processes to optimize revenue streams. By conducting thorough audits, they can identify areas for improvement and implement revenue-enhancing initiatives. Outsourcing partners will also stay up to date with evolving regulations, compliance requirements and industry trends to ensure adherence to billing guidelines, mitigate the risk of penalties and reduce rejections and denials.

With streamlined revenue cycles, healthcare organizations can maximize revenue collection, minimize revenue leakage and ultimately improve financial performance. Outsourcing revenue cycle management empowers healthcare providers to focus on core competencies so experts can handle the intricate aspects of revenue management, resulting in improved revenue cycle performance.

Reduced Administrative Burden + Costs

Trying to manage revenue cycle management in-house can be resource-intensive and result in a financial burden. With RCM outsourcing, you eliminate the need for extensive infrastructure, technology investments and dedicated staff, resulting in significant cost savings. Outsourcing partners operate at scale, spreading costs across multiple clients, enabling them to offer services at a lower cost than if you were to maintain an in-house revenue cycle management team.

Outsourcing can alleviate the stress and administrative burden of keeping up with ever-changing regulations, compliance requirements and industry trends. Through a managed services partnership, you can benefit from the expertise of specialized professionals who are well-equipped to adapt to the dynamic nature of these rules. This ensures your RCM processes remain accurate, efficient and compliant, allowing your internal teams to focus on other critical tasks.

Enhanced Patient Experience

Entrusting revenue cycle management tasks to a dedicated outsourcing partner ensures healthcare providers can allocate more time and resources to patient care. Streamlined revenue cycles allow providers and healthcare professionals to focus on delivering quality treatments, enhancing patient satisfaction and improving overall healthcare outcomes.

An inefficient or poorly run revenue cycle can negatively impact patient satisfaction in several ways. Delays and errors in billing and insurance processing can result in confusion and frustration for patients, whether due to receiving unexpected bills or difficulties understanding financial obligations. This stress can ultimately erode their trust in the healthcare provider.

A disorganized revenue cycle can also lead to longer wait times for appointments or procedures. The scheduling and pre-authorization process needs to be optimized to prevent these unnecessary delays before receiving care to prevent dissatisfaction and the perception the patient’s time and needs are not being prioritized.

Optimizing the revenue cycle through a dedicated outsourcing partner can elevate the patient experience. By leveraging the expertise and technology of a specialized partner, healthcare providers can streamline billing, coding and claims management processes, resulting in faster and more accurate billing, reduced billing errors and enhanced transparency in financial transactions.

When processes related to financial obligations are smooth and efficient, the patient can focus more on their healthcare journey for a more positive perception of the provider. Reducing the administrative burden on healthcare professionals will also allow them to dedicate more time and attention to patient care, fostering better communication, empathy and personalized treatment plans.

Better Financial Forecasting + Management

Through the expertise of outsourcing partners, healthcare providers and organizations gain access to comprehensive financial reporting and analysis. A good outsourcing partner will generate detailed reports on key performance indicators, revenue trends and financial metrics, providing valuable insights into your organization’s financial health.

This accurate, timely financial data helps healthcare providers make informed decisions, identify potential bottlenecks and implement proactive measures to optimize revenue streams. Revenue cycle management outsourcing also offers robust revenue cycle analytics and predictive modeling capabilities to enable organizations to forecast revenue, identify revenue leakage points and strategize for future growth. Outsourcing partners will utilize advanced technologies and industry best practices to improve revenue capture, reduce bad debt and enhance cash flow management.

Relying on the expertise of an outsourcing partner helps your organization achieve better financial forecasting and management, leading to increased revenue, improved financial stability and long-term sustainability.

What To Look for in an RCM Outsourcing Partner

Choosing the right RCM outsourcing partner is crucial for the success of your healthcare organization. It’s important to apply careful evaluation and consideration of various factors. Your ultimate goal is to select a reliable, capable RCM outsourcing partner with a track record of delivering consistent results for organizations like yours.

Below are the top considerations when looking for an RCM outsourcing partner.

Understanding Your Organization’s Needs

Every healthcare organization has unique requirements, challenges and goals within its revenue cycle operations. By thoroughly understanding your organization’s needs, you can find an outsourcing partner that aligns with your specific objectives and can effectively address your pain points.

