In today’s fast-paced healthcare environment, running a medical practice is a big responsibility that involves multiple steps, from patient registration to final reimbursement clearance. However, financial systems like Revenue Cycle Management (RCM) can help providers streamline the whole process from appointments, insurance checkups, billing and claims. Therefore this implies a well and sound RCM system; healthcare practices can emphasize delivering quality patient care, and payments are done without any delays.
Along the way, healthcare providers often face significant challenges in managing the revenue cycle that can hinder cash flow and revenue loss if not addressed. But by addressing these concerns, healthcare providers can optimize their RCM process smoothly and improve revenue collection as well as satisfactory patient outcomes. From billing to coding, delayed payments, and technical glitches, we’ll explore the top 5 RCM challenges with actionable solutions to each.
Complex Patient Demographics
Healthcare organizations deal with large amounts of patient data and process several different claims to insurance companies. When there is a huge amount of data, errors occur possibility may rise, resulting in inaccurate patient information, long wait times, insurance verification difficulties, delayed payments, and claim rejections. Moreover, dealing with different insurance companies can be like a complex and frustrating task; with different rules, requirements, and paperwork.
How to Overcome It:
– Automate Data Entry and Verification:
Implement automated data entry systems like EHR and verification systems to update patient data and insurance eligibility in real time. Integration with AI-powered tools can also help to validate and improve data accuracy with speed record-keeping without any human errors. Otherwise, use the cloud based tool Optical Character Recognition (OCR) to extract data from patient records from documents like insurance card forms, which helps to minimize manual data entry.
– Standardize Insurance Verification Processes:
Use integrated RCM systems that can link your system with payer databases to automatically fetch the most accurate and current details without any hassle of manually updating everything. This integration can also help to check patient coverage with multiple payers, before the services are provided, reducing the chances for data error and claim denials.
– Maintain an Up-to-date Centralized system:
Keeping a check on your centralized system is crucial to reduce risk factors of error and streamline workflow. Always, keep your system up-to-date with all the regulatory requirements and rules to improve your overall revenue cycle efficiency and correct procedures that are followed for each insurer.
| Tip: Regularly audit and update your automated systems and centralized database to ensure they reflect the latest payer rules, regulatory changes, and patient information. |
Denied Claims and Payment Delays
In revenue cycle management (RCM), healthcare providers often face the issues of incorrect or incomplete coding, insufficient documentation, payer authorization issues, and incorrect patient information, resulting in claim denials and reimbursement delays. These issues can be a big problem for high claim denials that lead to revenue loss and negatively affect the financial operations of healthcare organizations. As these denials cost a fortune for healthcare providers.
How to Overcome It:
- Update Coding Systems and Training:
Conduct regular training programs for your coding staff to reduce errors. Implement regular internal audits for your team to get feedback to identify loops and errors among different specified and unspecified code confusion. Make sure your coding team is always up-to-date with all the latest code updates for ICD-10, CPT, HCPCS, and modifiers.
- Enhance Documentation Practices:
Use a set standardized templates policy to emphasize accurate and thorough documentation for each patient encounter for different specialities. Also, include clear justifications for medical necessity and check with your healthcare team in between that they are trained on all the detailed descriptions of services rendered. With that, implement the front-end verification process to ensure your patient demographics information is accurate before submitting any claims.
- Denial Management:
Create a dedicated team for managing all your denials that reviews the reason behind the claim rejections and resubmits the appeal with all the correct requirements. A clear process of transparency should also be there with your payer to resolve the issue quickly within the reimbursement timelines.
- Claim Scrubbing and Guidelines:
Adopt claim scrubbing tools that automatically check errors to minimize rejections as per requirements and policies. These automation tools can be integrated with the payer’s database by installing centralized systems to store all specific guidelines and requirements.
Evolving Regulatory Compliance
A complex and ever-evolving set of regulatory requirements or updates can be a big problem in your revenue cycle management (RCM) for streamlining any healthcare process. These include managing annual updates in ICD-10 code with new codes and modifiers. Also, adhere to HIPAA (Health Insurance Portability and Accountability Act) mandate security protocols to make sure all patient record data is stored in strict security manners. Staying up to date with all these codes and HIPAA regulations, manual updations often require time to spend as compared to other critical tasks.
How to Overcome It:
- Automated Updates for Codes and Modifiers:
Integrate the API connections of your RCM software with the official coding databases to automatically fetch and apply updates to ICD-10 codes, CPT codes, and all other modifiers as soon as any update is released. It will help to build a mechanism that can handle all the manual updation processes without creating any chances of human error for a fast billing and claim process.
