The original revenue cycle management systems were designed to improve the speed and accuracy of claims filing for healthcare organizations and their implementation has, for the most part, succeeded in helping to reach those goals. Yet many providers are still utilizing technology that goes back decades and doesn’t have the functionality for an increasingly complex billing landscape.
It raises the question – are first-generation RCMs ripe for a “rip and replace” treatment? Or can they continue to be used if they show no sign of obsolescence?
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Patrick Hall, executive vice president for Austin, Texas-based e-MDs, said it comes down to a simple conclusion: “When your current system doesn’t work for you anymore, it is time to upgrade.”
Every provider organization should evaluate its RCM system every year or two to determine if it can meet the expectations of the billing workflow processes, Hall said. With the changes to the Medicare and commercial health plans from fee-for-service to more advanced value-based business models, he says revenue cycle methods are evolving into a more sophisticated methodology.
“What we’ve seen is that clinical and revenue cycle workflows are merging – it is a reflection of the new dynamics in which integrated systems are preferable,” Hall said. “The elephant in the room is the drive for quality and better data. Practices and medical businesses are facing ICD-10 coding and won’t make the jump or make it well without a sufficient RCM system.”
‘Touchless’ system
Healthcare providers should be striving for a “touchless” billing process from patient intake all the way through to claims adjudication, said Jay Deady, CEO of Denver-based Recondo.
“The purpose is to automate as much of the process as possible, eliminating manual intervention,” he said. “It’s about taking what was thought of as the ‘back office’ work, bringing it up front and making the claims as clean as possible. This includes registry, eligibility and estimation information.”
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The emphasis should be on upfront cash collection, Deady said, so the provider can settle a patient’s status ahead of time. Recondo’s Reconbot technology takes the out-of-pocket estimation and drives it for 30 percent to 40 percent more accuracy, he said.
“It’s not just patient deductibles at the plan level, but out-of-pocket collection,” he said. “The process moves to the front and accurate tools secure it in the record for adjudication.”
Manual processes are indeed part of a circuitous path patient data often follows with antiquated systems, but Hall says the manual handling that can be part of the mix is more an education issue than a technological one.
“They have the capability to automate the process, but it still has to be correctly implemented,” he said. “They still have to ask for the money and it can be hard for some people to do.”
Forensic claims chasing
Weaving critical patient insurance information into the initial encounter ensures that all the necessary details are included for claims submission that is correct the first time, RCM specialists say. Otherwise, back office personnel are left to engage in an often convoluted, time-consuming series of forensic investigations.
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“The big gap is real-time adjudication of services,” Hall said. “A lot of private plans have co-insurance models…more like a Medicare deductible without the gap. It is imperative to get that information from the patient right at the start.”
Recondo’s technology mines payer sites of documents associated with the claims, grabs it, takes a “snapshot,” brings it back into the system, parses it and combines it with the claim in the work queue. This eliminates the need for staff to check payer sites for claim status, letting them bypass clean claims and focus on potential problem claims.
“The savings comes from not having to check on the status of every claim,” Deady said. “If the claims are clean, they don’t need checking – just the ones that need help. It results in quicker payment and better cash flow.”
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