Specialty practices play an essential role in the healthcare ecosystem, offering expert diagnostics and innovative treatments for the most challenging patients. Specialists who focus on the very cutting edge of medicine work in an extremely complex clinical and financial environment that is fundamentally different from primary care or the inpatient setting.
Specialists such as oncologists, rheumatologists, and gastroenterologists often utilize high-intensity treatment plans, frequent lab work, consultations with other clinicians, and a variety of pharmaceuticals to treat their patients.
All of these services must be documented in detail, shared with the revenue cycle management (RCM) team, coded appropriately, and billed in a timely manner before the practice can be reimbursed for its efforts. In specialty care, where high cost therapies and treatments are common, any bottlenecks in the reimbursement process can have significant consequences for the sustainability of the healthcare enterprise.
While electronic medical records (EMRs) and other health IT systems have made it easier to generate digital data and documentation, the healthcare system is still struggling with how to capture, share, and leverage that information for improved clinical and financial outcomes.
Activity capture, also known as charge capture, is a key part of the revenue cycle in specialty healthcare. Optimizing and automating the activity capture process will create complete and timely records of the clinical interventions taken to support better patient care while ensuring compliant reimbursement and minimizing charge loss.
Examining the challenges of activity capture in specialty settings
In order to create a comprehensive, curated view of all the activities related to a specific patient, practices need to identify every relevant clinical service item, extract that information from its point of origin, and synthesize the data into a single view for subsequent use.
As discussed in the previous blog post, rich interoperability between disparate systems is crucial for ensuring visibility into the entire spectrum of patient activities.
However, many existing health IT solutions are limited in their capacity to do this effectively enough to meet the specific requirements of specialty practices. As a result, billers and coders are often forced to manually merge and examine hundreds of items line by line, which can be extremely time consuming and prone to natural human errors.
Identifying opportunities to improve RCM with automated activity capture and claims edits
Incomplete or inaccurate activity capture puts the revenue cycle in jeopardy. Without a full and accurate portrait of resource consumption – and detailed clinical documentation to justify the use of each service or therapeutic – practices typically experience claims denials and delays.
Even a simple error like a mismatch between the dosage of a medication prescribed in the EMR and the record of what was removed from a drug inventory management system can turn into a major problem for reimbursement. If the practice is not able to pull data from both the EMR and the drug cabinet to compare and reconcile the two pieces of information, the practice could incur thousands of dollars in lost income.
The ability to automate the identification and correction of such errors takes true specialty-focused RCM platforms to the next level. While health IT tools will never replace the enormous wealth of knowledge and critical thinking that an experienced coder brings to the process, sophisticated digital tools can make human billers and coders significantly more efficient.
For example, radiation oncology clinics often reassess a patient’s treatment parameters and verify radiation dose accuracy after every fifth visit. These continuing sessions are reimbursable when billed under their own CPT code. Without revenue cycle system assistance, a coder would have to manually keep track of whether or not every patient has reached his or her fifth treatment visit and add proper billing codes manually where justified. In contrast, a specialty-friendly claims edit solution can alert to the opportunity for appropriate and complete coding and in some cases even propose to complete the step independently.
Without comprehensive activity capture and intelligent claim edit capabilities, a practice may miss out on legitimate revenue opportunities or leave themselves open to costly errors. Practices that continue to rely on fully manual coding and billing also risk a slower revenue cycle with claims stuck in lengthy processing queues, which can lead to financial instability.
Looking forward to the future of RCM for specialty practices
Advanced activity capture creates more efficient workflows for RCM staff members as they prepare claims for reimbursement. With digital solutions for activity capture and claim editing, specialty practices can reduce pain points, speed up the reimbursement process, and allow RCM staff to focus on complex decision-making instead of spending time on simple, tedious tasks.
Practices that invest in tools that can extract critical information from every relevant health IT system, synthesize that data into a global view of clinical treatment activity, and actively suggest claim edits to enhance reimbursement, will position themselves for success in a challenging financial environment.
With a detailed, accurate, and comprehensive view into the clinical and financial activities involved in patient care, practices can maintain their business operations and begin to identify additional opportunities to improve their processes or expand their service lines.
This complete visibility into resource utilization can help specialists take the next big step into enhancing their revenue cycle performance: adopting a proactive approach to managing payer contracting and drug pricing.
In our next blog post, we will discuss the need for specialty-specific RCM solutions that offer contract management capabilities and robust reporting to give specialists the edge when negotiating with healthcare payers.