- Compliance Monitoring System:
Add real-time auditing features for continuously scanning billing, patient data management, and workflows to ensure compliance with all the HIPAA and other healthcare regulations. Using these advanced monitoring compliances will also reduce the risk of data breach and penalties while analyzing all the patterns of violations.
- Reporting for Compliance Audits:
A customizable dashboard for key metrics like claim rejection rates or patient data access in RCM software will help the healthcare providers to prepare the audits and regulatory review reports to find the loopholes. These on-demand reporting tools will help to simplify the audit process and improve accuracy and accountability rates.
| Top 5 Leading RCM Software Providers Offering These Features Athenahealth: Strong in cloud-based solutions, compliance, and automation. Kareo: Focuses on small practices with robust compliance and training tools. Maximus: Claims Management with focus on AR and denial handlings with robust analytics reporting.Cerner: Provides excellent automation for regulatory compliance and updates.eClinicalWorks: Offers scalable, cloud-based solutions with customizable workflows. |
Inefficient Prior Authorization Processes
Most staff for healthcare providers have to manually fill out the Prior Authorization (PA) form request via either fax or phone. Administrative staff spend excessive time managing all the PA submissions, and getting follow-ups usually prolongs the period of patient treatments and medications. Sometimes, even staff struggles with a lack of proper documentation and payers’ specific requirements, resulting in delaying billable services.
How to Overcome It:
- Real-Time Eligibility Verification:
Integrated real-time eligibility, automation for prior authorization requests, and benefit verification into your RCM software will handle all submissions electronically. These auto-forms use patient data from EHR/EMR via insurance portals to reduce time spent on manual processes and avoid any human errors in documentation. It also eliminates unnecessary submissions for services that don’t require authorization.
- PA Centralized Dashboard:
Include a centralized custom dashboard in RCM for managing, tracking, and following up on all the prior authorization requests. These models will help to give you real-time updates on PA statuses to reduce missed deadlines and follow-up lapses and give alerts for pending or expiring authorizations.
- Integration with Payer System:
Establish an API integration between RCM and payer portals for direct submission of PAs to insurance systems. With this integration, you can also have a built-in template library for each payer PA specific requirements for documentation checklists. Overall, it helps to reduce the factor of incomplete or incorrect submissions, as the system already varies the payer’s requirements.
- Denial Management and Appeals:
Adding a denial management feature in RCM is the best feature for streamlining your denial and appealing workflows. Its automated features for pre-filled appeals based on denial codes will be time-efficient and reduce revenue loss from denied authorization.
Lack of Skilled Workforce:
Healthcare staff often lack candidates with proper practical experience in RCM roles, including medical billing, coding (e.g., ICD-10, CPT), payer-specific rules and compliance regulations. Lack of skills in staff causes delays in claim process and billing errors. Meanwhile, hiring and onboarding new employees is also a costly, time-consuming process, with a whole lot of verifications and procedures.
How to Overcome It:
- Automating Key Features:
Use RCM with automated key features for coding, documentation, prior authorization processes, and denial management system to handle all the repetitive and time-consuming tasks, reducing reliance on manual labour. It will help to minimize human error and improve work efficiency for claim denials and delayed reimbursements.
- Integrate Training Modules:
Onboarding guides and built-in training modules with e-learning tools will help your employees keep themselves updated with all the new billing criteria, coding, and compliance. These periodic updates will reduce the cost associated with external training programs, and help the in-experienced staff to complete their tasks accurately and efficiently.
- Outsourcing RCM Functions:
Partner with other professional RCM service providers to manage all your end-to-end revenue cycle management operations. This comprehensive approach will ensure a seamless and error-free workflow with certified professionals with deep knowledge of industry standards, payer rules, and complaint requirements. It will help you to reduce the need to hire and in-house staff for all specialized tasks for billing and claiming processes. Outsourcing your RCM function will help you manage all your labour tasks and give you peace of mind to focus on your patient’s health care.
Final Thought
RCM is the backbone for any healthcare organization to streamline their financial operations. However some challenges can come in between, but by leveraging advanced embracing automation, staying updated on compliance requirements, and investing in skilled staff or outsourcing, healthcare providers can overcome these obstacles effectively. Prioritizing a robust RCM strategy allows providers to focus on delivering exceptional patient care while ensuring financial stability.Struggling to manage your RCM processes? Partner with us today, and let Medcare MSO, provide you end-to-end RCM services, from handling medical billing services and coding to managing denied claims and compliance. Let our experts take the burden off your shoulders so you can focus on what truly matters patient care.