Comprehending your organization’s needs can help a partner tailor their services and solutions accordingly. They’ll take the time to analyze your existing revenue cycle processes, identify areas for improvement and customize their approach to meet your specific requirements. A higher level of understanding ensures a more seamless integration of their services with your existing systems and workflows to minimize disruptions and maximize efficiency.

In addition, working with a partner who understands your organization’s needs can provide proactive solutions, offer valuable insights and adapt their services as your needs evolve.

Experience + Expertise

Having a revenue cycle management outsourcing partner with extensive experience means you immediately get industry-specific knowledge and insights brought to the table. They already understand the complexities of healthcare reimbursement, coding standards, billing regulations and payor requirements.

Their experience and expertise can help you navigate the intricacies of revenue cycle processes, identify potential challenges and implement best practices to optimize reimbursement. Additionally, an experienced outsourcing partner has likely encountered a wide range of revenue cycle scenarios and has developed effective strategies to overcome them. Their track record should demonstrate their ability to deliver results and meet or exceed expectations. You want to ensure your revenue cycle operations are placed in capable hands to stay ahead in the ever-evolving healthcare landscape.

Technology + Infrastructure

Working with a technologically advanced outsource partner means you can leverage state-of-the-art software solutions, automation tools and electronic health record (EHR) systems. These solutions will help streamline billing, coding, claims processing and other revenue-related tasks. A competent partner should have the capability to integrate seamlessly with your existing systems for smooth data exchange and to minimize disruptions.

Having a robust infrastructure is essential for handling the volume and complexity of your organization’s revenue cycle, so working with a partner that has strong infrastructure ensures you’re able to handle high transaction volumes, maintain data security and privacy and ensure business continuity. Technological proficiency contributes to efficient revenue cycle management, enhanced data security and scalability.

Reputation + References

The reputation of a potential outsourcing partner reflects their reliability, trustworthiness and the quality of services they provide. A reputable partner will have a positive track record, demonstrated by satisfied clients and successful partnerships. When evaluating the credentials of a potential partner, it’s beneficial to consider rankings and recognition from esteemed industry organizations. For example, HFMA recognizes healthcare organizations that meet industry standard revenue cycle benchmarks each year. Ask your potential partner how many of their clients have received this designation.

Check references and seek feedback from current or past clients to gain insights into the potential partner’s performance, responsiveness and ability to meet expectations.

It’s also important to inquire about their level of customer support, deadline adherence, billing and coding accuracy and overall client satisfaction. Having a revenue cycle management partner with a strong reputation and positive references instills confidence in their ability to deliver results and establishes a foundation for a reliable long-term partnership.

Additionally, third-party organizations like KLAS Research and Black Book Research release annual rankings of firms across a variety of categories, including RCM outsourcing. It’s essential to gain a clear understanding of the criteria employed by these organizations in formulating their rankings, including how client feedback is obtained and how performance is evaluated.

Communication + Transparency

A revenue cycle management outsourcing partner that provides clear and open communication channels ensures there’s a seamless flow of information between your organization and the partner. Regular, timely communication allows for addressing concerns, providing feedback and sharing updates. It fosters a collaborative relationship where both parties are on the same page regarding expectations, goals and project timelines.

The number one thing is communication. Not everything is going to go perfectly, and the key is how the customer and vendor react.

– Health System CFO

Transparency is equally as important as it promotes trust and accountability. An outsourcing partner who values transparency will provide clear visibility into their processes, performance metrics and financial reporting. They should be open about their pricing structure, contractual terms and any potential risks or challenges. Transparent communication helps build a strong working relationship based on trust and enables you to make informed decisions and monitor the progress of your revenue cycle management effectively.

Potential Risks + Challenges of RCM Outsourcing

Revenue cycle management outsourcing can undoubtedly bring several benefits, but it does come with potential risks and challenges to be aware of. One of the main risks is the potential loss of control and oversight over revenue cycle operations. Depending on a partner for performance can raise concerns about their ability to deliver and prevent financial disruption, ensuring they adhere to agreed-upon service levels. There may also be concerns surrounding data security and privacy as sensitive patient information is shared.

