Quiz1 Test Documents.pdf

Quiz1 Test Documents what is revenue cycle and why does it matter so we're going to go through 10 essential concepts that you need to know i'm vaughn i am the revenue cycle subject matter expert at genton i've been in revenue cycle in some role for the past 18 years so to get started let's all under...

Quiz1 Test Documents what is revenue cycle and why does it matter so we're going to go through 10 essential concepts that you need to know i'm vaughn i am the revenue cycle subject matter expert at genton i've been in revenue cycle in some role for the past 18 years so to get started let's all understand what revenue cycle management is it's the step-by-step life cycle from when a patient first books an appointment until the claim is fully reimbursed by the payer now this means as soon as you get that patient's information their demographics their insurance to the encounter to the claim to the submission of the claim and back to the reimbursement Revenue Cycle Management revenue cycle management we'll call rcm and billing can be managed in-house or you can outsource this to a billing company there's pros and cons to both and we're going to go over the difference of each so in-house billing you have an entire team demographics insurance verification coders auditors uh billers air follow-up posting patient balances you have to hire all of these roles and you need backups and cross-trainings and things like that to determine that are to make sure all of your roles are going to be covered in the event that you're short staffed someone's out someone leaves and you need to rehire with an outsourced billing company you typically get a bigger team so the way this is set up is you get a contact person so you have a revenue cycle manager in-house or a billing manager a director a billing in-house and that person works directly with a contact person at your billing company there's often shared responsibilities but you often get more experience more people and more technology than what you have in house as an independent physician you know practice owner you are focused on getting the patients in for the appointments getting them the treatment they need and a lot of times an outsourced billing option is a good thing because that is uh one piece of the the process that you don't have to be hyper focused on on a daily basis so let's go over in network versus out of network if you are in network this is a contract between you the physician and the payer this means you know what you should be paid this is your guarantee this is your paycheck this is also going to eliminate burden on patients with balanced billing so the patients know in advance how much they may owe you what their deductible is their co-pay but also you can give an estimate based on your contract with the payer with in-network status as a physician with a payer if a claim underpays or a claim denies you have the ability to fight for reimbursement so that means you can submit an appeal or a reconsideration and have that claim reprocessed with the payer out of network you're really it makes it difficult to forecast income you could also have higher patient balances from patient billing so if you don't have a really good collection process up front you could end up with patient balances on the back end meaning that you're working with collection or you're using a lot of attempts effort resources to collect on those patient balances you're often unable to send an appeal or a reconsideration and that's because you don't have a contract with payer so there's no agreement between you and the payer saying what you should be paid on a specific encounter date of service procedure maybe key performance indicators so there's a lot of kpis that you want to track with your revenue cycle process and we'll go through some of the highlights charge lag how many days does it take you to submit a claim one to five days is really considered the industry standard people that we talk to places i've been one to five days is uh acceptable anything you know six to ten maybe that's the average and over that you're really getting into the risk zone days in ar this is also known in some some specialties as dso so this this is a different metric this is the number of days from the date of service to the payment date so how many days from that encounter are you waiting to get your paycheck 35 days is the goal um you can be really aggressive with anything from 30 to 34. anything 45 or higher that's more of a risk and you need to really dig in and see is it taking you um longer to get your charges out the door back to your charge lag or is a payer just by you know by process taking that long clean claims rate so you want your clean claims to be like a really big metric 95 or above is a is a great goal and the reason why is you want to put your resources on the front end to make sure you you have went through every check and balance that you can to assure a clean claim is going to a payer for reimbursement you don't want to have to work this stuff on the back end you want to put your work in on the front end um ar so let's talk about ar we age it in 30 day buckets right anything over 90 days aged from the date of service you want that to be less than ten percent so ten percent ninety days and over there's some things out there um that take time to work maybe you're waiting on an addendum with medical records but you really wanna keep that ar 90 days and below rejection rate and denial rate those are just two ways a claim could get hung up and start hanging out on your ar for for an extended period of time so you want your rejection rate to be less than ten percent