Revenue Cycle Management for healthcare organizations has never been more important. Put simply, this process involves optimizing revenue integrity by reviewing every administrative and clinical function contributing to the collection of revenue and applying best practices to ensure maximum reimbursement for healthcare services in a timely manner.

The healthcare revenue cycle is complicated and intricate, with many factors that impact who pays, how much they pay, and how they pay. Patients may have no health insurance and are billed directly. Others have Medicaid or Medicare. Many are covered through a private insurance plan, often offered through their employer, which could involve any of the numerous US insurance companies - and in some cases multiple companies in collaboration. Mix that with the wide range of visit types and procedures, as well as coverage terms like deductibles, copays, and coinsurance, and you’ve got an environment ripe for errors and missed opportunities.

Clearly, in today’s complex and fluid healthcare industry revenue cycle management is about much more than just billing and collecting payments. Fortunately, with the help of digital solutions and third-party administrators who specialize in healthcare billing, healthcare providers are able to manage the complexity of these billing cycles, maintain reliable cash flow and deliver high-quality care to their patients. 

The Goal of Revenue Integrity

According to the National Association of Healthcare Revenue Integrity (NAHRI), the goal of Revenue Integrity is “to prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.” In other words, identify missed income for healthcare providers, determine the cause, and find ways to mitigate the issue in order to prevent it from happening with future payments.

Today, technology plays a crucial role in assisting providers, payers, and consumers in communicating efficiently, which breaks silos and improves durable revenue cycle management strategies. There are several critical areas that healthcare managers could focus on to ensure their medical facility optimizes its revenue cycle.
 

Reducing Claims Denials

As per the Healthcare Financial Management Association, claim denials cost an average of $5 million per year to each healthcare provider. Just reducing this amount could save a lot! 

More than 20% of healthcare claims are routinely denied, with some providers experiencing up to a 40% denial rate. However, 90% of these denied claims could have been prevented. 

Organizations can recover this loss by utilizing analytics that can provide a deeper view and help dig into patterns to understand the reasons behind denials. Such insights can help health systems implement prevention plans and procedures for recovering the denials.

A significant portion of revenue leakage comes from inaccuracies and errors that lead to denied claims. Unfortunately, the process of correcting and resubmitting these claims can also be costly and time-consuming. That’s why it’s critical for healthcare providers to take steps to prevent their claims from being denied. One proven strategy to reduce denied claims is partnering with a claims processing company like Exela. Our Global PCH solution substantially reduces the number of denials by correcting errors before the claims are even submitted, allowing healthcare companies to confidently submit “clean claims,” which are more likely to be accepted by insurance companies on the first pass.

By leveraging automation technology, streamlining communication between providers and payers, and reducing the number of resubmissions, PCH is able to significantly accelerate the revenue cycle time.

To learn more about Exela’s PCH solution, and for an in-depth look at Revenue Integrity, download this recent edition of Exela’s quarterly publication PluggedIN. 

Fix Medical Coding Errors 

Clinical documentation has a tangible impact on the revenue cycle. Unfortunately, there are cases where bills are unpaid due to documentation errors or medical coding. Managing these discharged-not-final-billed (DNFB) cases is essential for hospitals to improve revenue cycle performance.

Medical coding is a complex process requiring proper coding and proper documentation. Medical coders require compliance with government regulations and private payer policies as well as education in medical terminology, diseases, anatomy, and physiology. Documentation comes from the physician who needs to accurately detail the treatment and care provided so medical coders know which codes and modifiers to use. Any error could cost the provider. 

Due to its complex nature, healthcare providers may choose to outsource their medical coding needs. LexiCode, our medical coding services, aids providers of all sizes, scaling to each organization’s needs with quality assurance and productivity monitoring. Partnering with LexiCode, providers experience timely medical coding resulting in steady cash flow.

Hone in on Revenue Integrity

A revenue integrity (RI) plan is an essential component of optimizing the revenue cycle. This includes accessing current workflows for inefficiencies, implementing improvements, and upgrading technology where it can help. Unfortunately, not all providers have the time and resources to create a proper RI plan.  

Exela enables healthcare providers to attain revenue integrity through integrated solutions and proprietary technology that address the entire revenue and reimbursement lifecycle. Our Revenue Integrity solution helps identify and recover underpayments, maximize reimbursement from third-party payers, and provides a streamlined RI process. 

Leveraging decades of experience with Exela and our cutting-edge technologies, we maximize reimbursements and dollars recovered, and reduce or eliminate related overhead, all while enhancing employee, provider, payer and patient satisfaction. To know more in detail, take a look at our PluggedIN focusing on Revenue Integrity. 

Digital transformation in healthcare continues to be a key topic in many healthcare leaders' minds. Healthcare providers of every size face the same challenge of improving patient care and engagement while managing costs. However, many obstacles create complications including limited staffing, outdated systems, payer contract complexities, and more. By embracing digital transformation, healthcare providers can begin to tackle these obstacles and accomplish their goals for the future.

Digital transformation in healthcare affects many aspects of the business from freeing up resources that can be devoted toward patient care and increasing patient engagement to improving operational and financial efficiencies. With AI, automation, and technological advancements, the healthcare industry stands to gain improved processes, quicker payments, and fewer claims denials.