Additionally, there’s a risk of communication gaps or misalignment of goals between your organization and the outsourcing partner. A lack of clear communication and collaboration can result in misunderstandings and potential errors in revenue cycle management processes, which can negatively impact revenue. It’s also crucial to consider the financial implications as outsourcing does come with associated costs. Evaluate financial feasibility and be sure the potential benefits outweigh the expenses.

Lastly, the transition phase from in-house to outsourced RCM can present challenges like staff training, data migration and adjusting to new processes. Your organization will need to have a well-defined transition plan and effective change management strategies to address these challenges.

While these are very real risks to consider, considering what to look for in a revenue cycle management outsourcing partner upfront can help mitigate these risks to ensure you have a positive experience.

Ensure Less Worry About Your Outsourced RCM With the Right Partner

Partnering with an experienced revenue cycle management outsourcing partner is of the utmost importance for healthcare organizations seeking to optimize revenue cycle processes. At Spark, we offer a wealth of healthcare industry-specific knowledge, expertise and a proven track record to ensure a successful partnership. Through this experience, we can help your organization navigate the complexities of patient engagement, coding, billing regulations and payor requirements to ensure accurate and efficient revenue cycle management. With Spark’s outsourcing solution, we can help you streamline operations, enhance data security and achieve scalability. If you’re ready to improve financial forecasting, achieve better revenue cycle performance, and allow your team to focus on core competencies, contact us today.

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The post RCM Outsourcing Guide: Choosing the Right Partner Is Vital to Your Bottom Line appeared first on Spark Health Partners.

What Is Patient Experience + Why Is it Important to Healthcare Providers?

Amy Summers, SVP, Marketing + Commercial Operations — Fri, 02 Jun 2023 22:26:34 +0000

The medical profession is one that requires face-to-face interactions with patients on a daily basis. However, it’s not just the physician who’s responsible for creating a positive patient experience. The medical organization itself has a lot to do with how satisfied patients are, including facilitating a positive patient experience. Healthcare organizations should strive to provide an all-around positive experience for various reasons, from patient retention to improved staff morale. Determining how well your organization is performing within the patient’s perception first requires an understanding of the patient experience, how it differs from patient satisfaction and how to improve it, if and when necessary.

What Is Patient Experience?

“Patient experience” is a broadly used phrase with different meanings amongst different healthcare organizations. Unfortunately, there isn’t one standard definition, which can make it difficult to provide and measure. The Beryl Institute breaks down the multifaceted concept of patient experience into four critical themes: personal interactions, the organization’s culture, patient and family perceptions and the continuum of care.

The patient experience encompasses a wide range of interactions patients have within the healthcare system, with doctors, nurses and staff at hospitals, physician practices or other healthcare facilities. Patients place a lot of value on their experience when receiving care, such as whether appointments are timely, they’re provided with easy access to their health information and if healthcare providers are good at communicating necessary information.

For any organization looking to provide more patient-centered care, patient experience is essential. You need to be aware of the level of respectful, responsive care each patient receives. This includes how well the patient’s needs are met and values respected, as well as how much the health system values patient safety and effective care. For larger organizations, this information can be gauged through surveys and questionnaires, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

The Difference Between Patient Experience + Patient Satisfaction

While they sound similar (and are often used interchangeably), the patient experience is a different concept than patient satisfaction. Here are the key differences:

Patient satisfaction: Assesses whether a patient’s expectations regarding the healthcare visit were met. This can vary per patient based on their unique expectations as to how care should be delivered.
Patient experience: Determines whether specific, expected actions were taken during each visit or appointment, such as receiving clear communication or detailed instructions from the healthcare professionals before leaving, or being greeted by a staff member upon walking into the office.

While both play into creating a positive visit for patients, creating a positive patient experience is much more about determining set experience standards everyone should follow and doesn’t necessarily change based on treatments or reason for visiting.