meaning that you've attempted to submit a claim but didn't get it there to the payer and you want your denial rate to really be less than five percent so you want to make sure again you're going back to that clean claims rate and measuring to make sure you have checks and balances on the front end this may be with your technology this may be with scrubbers in your software this may be people looking at the process to make sure you're not missing anything cash collection so 90 plus percent you want to you want to have a net collection rate um of 95 or more now across the industry anything from 85 to 96 are the common numbers we hear 90 plus percent i would have a goal of 95 that to me is aggressive but it assures that you're getting that cash back in the door especially with those in-network payers where you have a contract and you know what you should be paid by debt this can be measured uh a lot of ways so the metric gauges the amount of non-contractual charges things that are right off you really want to limit this uh you don't want to work for free so you want this to be less than five percent if at all possible in the genten platform we can walk through some of these metrics just as as an example to show you how you should see this on the screen i'm sharing here you can see how many payments what's in your account receivable over to the right you can see your charges the allowable and the total reimbursed this is how you calculate your net collection rate so for any time frame you should be able to go in and calculate what you filled what you should have been paid and what you were truly paid this gives you a good sense as to how the process is going overall to know that your net collection rate is high analytics this is very important with revenue cycle knowing you know having the data knowing how to manipulate the data or access the data you know if you're using a great software it may be easily uh seen or reviewed like it is here on this screen if not you may be uh exporting spreadsheets and and doing that yourself but as an example this is a very user friendly um software and it's really easy to see what you're looking at so days to submit that is your charge like in this example you see two days that's a really great number like i said before one to five is is good and it's typically the industry standard median days in ar on this example 35 that number is good anything from 30 to 35 is a great goal uh you may have payers that pay a little sooner so if you have a payer that pays really quick you may get to that 30-day mark if you have a lot of commercial liability third-party payers you may see an extended amount of time you may see a 35-40 day mark of course your denials your rejections and your clean claims rate all again very important very easy to see here in this example so let's go to insurance verification insurance verification is a very very beginning of the process and it can be repetitive you may need great software to do this uh sometimes pair portables will not give you the detail that you need you need to know if this is an office visit a telehealth visit in network out of network the big things here are the patient's deductible what's remaining the copay and the coinsurance those are the three things that you need to know to provide an estimate to a patient again in the software you can see here it gives you that in detail so you can very easily say you know hey to your patient this is your deductible remaining this is the expected reimbursement from the payer your portion will be it's a much better process to collect up front than on the back when you're sending out those text statements email statements paper statements and possibly getting the payment you know in a payment plan maybe getting the payment delayed or even not getting the payment at all which means that you have to consider a collection process cpt coding and the claim scrubbing CPT Coding editing process now hopefully most of us are in a software that has warnings and alerts and edits that we can either build or that just that they exist for us but coding and scrubbing is very very important to submitting a clean claim the most important factors out in my opinion are making sure your coder has uh knowledge within the specialty in the industry that you are in so if you're a cardiologist you know a coder that has the ability to gain that knowledge by working with an internal team or an external team for you or someone that has has been in that industry and has knowledge around that specialty pair guidelines and payer performance each payer commercial or government can have guidelines on what cpt diagnosis and modifiers that you're applying to a claim payer performance that's important this is really very similar to payer guidelines but payer performance means you know anytime you have a certain cpt diagnosis combination you may need a modifier or let's say you know you're a pain doctor and sometimes the rtlt modifier is very important or a surgeon and the rtlt is very important but having that knowledge or that access to knowledge is very important now we've said before the billing platform with the ability to create these rules it's not ideal to manually scrub claims individually by a person so this is where you want to leverage technology if you have it available the billing platform that you're using should have the ability to create those rules and edits and warnings that i mentioned earlier so let's talk about the process front to back this is a chart that shows you everything from benefit eligibility to payment so the patient calls you obtain the demographic information you get the insurance information and