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Revenue cycle management (RCM) is a mission-critical concern for all healthcare organizations. The quality of revenue cycle outcomes impacts every element of patient care. A practice’s ability to sustain high-quality care delivery depends on accurate clinical documentation and clear communication between payers, providers, and patients combined to drive timely reimbursement.
Over the past decade, many health systems and physician practices have started to automate their RCM processes, leading to greater efficiencies and better patient experiences. But a number of significant challenges remain, particularly for specialty healthcare providers.
In the specialty environment, revenue cycle management is particularly complex. Medical disciplines such as rheumatology, oncology, ophthalmology, and gastroenterology, for example, must address a range of administrative and financial challenges which have exaggerated impact on financial performance relative to their peers. Whether it’s completing prior authorizations, contracting under Advanced Payment Models (APMs), or synthesizing the enormous volume of clinical and financial data generated by sophisticated medical devices and platforms, specialists require a data-driven RCM strategy that links clinical decision-making and the business office in a seamless, intuitive way.
In this new six-part blog series, we will explore the top challenges to effective revenue cycle management in the specialty healthcare context and discuss some of the most impactful strategies and tools available to support an effective and patient-friendly process.
Data interoperability is the foundation for success in the modern healthcare environment. During a specialty healthcare encounter, a single patient can touch more than a half dozen health IT systems including dedicated imaging and radiation therapy applications, digital medication dispensing platforms, clinical laboratory and pharmacy solutions, and electronic medical records.
All of these platforms capture an incredible volume of clinical activity. Systems interoperability is key to assembling a comprehensive, up-to-date portrait of the patient’s clinical status – and an accurate record of the reimbursable services provided.
Specialty providers need to develop a data infrastructure that readily supports the coordination of clinical activity capture, presents a holistic view of the patient’s status to clinicians, and ensures that related financial information is integrated appropriately into business office workflow. This seamless approach to interoperability can support some of the critical functions unique to specialty care, such as considering prior authorization requirements when designing a treatment plan or predicating future patient appointments on the achievement of regimen-driven clinical milestones.
Interoperability across clinical and financial environments creates the ideal conditions for accurate charge capture, coding, and billing. Because many different systems generate information necessary to treat highly complex medical cases, practices require automation to ensure that medical claims include sufficient detail about a patient’s diagnoses and treatments to qualify for appropriate reimbursement.
With the right tools, administrative staff can access an integrated history of activity from multiple data streams, identify potential discrepancies between charge capture and code-specific documentation, and take advantage of automated compliance and revenue cycle integrity rules in order to verify the full treatment picture for every patient.
Activity (charge) capture is particularly important for the growing number of specialists participating in value-based care models or bundled payment programs. When managing care in the context of capitated payments and/or ambitious clinical and financial benchmarks, practices need to be confident that they are fully accounting for all clinical practice-driven expenditures. Cost accounting methodologies depend on a full and accurate picture of resource consumption.
Appropriately detailed diagnosis codes are also essential for risk adjustment calculations that may impact incentive payments or reimbursement rates. An RCM platform tailored to the needs of specialty care can help providers succeed in the growing number of value-based care programs aimed at improving quality and reducing costs in complex medical delivery settings.
Specialty healthcare often involves cutting-edge pharmaceuticals and other therapies drawn from the higher end of the cost spectrum. Both payers and providers want to be sure these treatments are accessible to patients without contributing to the challenges known to plague the healthcare system.
Because of the rapid pace of innovation and the need to monitor spending, payers change their drug reimbursement rates frequently. For example, the Centers for Medicare and Medicaid Services (CMS) updates its Medicare drug reimbursement rates on a quarterly basis. Many of the nation’s largest private payers follow the same schedule, leaving specialty providers scrambling to keep up with the constant adjustments.
Even a small tweak in reimbursement for a high-cost drug can dramatically alter a practice’s financial projections, so providers need to maintain full visibility into their payer contracts, payment rates, and patient populations at all times.
Employing an RCM solution with highly capable contract management features and differentiated by flexible reporting is an important and necessary step in managing payer contracts and drug pricing updates. Particularly given the expectations of high service volume common in specialty healthcare today, it is critical to leverage RCM systems that can reduce burdens on administrative staff, support flexible adjustments to financial projections, aid in compliance reporting, and help practices maintain sustainability in a quickly changing financial environment.
For many specialists, prior authorization is a source of deep frustration. The process can seem opaque and onerous, but it does play an important role in controlling costs and ensuring providers utilize evidence-based medical protocols.
Practices are responsible for making sure that every patient’s treatment plan adheres to the unique requirements of his or her insurance coverage. Because prior authorization is not one-size-fits-all for payers, specialty practices benefit by adopting technology platforms that can handle significant aspects of the prior authorization process via customized, automated workflows designed to meet each payer’s requirements.
Providers who focus on fostering an interoperable, data-driven environment are able to leverage their technology tools to react effectively to provider declarations of treatment intent, acquire and archive supporting clinical documentation, and capably meet other payer-specific requirements to expedite approval of important patient care.
All of these challenges relate to the goal of increasing operational efficiency across the entire practice. Employing robust, integrated, and intuitive technology tools is crucial for practices that wish to improve their back-office operations – and their front-end patient experiences, too.
With an RCM solution that provides more visibility around the entire cycle of patient care, practices can engage patients more efficiently with less time and manual effort. This includes automating intake processes with strategies like notification delivery via text message or the deployment of mobile, self-service sign-in features.
Individuals facing serious health issues also need simple and convenient ways of handling their out-of-pocket financial responsibilities. Digital self-pay features can improve collections while reducing stress and anxiety for patients, resulting in higher patient satisfaction scores and more positive patient-provider relationships.
As specialists continue to adopt the latest in clinical technologies, patient engagement tools, and reimbursement strategies, those solutions will depend on the quality and capabilities of the underlying RCM platform. An RCM application that is tailored to the complex needs of specialty healthcare provides the foundation for smoother payer transactions resulting in sustained financial success for the practice and ultimately better clinical outcomes.
Throughout this blog series, we will examine each of the top five revenue cycle challenges faced by specialty healthcare in more detail to provide actionable insights for specialists looking to improve their revenue cycle management outcomes. Stay tuned for our next article – a deeper dive into the strategies and technologies required to start building an interoperable RCM environment in specialty healthcare.