Why Patient Experience Matters

Although the health system exists to help people, stepping into a healthcare setting can often make people anxious and uncomfortable. Creating a positive patient experience can do so much to help alleviate this and provide the following benefits:

Better patient safety, improved clinical outcomes and higher patient satisfaction scores
Shorter hospital stays and reduced readmissions
Greater equity in access to care (i.e., translation services, offering specific-needs support, etc.)
Improved staff morale and motivation leading to improved recruitment and retention
Greater patient engagement and empowerment related to their own healthcare
Reduced risks within the office, hospital, etc. (i.e., effective cleaning and maintenance to reduce or remove slip and trip hazards)

Patients who have a positive experience will generally feel more comfortable and less anxious during their visit, allowing for better engagement when discussing their health and care, supporting a better patient outcome.

Influential Factors for Patient Experience

Doctors and nurses are typically the ones with the most patient interaction on a daily basis. Still, when patients come in, they’re noticing much more — is the facility clean and maintained? Are administrative staff courteous and informative? Is the billing department helpful when questioned about affording patient care?

Obviously, the physician-patient relationship is an essential piece for a positive patient experience as they take charge of providing treatment options, preventative plans and discharge instructions. But those behind the scenes can help — or hinder — the overall patient care experience, even after a positive interaction with medical staff. These can include:

Administration: Reception, appointment letters, follow-up communications
Facilities Management: Food, cleaning, environment, parking, bathrooms
Clinical: Pharmacy, treatment, ward rounds, consultations, care delivery

Top Causes of Negative Patient Experience

If you find your organization is lacking in patient experience, there are a few common causes that could be to blame. While the following aren’t the only possible contributors to a negative patient experience, they should be the first places to review when looking to make improvements.

Limited Resources

When physicians have limited resources at their disposal, it can make practicing efficiently more difficult and leave patients with less options for care access. Are patients offered various ways to contact medical staff, such as over the phone, through a patient portal or via email? Are accessibility and diversity needs met such as language options and available primary and urgent care locations? How is the phone system handled? Can patients reach a person right away, or do they need to be processed through a call center or machine service? Can patients easily pay their medical bills online, over the phone or in-office? Doctors and medical staff are unable to provide the level of care they need if patients are unable to reach them in the first place.

Resistance to Change

Healthcare is a quickly evolving concept, constantly introducing new technologies and new processes. If at any point, anyone from a single nurse to the entire organization, resists necessary workflow changes, it can quickly sour the patient experience. Resistance to change can result in care delays, poor record-keeping and even an inability to collect payments for medical care effectively. If and when a new process is introduced, staff must be thoroughly trained on how to use it properly and attention must be given to ensure everyone follows the process.

Lack of Awareness

When it comes to patient care and services, there are a variety of options available to get the most out of their care. However, if medical staff are unaware of available services, patients aren’t getting access to the best healthcare support they can. A physician’s lack of awareness of available patient services could be limiting the usage of things like remote monitoring offered by pharmaceutical companies. Physicians should be educated about all available avenues of care, and patients should be offered any potential solutions that may be helpful for them.

Complex Healthcare System

Anytime complexities are introduced, the process becomes more difficult from start to finish. Patients need to be presented with a straightforward process, from making an appointment to receiving treatments and paying the bills. If they’re given the runaround regarding how to complete their care, it’s going to create a negative patient experience. No one likes to feel like they aren’t receiving a straight answer or as if they are being tossed around to different contacts to repeatedly retell their story, only to be directed elsewhere again. Processes should be examined to ensure they’re as straightforward and direct as possible.

Health Disparities

Empathy is important in healthcare, but disparities can indicate a lack of empathy for specific groups of people, whether due to socioeconomic status, ethnicity, gender, age, disability or sexual orientation. If the medical or administrative staff at any level of the health system lack empathy for particular groups of patients, their concerns and symptoms could be dismissed, leaving them without the answers or treatments they need, leading to a poor patient experience. Everyone should treat each patient fairly and provide the same, high level of care regardless of their demographics.

Strategies for Improving Overall Patient Experience

A poor patient experience shouldn’t be ignored. Healthcare professionals and organizations should always be looking to maintain and improve patient experience. Thankfully, there are strategies you can implement to improve it.