step one of securing your revenue cycle process is checking the benefits and eligibility making sure that you have the right payer and making sure that there's not a term date on that plan making sure that it's a covered benefit your network all of those things are helpful once you get the patient's insurance information once that happens and the encounter has happened so the patient and the physician or the clinician have met the coding and charge capture comes into play so you're coding from the documentation that the physician has provided and then you're entering the charges or hopefully the charges are populating for you once you enter those cpt codes and diagnosis codes to create the claim the claim is what goes to the payer so now you want to have your claim scrubber kick into play hopefully again that is an electronic you know magical process that happens where your software gives you a warning or a stop you know if it's something that's a date of birth that's absolutely going to be needed on all claims that should be a hard stop in your software your software should say don't go past this point there's a field missing um there may be some softwares that have a warning though and that may say you know this diagnosis and this cpt code are mismatched and that's a warning to show you may want to go back and look at this one more time with your documentation to make sure there wasn't a typo or maybe in a lot of scenarios there's a drop down where you get an error claim status inquiry you've submitted the claim 30 days let's say has passed and you don't have an era correspondence or a paper this is where you call the payer you go online you utilize your clearing house your billing software to get an enquiry on the claim so what's what's going on is the claim still in process is the claim denied uh maybe the claim was just processed and you're going to get an era soon but you do need to follow up on those claims the recommendation is that a claim not go 30 days without a follow-up remittance advice so a remittance advice is the equivalent to what the patient gets as an eob an explanation of benefits most providers now have eras so you have an electro electronic remittance advice that comes back through your clearinghouse that's definitely a quicker way um and in a more secure way of not losing paper not getting mixed or lost in the mail you want to try to get an era when at all possible he already comes back in you're at the risk of denials and appeals so let's say you have a partial denial a full denial an underpayment this is where either you have a full denial and you need to maybe submit medical records with a payer specific form for reconsideration maybe you can call to submit an appeal maybe you can go on the payer's website or a lot of times again in your tools your software that you're using you can select to submit an appeal electronically to a payer posting any money that's come back in you need to post that you need to make sure it's posted in your software and you need to reconcile your bank to your software to make sure that you're not getting money in the bank with claims not posted or make sure that claims are not posted and the money is is missing from the bank patient statements go out and there's patient follow-up at the end we all hope that just you know one statement goes and payments come in but the reality is mailing paper statements isn't the only approach or method we should have now you should be able to text email and send some paper statements you want to give people the ability to pay on their phone you want to give people the ability to send it in of course they may call in to make that payment but the big thing is hopefully you've collected the majority of the what's going to be due up front and now you're on the back end sending a smaller balance and you have options on how to get that delivered to the patient claim rejections and denials so we went over this a little but there's a lot to know about claim rejections in the niles so appeals reconsiderations corrected claims these are all the path you're taking to get the payer to to re-review the claim whether that be um an automated process with their software or there's a form or an approach or a submission that says please manually review this we understand that this diagnosis and the cpt may appear to be a mismatch but here's the documentation please review it so know your payer specific forms and ways to send the appeal this is super important a lot of commercial payers will let you log into their portal but some payers and i'll say medicare specifically still uses the actual printed paper that you need to send in for an appeal so this is important knowing the delivery method of how to get your appeal or your reconsideration to the payer very important another important fact around sending these appeals to the payer is the timeline filing so just like you have a timely filing limit for the initial claim submission you have a timely filing limit uh in some pay it with some payers for the appeal or the reconsideration so if you get a denial on january 1 you may only have until february 1 to get that reconsideration back out to the payer payer underpayments this is payer performance um a lot of times when we say payer performance the folks that we talk to don't really understand but what this means is how well is your payer performing to your contract so if a claim is underpaid you need to have the ability to identify that you have to have the ability to track and trend and know how often the payer's underpaying or how often the payer hopefully is paying the way it should to your contract so you have to have a tool in a