Managing the money tied to patient encounters at each step along the way is critical, but in an era of high deductibles and tightening payer reimbursements, revenue management is an increasingly complex task.
Patients are more commonly required to pay something out of pocket. Insurers require more data. How can practices improve their revenue cycle management (RCM) process in the midst of all this change?
For some, it may take support from vendors, revisions to internal processes, the deployment of additional technology tools, or a combination of all three, according to experts.
The ever-changing healthcare marketplace
Many of the challenges practices encounter throughout the RCM cycle are outside their control. The current shift in patient payment obligations is one such issue.
“We have a lot of people choosing low-premium health plans for economic reasons,” says Timika Lucas, MBA, president and chief executive officer of Lucas RCM Consultants Inc. in Hazel Crest, Ill.
Magnifying the effects of that trend is the move toward high-deductible plans as consumers seek to more closely manage their healthcare expenses and usage. “That’s resulting in insurance companies making patients responsible for a higher percentage of their care costs,” Lucas says. As patients see their out-of-pocket expenditures climb, an increasing number are finding it difficult to pay, or to pay on time.
Recovering payments from patients is a challenge Lucas sees across the private practice spectrum, particularly when the dollar amounts are higher. Working with a multitude of payers — a portion of the industry also undergoing significant changes in the current environment — presents its own difficulties.
“A lot of reimbursement is regional, so it depends on payers in your area and what kind of programs they have and their level of sophistication,” says Drew Borland, chief technology officer at Alpharetta, Ga.-based Philips Wellcentive, a population management and revenue growth platform provider. Navigating through compliance requirements that are still maturing adds to the complexity for practices. “The issues are evolving as we go from an incentive-based world to a value-based penalty world, where if you don’t do things with a certain level of quality, then you can get dinged,” Borland says.
The practice's lack of time, a phenomenon that seems to be getting worse rather than better, is another factor hindering practices’ efforts to recover the highest possible reimbursements. Moreover, physician burnout sometimes keeps providers from focusing on RCM and the components that go into it.
“They don’t always have good knowledge of the revenue cycle, and they don’t have the time to look at it,” says Ginny Shipp, professional services at revenue cycle technology firm Waystar, in Duluth, Ga. She says she doesn’t believe it’s necessary for providers to directly manage the RCM process, but too few have a working familiarity with how the cycle works or what a solid RCM strategy looks like if they do oversee it.
In-house mistakes practices make
Lucas points to common internal work flow issues as another potential barrier to maximizing revenue. She says staff already have a full plate when it comes to complying with payer requirements.
“[Practices] need to make sure that preapprovals are obtained, or they need to make that call to the insurance company to find out if it’s necessary or not,” she says. Insurers may change policies and requirements for certain procedures, but staying abreast of each update is difficult and time consuming.