Maximize efficiencies to prevent delays or patient wait times by assessing your current operational and patient flow.
Focus on empathy through effective, caring and compassionate communication.
Listen to patients without interrupting.
Assure patients understand their treatment plan once discussed.
Overestimate the time it will take for evaluation and diagnosis, and over-deliver by accomplishing it more efficiently.
Keep patients informed if/when delays occur.
Address any patient anxieties and help them feel at ease and more comfortable.
Utilize the “teach-back method” when providing discharge instructions to confirm the patient’s knowledge.
Modernize patient access with more digital touchpoints.
Don’t forget about the wellness and morale of your staff and units — happy staff equates to happy patients.

Improve Patient Experience With Improved Revenue Cycle Management

Creating a positive patient experience is absolutely essential, from patient safety to healthcare quality. While the staff has a big role to play, so do the processes your organization has in place. One excellent way of improving the patient experience is by having an improved revenue cycle management process and with the help of Spark Health Partners, you can easily put your focus back on patients — not on their payments.

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The post What Is Patient Experience + Why Is it Important to Healthcare Providers? appeared first on Spark Health Partners.

Revenue Cycle 101 Archives – Spark Health Partners

Deep Dive: Is Your Practice in the Pre-Payment Review ‘Penalty Box’?

1. Make sure you’re aligned with CMS standards

2. Assess the ask and your own resources

Compliance risks:

Administrative burden:

Impact on cash flow:

3. Engage the payer using proven practices

The bottom line

Your revenue cycle is too important to be left to chance.

A Closer Look at Coding the Social Determinants of Health Risk Assessment

Why Revenue Cycle Data Is a Key Differentiator

What you need to know

What is the value of data for analysis?

Where are the sources of revenue cycle data in RCM + how are they used?

Front office:

Mid-office:

Back office:

What are key challenges in compiling revenue cycle data?

Data heterogeneity and inconsistency

Lack of meta-information and quality for unstructured data

Lack of systems interoperability

Regulatory compliance and privacy

The bottom line

What Is a Reference-Based Pricing Plan?

What you need to know

What's the difference between Reference-Based Pricing plans and other commercial health plans?

Who's driving the adoption of these plans?

Why might employers choose this type of plan?

How should providers go about accepting RBP plans?

FAQ

When can providers choose not to accept a Reference-Based Pricing plan?

Who sets the rates? How is the benchmark defined?

What sort of agency do providers have for recouping payment for non-emergency services or elective services?

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Tips for Providers Thinking of Going Out of Network

Why Consider Going Out of Network?

Impact on Providers

Impact on Payers​

Tips for Considering + Implementing an Out-of-Network Strategy With Major Payers​

Assess Current + Prospective Out-of-Network Patient Volume

Be Selective About In-Network Services

Educate Physicians About the Out-of-Network Experience

Connect With Impacted Self-Funded Employers

Keep Patients Informed + Engaged

Make Your Position Public

Prepare Your Operators for a Smooth Transition

In Summary

When healthcare organizations consider the decision to go out of network with a payer, it requires careful analysis and planning.

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What Is Healthcare Revenue Cycle Management?

Healthcare Revenue Cycle Basics

What is Revenue Cycle Management?

Step 1: Scheduling an Appointment.

In the revenue cycle, this is known as pre-arrival services.

Step 2: Arrival + Intake

Referring to a patient's initial encounter with the healthcare organization, this is called Patient Access.

Step 3: Care Delivery + Documentation

This is known as "the critical middle" or the revenue integrity function.

Step 4: Medical Billing + Collections

The final phase of the revenue cycle management process is known as "the back end" or business office.

Common Revenue Cycle Management Challenges

Overwhelming Complexity

Lack of Experienced Resources

Disjointed Systems + Error-prone Processes

What Are the Key Components of a Successful Revenue Cycle Management Program?

Technique

Talent

Technology

In Summary

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6 Tips to Ensure Your RCM Partnership Will Go the Distance

6 RCM Tips to Consider When Looking for a Compatible Match

1. Make Sure They’re Who They Say They Are (Don’t Get Catfished)

2. Ensure They Share Your Values + You’re Both on the Same Page

3. Evaluate Their Technology + Infrastructure

4. Make Sure It’s Not One-sided

5. Set Clear Expectations From the Start

6. Look for the “Whole Package”

Moving Forward with an RCM Partnership

Impact on Payers

Tips for Considering + Implementing an Out-of-Network Strategy With Major Payers