lot of cases or you have to have a lot of excel spreadsheets that you're downloading and manipulating and doing all of your analysis with to identify and resolve the underpayments by paying things to remember most payers process claims in 7 to 14 days that's in the perfect scenario you've submitted a clean claim you have the right payer everything's went through great seven to 14 days medicare on average we have found seven to 14 days as normal commercial payers a little higher 14 to 21 days so those are just some some things to know as you go through your revenue cycle process Payment Posting the payment posting process this is important you need to know that you've been paid you've received the reimbursement or the paycheck as a provider that you expected when you when you had the visit of the patient so the billing or sometimes called the posting team will post the payer's reimbursement to your software this is a snapshot of your financial health this is showing um that the process has been completed right this is kind of the final stage you may get this in an eft you may get a paper check i mentioned this earlier reconciling your bank deposits to your postings is very important this is a a practice function in in most scenarios if you're in-house billing outsource billing you always still need to make sure that your bank account matches what's posted in your software any mismatches um it may mean that you have less or more money than you think you have or more or less ar than you think you have balance billing payments could be sent to patients out of network this is huge with balance billing um and when you're out of network where your payments go so again there's no contract between you and that payer meaning they can send that you can file that claim as a courtesy and they can process that claim and then send the payment to the patient this is another really good reason to make sure you have an upfront collections process patient statements now i talked earlier about some patient statements having the ability to send them by text email paper um a lot of us in in the year of 2022 always have our phones with us so if we get a reminder or a bill and our alert you have an appointment or you have a balance it's easy to pay right there so collecting payments up front is important sending an estimate is really important so you're letting that patient know in advance now i've heard complaints from providers saying i don't want to send an estimate that may um you know that may make the patient think well i'm not going to be able to pay this i'm going to cancel the appointment um that's an opinion and i you know my my opinion is that you should still send the estimate if the patient's not going to pay up front you really need to think about if they're going to pay after the procedure too um but giving that estimate getting that information out as soon as possible having all delivery methods available is really important to the collections process or the patient collection process on balances that will be due or are due expect some patients to call the office so even though the tool that you're using says this is an estimate some patients will call some p some patients will you know really understand their benefits and really want to know how you determine this to be the estimate and some may pay right away some may not pay right away these are all uh you know different things that need to be considered when you're sending out the estimates but again back to knowing your contract knowing what the allowed amount should be so you can be educated as well as the patient Conclusion so many patients are unable or unwilling to pay the balance and you know that that's just a risk right you can offer payment plans you can work with a soft collections uh process company again you can do this in-house or you can outsource this a lot of things that i've read a lot of studies a lot of surveys it's a misunderstanding so the patients are not aware of their benefits they're not aware of what the denied claims are they're not aware of you know just the high cost of the service in general so that comes back to the estimates on whether you know you have the ability to send out a good faith estimate that is a good representation of what the patient may owe it does become the responsibility of you the health care provider to contact the patient and attempt collection on these outstanding balances so as you're going through this patient billing and patient collection process you know it it is definitely important to know what your office approach is or how aggressive you're going to be so all of that being said i hope you guys found some of this helpful if you are a current client of gentem you can reach out to your revenue cycle manager with any questions around this webinar so stop wasting time on clunky and outdated processes uh jensen likes to deliver these educations and webinars and you know just little snippets of information to you to show you that we are keeping up with the trends in the industry showing you that we have a platform that's built to help you run a smooth revenue cycle process Days in Accounts Receivable (AR) is an important metric in the revenue cycle that measures how efficiently a hospital is collec ng payment from its payers. The Revenue Cycle - The revenue cycle refers to the end-to-end process of genera ng revenue for a hospital. It starts with iden fying customer needs and ends with collec ng cash from sales. - Key parts of the cycle include Pa ent Services, invoicing, cash collec on, and managing accounts receivable. How efficiently a hospital manages this cycle impacts financial performance. Accounts