By HGS Healthcare
Across the healthcare industry, health information mismanagement is causing a loss of millions of dollars each year. Inefficient use of staff resources and systems, or the failure to invest at all, reduces a healthcare provider’s already thin margins. Provider finance leaders are struggling to address the financial impact of post-pay audits, denials, and processing appeals, while revenue cycle departments are inundated with backlogs of denials on previously paid claims, distracting them from standard claim resolution processes.
Proper revenue cycle management (RCM) involves careful documentation of the entire patient journey, from pre-registering through payment collection. The solution for streamlined, successful RCM requires hiring for the right skill sets and leveraging the right tools to track and analyze patient and member data—and healthcare organizations must prioritize this challenge.
Because each detail of a person’s path of care must be recorded accurately, the ideal candidate for this type of work is meticulous and adheres to the many and varied processes that payers provide. Timeliness is essential, as is proactive self-motivation to ensure each step is completed. An ability to communicate effectively with multiple people and departments, along with knowledge of medical terminology, are essential skills.
Perhaps the most desirable skill is familiarity with or the aptitude to quickly grasp the tools and software used to perform data collection, analysis, and reporting. Although technology-enabled RCM services are widely available today, many organizations are running on antiquated systems that fail to integrate with more modern options, which contributes to inefficient operations and additional lost revenue.
Track it all with the right tools
Once captured by a proficient employee, patient and member data can be handed over to artificial intelligence (AI)-based systems. Machine learning (ML) and Natural Language Processing (NLP) help reveal insights from the information gathered, and predictive analytics can provide recommendations based on patterns detected.
Although critical, patient and member data isn’t the only information to track. The work performed by employees and the tasks themselves must also be monitored. With good data and analytics in place, key performance indicators can be reviewed and improved upon regularly.
A recent article in Becker’s Hospital Review states, “By effectively tracking your issues, you can improve your revenue cycle by prioritizing the issues with the largest impact on fiscal management, revenue cycle processes and workflows and ensure personnel are held accountable to meet target dates and goals.”
A huge source of revenue leakage is due to post-pay recoupment, according to Belinda Cridge, Director of Client Services at HGS. Although the contracting and revenue cycle management functions previously worked in silos, she says, “Contracting now proactively reaches out to the billing and follow-up folks to check on issues related to post-pay audits while they go into new contract negotiations.”
Cridge adds that although there’s no way to estimate or predict the number of upcoming recoupments, proactive tracking is important. “Set up your system to be able to track recoupment and to track audits,” she advises.
HGS Director of Client Relations Matthew Betts agrees. “You definitely need a tool to track and monitor the information, and you also need resources who know how to use that information to prevent denial kickbacks, manage the audits, and provide upward feedback with leadership.” Information needs to be incorporated into your denial reduction initiatives in a timely fashion to prevent further revenue leakage in future audits.