Like any good narrative, the story of revenue cycle management starts at the beginning. For a hospital or health system, that means the patient intake process.
As revenue cycle management systems have advanced to share patient information across the pathways of care, the necessity of getting correct information from the point of initial patient contact has become paramount. Otherwise, errors that occur on the front end travel through to the back end and result in inaccurate claims.
Keeping the information flow untainted is a formidable task, agreed Kimberly Hollingsworth, partner, revenue management with Chadds Ford, Pa.-based IMA Consulting.
“There are a lot of challenges in this – specifically on the front end with admissions and registration – at the time the patient comes in for service,” she said. “The desk has to understand all the insurances, what the requirements are, how much the insurance will pay and how much the patient must pay. They need to know what is covered and not covered. That is a very complex environment.”
Right or wrong, the information that appears at the back end is what matters most in the billing process, said Richard Williams, managing director for Chicago-based Protiviti’s healthcare practice.
“Denials are the best indicators to show the health of the revenue cycle,” he said. “Though RCM is generally viewed as a back-end responsibility, 60 percent of the claim form is captured by patient access. Information that is captured wrong at the registration process will inevitably result in a denial.”
As the demands on admission representatives increase, so should hiring requirements, training and compensation, Hollingsworth said.
“Training is critically important – hospitals should have a component of training that addresses everything that is required of this position,” she said. “They should have a baseline to figure out what is needed before the training and conduct a test to see the effectiveness of the training. Give them the tools and knowledge to do their job well and then monitor the job they’re doing to see their effectiveness.”
In analyzing what Williams calls “patterns of wrongness” in the revenue cycle, he pinpoints an absence of accountability as the catalyst.
“Many times there is no accountability factor because going back to denials, the kind of reporting for root cause issues is not provided,” he said. “It is not being taken to a level of detail needed. But these issues are the easiest to fix.”
‘Path of Certainty’
Skip Lemon, managing director for Chicago-based Huron Healthcare says the mistake many provider organizations make is that they take a reactive approach to problems.
“If you’re just reacting to fix claims without getting to the source of the problem, you will be in a constant state of addressing problems,” he said. “If you have a proactive front end that deals with pre-registration and insurance verification that is secure as possible before the bill gets cut, it reduces the denial volume, claims reworking and overall it improves the system. You have a fixed window of time to get it right.”
Lemon recommends revenue cycle staff develop what he calls a “Path of Certainty” to ensure information integrity through every episode of care. The concept entails effective communication, cooperation from all departments and standardization of procedures, he said.
“It means having absolute clarity around everyone’s role in the hospital so that they work well together,” Lemon said. “There is a lot of unnecessary variation so you need to standardize that process and make it consistent. There are all kinds of metrics to review, so you need to be clear about what you’re shooting for.”
Broken links
Radiology, anesthesiology and pathology are all links in the health system information chain, but because they often operate as separate entities, they tend to be disconnected from the rest of the organization. Being removed from the revenue cycle equation – at least figuratively – can be problematic for these entities when it comes to billing, said Taylor Moorhead, partner with Carmel, Ind.-based Zotec Partners.
“These specialties are smack dab in the middle of the revenue cycle, yet they hardly ever interact with the patient while the others control the patient,” he said. “They are clearly riding the coattails of facilities where services are rendered and have to trust that those responsible for payment are getting the right information.”
Zotec serves as an advocate for these disenfranchised groups, analyzing the data that comes in and providing feedback to them. The company deals with both ends of the revenue cycle – primary providers and payers for denial management.
“We audit 100 percent of all services rendered to make sure they are getting paid for everything they do,” Moorhead said.
RCM cloud
The cloud concept has been adapted for just about every healthcare function and RCM is no exception. Birmingham, Ala.-based SourceMedical offers revenue cycle cloud services that are tailor-made for provider organizations “where IT expertise and staff are not abundant,” said SourceMedical vice president Kevin McDonald.
Outpatient surgery centers are the main customers for the cloud service, though some physician practices are also part of clientele. Operating in the cloud often helps these groups get up and running quicker without much training.
“On the RCM side, we have the ability to quickly bring them up on a standard set of data that they can customize afterwards,” McDonald said. “And they don’t have to worry about hardware upgrades.”
Security concerns have been an issue, but once customers find out about the level of safety the company provides, he said, their fears subside.
“The data is just as secure as if it was housed in their facilities,” McDonald said.