Receivable - Accounts Receivable represents money that is owed to a hospital by the insurance companies for services provided to its pa ents. - It is shown as an asset on the balance sheet, as it represents future cash that will come to the Hospital. It is converted into cash later when the insurance companies pay their outstanding invoices. Days in Accounts Receivable - This metric indicates the average number of days it takes a hospital to collect payment from its payers. - It is calculated by dividing Accounts Receivable by total credit services over a period and mul plying by the number of days in that period. For example, over 90 days. - A higher days in AR indicates Insurance companies are paying more slowly, tying up the Hospital's cash flow. A lower days in AR is generally more favorable. Examples of Days in Accounts Receivable: Example 1 - On December 31st, a clinic had AED 550,000 in Accounts Receivable - Over the last 3 months (90 days) they had AED 3,700,000 in total credit sales - Days in AR = Accounts Receivable / (Credit Sales/Days in Period) - Days in AR = AED 550,000 / (AED 3,700,000 / 90) - Days in AR = 13.5 days Example 2 - Over the fiscal year (365 days), a hospital recorded AED 73,500,000 in net pa ent service revenue. - On June 30th, they had AED 14,700,000 remaining in Accounts Receivable. - Days in AR = Accounts Receivable / (Net Pa ent Revenue / Days in Period) - Days in AR = AED 14,700,000 / (AED 73,500,000 / 365) - Days in AR = 60 days Example 3 - A surgery center has AED 2,570,000 in Accounts Receivable at end of August - Their monthly credit sales average AED 4,030,000 (for 32 days) - Days in AR = Accounts Receivable / (Avg. Monthly Credit Sales / 31 days) - Days in AR = AED 2,570,000 / (AED 4,030,000 / 32) - Days in AR = 24 days Benchmarking - Days in AR varies widely by industry. Each Hospital can benchmark against their historical trends and industry averages to evaluate efficiency. - For example, the average in retail is 30-40 days. Construc on and hardware may be higher at 60-90 days. So ware is o en lower at 30-60 days. Improving Days in AR - Strategies to help improve days in AR include clearly defining credit terms with customers, invoicing accurately and quickly a er goods are delivered, incen vizing early payment, and ac vely collec ng past due invoices. Learning Objec ves Describe the flow of ac vi es that comprises the revenue cycle of a healthcare facility. Dis nguish among key players and departments that par cipate in revenue cycle ac vi es. Define the health informa on management (HIM) role in revenue cycle management. Iden fy the revenue cycle func ons that can be supported by HIM professionals. Explain key revenue cycle performance measures. List performance improvement methodologies that apply to revenue cycle management. Overview of the Revenue Cycle Revenue cycle refers to the series of ac vi es that connect the services rendered by a healthcare provider with the methods by which the provider receives compensa on for those services. Revenue is the sum earned by the provider, measured in dollars Pa ent Appointment Scheduling Scheduling the pa ent visit based on need Demographic and insurance informa on collected SLAs for different appointment types Pa ent Registra on and Visit Pa ent arrives and completes registra on forms Verifica on of pa ent informa on Services delivered based on provider orders Coding of Diagnosis and Procedures Professional coders assign standard codes ICD codes for diagnoses CPT codes for medical procedures Must capture complexity to support billing Medical Billing and Insurance Claims Itemized charges entered with codes Electronic claims filed to payers Creden aling ensures provider in network Claims Processing and Payment Payer verifies eligibility, policy coverage Pa ent out-of-pocket costs calculated Payments remited according to contracts Pa ent Billing and Collec ons Statements sent for balances due Follow-up pa ent calls for outstanding balances Bad debt and charity care rules applied Payment Pos ng Payments from pa ents & insurers entered Adjustments, deduc ons also updated Accurate payment pos ng cri cal Revenue Reconcilia on Denied claims need follow-up and appeal Underpayments also require adjustments Provider performance tracked Key Revenue Cycle Metrics Denied claims need follow-up and appeal Underpayments also require adjustments Provider performance tracked Revenue Cycle Process A pa ent visits a physician in the physician’s office for an examina on. The physician records some demographic and clinical informa on about the pa ent, performs the examina on, and renders whatever treatment or medical advice is necessary. Before leaving the office, the pa ent is required to pay the co-pay or any co-insurance. The physician takes the payment and deposits it in the bank. Breaking this example down into its component parts, as in figure 1.1, illustrates the revenue cycle as it applies to all healthcare facili es: pa ent intake, clinical services, charge capture, billing, and collec ons. Figuure 1.1 In the hospital se ng, the cycle is the same. The hospital also collects demographic and clinical data, treats the pa ent, sends a bill, and collects the amount due. The fundamental differences in the case of the hospital are in the volume of pa ents and the types of services rendered The key players in the hospital revenue cycle are typically whole departments of individuals who support the revenue cycle components. Administra on and finance departments look at opera onal efficiency and effec veness, achievement of strategic goals, and the maintenance of adequate cash flows to support the business. Payroll, payments to vendors, and