The current economic climate has imposed considerable pressure on businesses of diverse backgrounds on a global scale. Of note, the healthcare sector is experiencing multiple strains stemming from such factors as inflation and the aftermath of the COVID-19 pandemic. As such, healthcare institutions such as hospitals, clinics and other related organizations might be contemplating their future trajectory. Given that the world has undergone significant transformations in the past three years, a thorough evaluation of an organization’s revenue cycle may be necessary. In this regard, the ensuing checklist offers a starting point for healthcare organizations to streamline and optimize their revenue management procedures.
Build an Efficient Team
To maximize your organization’s revenue stream, you need ample documentation that shows all diagnoses and treatments for every patient. A Clinical Document Integrity (CDI) team can ensure that your files are complete and error-free.
A CDI program reviews patient records for thoroughness and accuracy. An effective CDI team should include individuals with clinical experience and knowledge of medical coding systems. The team confirms that each patient’s records are legible and complete and that they translate correctly into coded data. This data may then be used for receivables and reimbursement.
Manage Your Receivables
Health insurance policies tend to have higher deductibles than in years past. This reflects inflation to some extent, including regular inflation and recent inflationary trends. The end result is often a change in how healthcare organizations must handle their receivables. Higher deductibles mean that patients are often the primary payers. Billing patients for services is now at least as important as claiming reimbursement from insurance companies.
Give Patients What They Expect
Patient expectations have changed when it comes to medical care. Many healthcare organizations continue to communicate by phone or fax, but the world has largely moved on from those methods. Patients want simple, straightforward processes for scheduling, paperwork, communication and billing. Ideally, all of these features may be available through an online portal geared toward consumers. The more easily patients can communicate with their healthcare providers, the more likely they will be to pay their bills.
Streamline Your Claims Process
Insurance claims from healthcare providers make up a significant portion of total healthcare expenses in the U.S. Many of these expenses are administrative costs unrelated to the actual provision of care. While insurance companies share the blame for these inefficiencies, healthcare organizations can work to streamline their end of the process to reduce their own costs.
Healthcare organizations often forgo vast sums of money because of insurance company denials. The denial rate may be as high as 10% in many parts of the healthcare industry. This amounts to a loss of as much as 20% of the total value of all claims. The overwhelming majority of claim denials are avoidable, but providers often never resubmit denied claims.
A Denial Management Program (DMP) can help your healthcare organization improve its returns on insurance reimbursement claims. Once you have developed a plan, you need a team to implement it. Your DMP team should include expertise in clinical work, medical coding and reimbursement claim processes. The team’s functions include:
- Review of reimbursement denials;
- Determination of causes for denials;
- Identification of trends in the organization’s billing and claims processes that require review; and
- Modification of the organization’s processes, based on data collected, to improve its reimbursement rate.
Prepare for Audits
Post-payment audits are becoming more common for healthcare organizations. Insurance companies conduct audits to address potential waste, fraud and other concerns. They may select a provider for an audit based on reviews of payment data, or for a variety of other reasons. Audits may be especially common when Medicare or Medicaid are involved.
Healthcare organizations should view audits as an inevitability and be prepared for them. You need a plan that enables your organization to respond to an audit request and assemble the necessary materials quickly and accurately.
Automate
Many components of a healthcare organization’s revenue process do not need constant attention from employees. Automated systems can improve efficiency by making sure human attention remains where it is most needed.
As mentioned, an online client portal can reduce the need for staff to handle scheduling and other communications. Automated systems can also keep track of many parts of the patient billing and reimbursement claim processes.
Many new advances are occurring in artificial intelligence (AI) and robotic process automation (RPA). Some of these developments could be useful to your organization. AI and RPA tools may be able to handle many recordkeeping functions, for example, with human oversight.
It is crucial for healthcare organizations to evaluate their revenue management procedures and streamline their processes to optimize revenue. Implementing the checklist outlined in this article can help healthcare organizations build an efficient team, manage receivables, give patients what they expect, streamline their claims process, prepare for audits and automate where possible. By taking these steps, healthcare organizations can be in position for success in the rapidly changing landscape of healthcare.
If you have any questions or would like additional information, please contact DMJPS.
Sarah Hayes, CPB, CPCO
As a member of the DMJPS Healthcare Consulting team, Sarah is responsible for a number of special projects including HRSA Provider Relief Reporting. Sarah is a Certified Professional Biller and a Professional Compliance Officer. Her continuing education and certifications provide clients with an additional resource for HIPAA, human resource needs, and compliance concerns.