Navigating the Complexities: A Back-to-Basics Approach to Common Healthcare Revenue Cycle Management Challenges
Healthcare revenue cycle management plays a vital role in the compliant financial health of healthcare organizations, extensively involved in patient satisfaction, coding/charge capture, managing claims, processing payments, and revenue generation. Despite technology and solution modernization, revenue cycle management still faces countless challenges that impact clinical and operational efficiencies, overall financial performance, and ultimately organizational success and sustainability. This article is designed to explore some of the common pain points and challenges facing healthcare organizations through streamlining the basics in revenue cycle processes.
Complex Payer Contracts and Reimbursement Models:
Navigating complex payer contracts, varying reimbursement models, and evolving regulatory requirements remain prominent challenges for healthcare organizations in managing revenue cycle processes.
Can we have a data-driven conversation: Ask your payers if you’re getting the best possible rates for the quality of care you’re providing. Ensuring mutual compliance within contracting terms, adapting to value-based payment models, and highlighting documentation standards of care can aid in cultivating a genuine payer relationship, with continuous monitoring, and create favorable contract management.
Patient Financial Responsibility and Experience:
Rising healthcare costs, high deductible health plans, and increased out of pocket patient financial responsibility have shifted a significant burden onto patients to cover their healthcare expenses prior to the payer covering any of those expenses.
Can we discuss what your plan means: Proactively and candidly discuss with your patients what their plan types truly cover. Create the expectation of support through their healthcare experience, understanding collecting of payments, estimating costs accurately, offering financing options (i.e. payment plans), and addressing any financial concerns are essential to maintaining mutual trust and optimizing revenue cycle collections.
Billing and Coding Errors:
One of the most prevalent challenges in revenue cycle management is the recurrence of billing and coding errors. Incomplete documentation, misinterpretations, and inaccurate diagnosis sequencing and charge capture can lead to claim denials, delayed reimbursements, and revenue leakage and loss.
Can we orchestrate a continuous internal training program: With the ever-evolving guidelines within healthcare, reinvesting in staff training and development is essential for maintaining a learning-organizational culture. Having a structured training program for all functional roles, coupled with quality assurance processes with identifiable career pathways, and leveraging EMR/system edits to mitigate errors and prevent coding/billing errors will lead to a highly resilient and performing revenue cycle.
Claim Rejections and Denials:
Claims rejections and denials are considerable pain points that not only impact revenue cycle efficiency but also the patient’s experience.
Can we leverage analytical trends to proactively remedy: Encourage and implement a continuous process improvement mind-set to identify and address the root causes of denials. From demographic mismatches, missing or errant information, eligibility and coverage issues, to visit and scheduling types, and coding errors; having a denials management strategy leveraging analytics for trend timely trend analysis can reduce avoidable denial rates and maximize revenue capture. Do not forget to share findings through your enhanced communications with payers to ensure all efforts of denials prevention are transparent and maximized.
Compliance and Data Security:
Protecting patient health information, ensuring data security, and maintaining compliance with evolving regulations are paramount to the revenue cycle, IT, and the patient-organization relationship.
Can our training include practical application of mitigating non-compliance: Additional investment in robust cybersecurity measures, computer training with Phishing exercises, and risk management practices with communications on how to safeguard data integrity can mitigate potential breaches that erode patient trust and negatively impact organization revenue and branding.
Designing, employing, and maintaining a high-performing revenue cycle management team to combat these common healthcare challenges takes deliberate and focused leadership to ensure financial sustainability, an engaged culture, and returning satisfied patient. Through recognizing and addressing these challenges such as payer complexities, patient financial obiligation, billing and coding errors, claim denials, and compliance issues, organizations can streamline processes, optimize coding and revenue capture, increase patient engagement, and improve the overall financial performance of the operations. Significant investment in unified strategies, technology adoption, staff training, and continuous improvement efforts remain key to effectively navigating the complexities of revenue cycle management.
Garland F. Goins, Jr, MBA
Vice President, Revenue Cycle Management
Garland F. Goins Jr., is the Vice President of Revenue Cycle Management for Alo / Avance Care in Durham, NC. In this role, Garland is responsible for organizational charge compliance, revenue preservation and enhancement, and value-based care integrity. Garland has held progressive leadership roles in the revenue cycle for Comprehensive Primary Care and Academic Medical Centers for over 18 years and is an active local and national member of HFMA’s Physician Practice Executive Council, AAPC, NAHRI’s Leadership Council and AHIMA.