investment in and maintenance of the infrastructure are key cash-flow concerns. Pa ent FinancialServices(PFS), also known as payer services, nego ates the payer contracts and the establishment of administra ve policies and procedures to ensure accurate reimbursement for services, which are cri cal components of revenue cycle management The pa ent access department is the data-integrity gatekeeper of the revenue cycle. The data collected and recorded at the point of registra on drives many of the controls later in the process; therefore, data quality is the primary concern of this department Pa ent access is also responsible for the verifica on of pa ents’ insurance coverage and precer fica on or authoriza on, as needed, of services to be rendered, whereas case management works with the payer to keep the pa ents medically approved for inpa ent services. The HIM department plays a key role in ensuring data integrity and contributes to the revenue cycle in a variety of ways. The case management department plays a significant role within the revenue cycle process for all inpa ent cases. Case management needs to make Thiqa, Daman, etc meet the payer’s specific u liza on management medical-necessity standards OF QUALITY t Charge Capture Along with documenta on of services, the clinical services department must also record the charges for those services. Charges are not just for reimbursement; they may also be used for tracking volume as well as inventory. laboratory charges enables the facility to track these services not just for reimbursement purposes but also to ensure sufficient laboratory staffing and supplies For example, if the facility charges for 100 doses of morphine in a period, it can reconcile these charges with the number of doses purchased and the number le in the pharmacy’s inventory. This process provides an internal control for detec ng discrepancies. Internal controls are policies and procedures designed to detect, correct, and prevent errors. Data governance deals with the quality and integrity of data within an organiza on, wherever and however data are collected, transmited, and stored. Data governance includes, for example, data quality and security informa on governance establishes a “comprehensive pla orm for the effec ve and efficient management of the informa on lifecycle” (Knight and Stainbrook 2014).  Informa on governance does the following: stablishes policy-level rules Defines investment priori es Ins tutes accountabili es Aligns implementa on outcomes to business priori es Measures results Revenue Cycle Management refers to the financial process that healthcare ins tu ons follow to manage all aspects of pa ent service revenue, from service provision to final payment or adjustment. Effec ve Revenue Cycle Management is crucial for healthcare organiza ons to maintain financial health, ensure compliance with regula ons, and improve pa ent sa sfac on. Purpose of Revenue Cycle Management: 1. Financial Stability: Revenue Cycle Management ensures that healthcare providers are compensated in a mely and appropriate manner for the services they provide. 2. Compliance: Revenue Cycle Management processes ensure adherence to complex healthcare regula ons, reducing the risk of financial penal es or other sanc ons. 3. Pa ent Sa sfac on: By streamlining administra ve tasks, pa ents experience fewer billing errors and clearer communica on about financial responsibili es, leading to a beter pa ent experience. Processes Involved in Revenue Cycle Management: 1. Registra on: This is the ini al step where pa ent demographic and insurance informa on are collected. Ensuring accurate data at this stage is crucial to avoid billing errors and claim denials down the road. 2. Charge Capture: A er a healthcare service is provided, relevant informa on is documented to account for each service. This ensures that all rendered services are billed. 3. Medical Documenta on: Clinicians record details of the care provided to pa ents. This documenta on forms the basis for coding and billing. It's impera ve for this informa on to be accurate and complete to ensure proper reimbursement and to avoid legal complica ons. 4. Coding: Trained medical coders translate medical documenta on into standardized codes using systems like ICD (Interna onal Classifica on of Diseases) and CPT (Current Procedural Terminology). Proper coding is vital for ensuring accurate billing and minimizing claim denials. The Coding Component in Revenue Cycle Management: Medical coding is a pivotal process in the healthcare industry. It involves conver ng pa ent health informa on, such as diagnoses, treatments, medical services, and procedures, into a standardized code. These codes are universally understood and crucial for billing and claims processing. Without accurate coding, healthcare providers might not receive accurate compensa on for the services they offer. The Billing Component in Revenue Cycle Management: Billing is a fundamental phase in the Revenue Cycle Management process. Once services have been provided and coded, the healthcare provider needs to create and send out bills or claims to insurance companies or directly to pa ents for reimbursement. The accuracy and meliness of this step directly affect a healthcare provider's cash flow. Pa ent Access Challenges Long registra on wait mes - Pa ents forced to wait over 45 mins to complete intake forms, provide insurance info, etc. leading to poor sa sfac on - Manual paper registra on processes failing to keep pace with pa ent volume - Lack of self-service kiosks or remote registra on op ons Insurance verifica on issues - Difficulty verifying eligibility in real- me with ~30% verifica on failure rates - Inability to iden fy uninsured pa ents upfront and have financial conversa ons - Backlogs created from having to rework denials a er services rendered Lack of price transparency - Pa ents expressing frustra on over surprise medical bills post-discharge - No pricing tools for pa ents to es mate out-of-pocket costs - Call center overwhelmed with pricing es mate requests delaying access Pa ent Access Solu ons Implement online pre-registra on - Launch pa ent portal allowing remote insurance capture, paperwork comple on - Deploy self-service kiosks across campus for check-in and payments - Achieve 50% reduc on in in-person registra on volume Automate insurance eligibility checks - Invest in eligibility system integrated with payers and EMR - Configure system to run real- me verifica ons during scheduling - Reduce manual verifica on work by 80% improving produc vity Provide cost es mates upfront - Build online price transparency tool pulling payer contracts - Enable call center access to tool to quickly answer pricing inquiries - Require registra on to provide indic ve price quotes at check-in Coding Challenges Inaccurate coding leading to denied claims - Claims denial rates have increased to 35% in past year - Clinical documenta on lacks specificity delaying coder review - Insufficient internal audits and educa on around documenta on Lack of trained coders - Shortage of cer fied coders with 5+ years experience - High turnover from burnout/higher salary offers - Frequent coding backlogs of >150 accounts Complex coding systems - Coders struggle naviga ng 20+ interfaces to pinpoint required codes - Confusion resul ng from annual ICD/CPT code updates - Inability to leverage automa on around coding logic checks Coding Solu ons Implement coding audits and training - Perform quarterly documenta on audits iden fying common deficiencies - Conduct 2-hour in-service for physicians on documenta on best prac ces - Require coders to atain minimum of 20 CEU annually U lize coding so ware - Procure computer-assisted coding pla orm to automate code sugges ons - Configure rules engine with payer-specific guidelines to reduce denials - Achieve 30% increased coder produc vity Outsource coding needs - Iden fy offshore coding partner to support overflow volume - Implement daily coding file transfer to partner to limit onshore backlog - Redirect excess inhouse coding capacity to audit/quality assurance Billing Challenges Manual processes leading to errors - Data entry into outdated pa ent accoun ng system causing duplicated bills - Lack of integra on between EMR, coding, and billing driving rework - Invoice defects requiring write-offs equa ng to 3% of total revenue Difficulty keeping up with changing regula ons - Lead biller inac ve in latest billing protocol updates from CMS/payers - Payers frequently upda ng submission guidelines without visibility - 7% increase in compliance viola ons last audit cycle Iden fying and resolving rejected claims - Over 2% monthly claims rejec on rate consuming rev cycle resources - Iden fying root cause of rejec on difficult with unclear payer codes - Lack of defined denial workflow adding days to resolve issues Billing Solu ons Automate billing system - Invest in EMR-integrated billing solu on to eliminate manual data entry - Configure auto-rou ng of clean claims mee ng all requirements - Reduce billing defects by 50% through automa on Stay up-to-date on regula on changes - Have lead biller join industry associa on for latest guidance - Subscribe billing team to weekly payer e-update newsleters - Minimize compliance viola ons through proac ve updates Implement denial management workflow - Purchase claims analy cs iden fying leading denial root causes - Map clear process for research, follow-up, and appeal - Resolve 60% of denials in first 30 days to maximize collec ons Payment Pos ng Challenges Applying incorrect payments to accounts - 30% of misposted payments ed to insufficient account number verifica on - Inability to match all details on electronic payment details - Rework consuming 15+ hours/week in payment reversals Pos ng delays - Average payment pos ng turnaround me increased from 2 to 5 days - Staffing gaps with payment poster role recently vacated - Playing "catch up" with large payment backlogs Lack of payment plan op ons - Calls from pa ents indica ng inability to pay large balances - No formal process for pa ent advocates to extend terms - Leading health systems offer 36 - 60 month arrangements Payment Pos ng Solu ons Automate payment pos ng - Procure RPA (Robo c Process Automa on) solu on to integrate payer files and post payments - Configure payments dashboard with auto-matching algorithms - Reduce manual payment pos ng by over 50% Offer online bill pay - Implement pa ent portal enabling credit card, bank payments - Promote portal access during preregistra on, checkout - Provide consistent 24/7 payment avenue Expand payment plan eligibility - Update financial assistance policy expanding criteria - Extend maximum payment term to 48 months - See improved pa ent collec on rates by 10%+ Accounts Receivable Challenges Long collec on cycles - Average Days in AR metric has climbed over 45 days past 3 months - Legacy system lacks workflow to segment self-pay accounts by risk High denial rates - Denial write-off dollars nearing 9% impac ng botom line - Root causes include eligibility, medical necessity, mely filing Iden fying delinquent accounts - Collectors lacking visibility to priori ze follow-up outreach - Nearly $3M in delinquent balances over 120 days Accounts Receivable Solu ons U lize advanced analy cs to predict AR - Build AR forecas ng model accessing historical data - Configure AR risk scoring iden fying pa ents requiring proac ve outreach - Reduce bad debt provision expenses by 7% Automate denial management - Purchase automated tool to research causes and ini ate appeals - Program system to auto-route denials by reason for workflow efficiency - Improve denial overturn rate by 10% over manual process Implement standardized collec on workflow - Map out account ering criteria based on age and risk - Create meline for automated leters, calls, setlement offers - Construc on robust call scripts for consistency Analy cs Challenges Lack of real- me dashboard visibility - No single version of truth across pa ent access, billing systems - Repor ng refreshed monthly preven ng opera onal changes - Leadership lack metrics ed to revenue cycle goals Inability to drill down into data - Iden fying root causes of metric fluctua ons not feasible - Manual data requests/analysis requires weeks of lead me - Improving repor ng specificity cited as top priority Iden fying areas for improvement - Absence of sta s cal tools to diagnose revenue leakage - Determining impact and ROI for new ini a ves guesswork - Benchmarks to evaluate performance vs. peers unavailable Analy cs Solu ons Implement intui ve BI pla orm - Procure modern BI system with AI/ML (Ar ficial intelligence and machine learning func onali es) - Ingest data from EMR, billing, pa ent access databases - Configure single revenue cycle data set Build custom reports and dashboards - Establish KPIs across pa ent access, AR, denials, revenue - Develop role-based visualiza ons on KPIs trends - Enable drill down into drivers behind metric fluctua ons Provide self-service analy cs - Create centralized data portal for ad hoc analysis - Provide starter templates for common ques ons - Reduce reliance on IT for report building Technology Challenges Legacy IT systems - Pa ent access and billing systems over 20 years old - Frequent outages and performance lags due to aging infrastructure - Vendor end-of-life projected in next 18-24 months Lack of integra ons between systems - major workflows reliant on manual data re-entry - Eligibility verifica on, coding, denial management disjointed - 7-10 days of rework iden fied ed to integra on gaps Cybersecurity risks - 160% increase in healthcare cyber atacks in 2021 alone - No formal applica on security tes ng performed recently - Pa ent Trust compromised without controls moderniza on Implementa on of RCM system Technology Solu ons Modernize IT infrastructure - Budget for new pa ent access and billing system - Priori ze cloud-based solu ons with embedded automa on - Set 3-year meline aligned to vendor end-of-life Implement middleware - Design interface engine to integrate core pa ent systems - Develop APIs to link workflows across eligibility checks, coding, AR - Reduce manual rework by 50% via systemic interoperability Strengthen cybersecurity protocols - Perform applica on security pen tes ng annually - Implement latest endpoint detec on and response tools - Con nually patch systems to address vulnerabili es - Conduct quarterly end-user educa on on phishing risks Pa ent Payments Challenges Increasing responsibility for pa ents - Pa ent por on of medical bills up 38% over 3 years - Specialists visits and high deduc ble plans contribu ng factors Offering mul ple payment op ons - Limited to mail-in checks, accoun ng phone payments - Lacks ability for pa ents to pay online via web/mobile app Inefficient payment workflows - Payment pos ng process not streamlined delaying account updates - Intake staff ill-equipped to set up tailored payment plans - Technical issues blocking advisors from collec ng during outreach calls Pa ent Payments Solu ons Promote financial assistance programs - Update hospital website with details on various assistance op ons - Train registra on staff on screening criteria and applica on process - Provide pamphlets across all wai ng areas/rooms Expand online payment op ons - Implement chatbot on website for balance inquiries - Enable payments via pa ent portal and mobile app - Promote text/email links during outreach for card payments Streamline back-office workflows - Launch intake module to automate payment plan crea on - Integrate interac ve voice response for inbound calls - Configure speech analy cs for QA monitoring Regulatory Challenges Complex government mandates - Growing pressure to track metrics around price transparency - 500+ pages of annual changes to guidelines across Medicare, Medicaid - Lack of clarity around CMS interoperability rule impacts Staying current with shi ing requirements - 2 dedicated FTEs previously required for compliance tracking - Trends showing increased payer-specific and state-level changes - Outdated processes unable to pivot with speed of changing rules Increased risk of audits - 6 health systems fined in state last year for hospital charge pos ng non-compliance - General counsel concerned around Stark Law viola on risks - Non-compliance penal es averaging $250K over 3-year period Regulatory Solu ons Seek external guidance on new regula ons - Subscribe leading advisory firm for personalized policy updates - Atend quarterly webcasts to clarify mandate interpreta ons - Leverage third-party exper se to supplement internal bandwidth Conduct internal audits - Hire dedicated clinical auditor to oversight key workflows - Establish annual mock audit program across divisions - Promote transparency and surface gaps proac vely Automate compliance controls - Invest in automated tracking and repor ng so ware - Build comprehensive requirements matrix linking systems - Configure dashboards and alerts ed to high-risk metrics - Reduce manual oversight hours by 65%