Digital Transformation in Healthcare Starting with Automated Claims Processing

Claims management and processing is a major operation in need of digital transformation in healthcare. This is often a thorn in healthcare providers' sides because of its complexity. Claim denial rates are between 6% and 13%, which eats away revenue. 

These statistics highlight the importance of submitting clean claims right from the start. However, this is easier said than done especially when relying on manual processing and outdated systems. Many healthcare claims are being denied for simple reasons such as a spelling error, incorrect coding, missing patient identify information. Given that healthcare organizations' resources are stretched thin, it makes sense that claims processing would be vulnerable to human error.

Once again, digital transformation in healthcare can step in and smooth the process. Exela is a leading claims processing provider with a solution that enhances claim processing by unifying data from all incoming communication channels, performing pre-submission checks to create clean claims, and intelligently routing correspondence for optimal processing using automated decisioning. Exela’s Healthcare Claims Processing solution reduces denials and resubmissions by applying business rules to produce clean claims prior to submission. Using automation and artificial intelligence, Exela increases transaction processing rates and accuracy while reducing manual processing and rework.

Take Complex Claim Processing Further

According to a 2021 CAQH report, only 21% of medical administrative transactions are digital while the rest are paper. Exela leverages exclusive vendor contracts with leading health plans for complex paper claims processing.

Embrace digital transformation further with Exela's PCH Global solution, a powerful digital platform that not only provides a single point of access for claims management but provides a central bridge between all parties including the provider, payer, and patient. 

PCH Global promotes clean claim submissions by identifying certain-to-denied claims, thereby improving first-pass rates. Its iterative feedback loop technology helps the system continuously learn and improve to identify errors enabling proactive claims management with system flexibility as your contracts change. 

Finally, the system automatically tracks and records any addition, deletion, or modification to transactions along with user reference and timestamps providing clear audit trails and ensuring full compliance.

Digital Transformation of Remittance Payments

The 2021 CAQH report determines that the healthcare industry could save 48% of annual spending by transitioning to fully electronic transactions. Manual processing significantly slows down operations especially when human errors are taken into consideration. Automation streamlines this process reducing errors, posting payments quicker, and improving overall efficiency making it a terrific place for digital transformation in healthcare.

Exela's Medical Lockbox simplifies the healthcare payment process by digitizing and automating manual, paper processing tasks. Using a state-of-the-art scanning platform and intelligent OCR/data capture technology, Exela’s Medical Lockbox solution converts paper EOBs from any source into 835, electronic remittance files, payment reconciliation and posting to the healthcare organization's medical billing system. By streamlining the payment path, Exela’s Medical Lockbox solution reduces the time it takes for payments to post and allows quicker access to deposited funds. Submitting secondary claims or patient billing, depending on the patient’s coverage, makes the payment cycle faster from Primary, Secondary, Tertiary or Patient payments.

Not only does Exela's Medical Lockbox streamlines payment processing, but it also features a web-based denial management tool designed to increase the recovery rate on denied claims. This web-based management tool presents the original claim and all related remittance information in a single view simplifying the process for users to adjust the claim, bill the patient, or appeal the denial. Insights are gleaned through reimbursement metrics presented within Exela’s Medical Lockbox’s configurable reporting function. These insights are valuable with billing system audits and contracts negotiations.

Automated Contract Management

Healthcare payer contracts vary greatly, each having different policies, regulations, and parameters. The contracts of each insurance company are often revised and updated annually so healthcare organizations need to renegotiate several payer agreements every year.

Keeping track of the current contracts and any annual updates is an enormous task that burdens healthcare resources. Without a handle on contract management, healthcare organizations are vulnerable to underpayments which affect their bottom line. Contracts and underpayment management are yet another place where digital transformation in healthcare is needed.

Exela’s Revenue Integrity solution automates the contract management process, document scanning, indexing, profiling, loading and maintaining all third-party payer agreements. Agreement terms are tracked and providers are presented with notifications of important dates as well as amendments and updates. Instead of using limited resources to keep track of contracts, automation is ready to step in.

Exela’s Revenue Integrity solution also offers predictive contract modeling that provides accurate reimbursement calculations for current and future contractual agreements. By providing multiple scenarios and utilizing the most recent one-year patient data set, the platform presents the net dollar and percentage increase or decrease.

This solution also identifies retrospective, current and prospective underpayments from all contractually obligated third-party payers.

Summary

Digital transformation in healthcare opens many doors and it’s time providers embrace the opportunities available to them. AI and other technologies are ready to streamline antiquated processes, increasing efficiency and accuracy while freeing up personal time. 

The pandemic has brought about massive, global changes for every industry, including the healthcare sector which has been severely impacted. While the pandemic has pushed digital transformation in healthcare ahead by several years, the challenge to keep technology tied with processes is still an ongoing effort. 

In the case of healthcare, there is an added struggle - to achieve financial margins. When the number of patients only increased, there were significant challenges behind the scenes: remaining efficient and optimizing the reimbursement/payment process while being compliant. And this is how the term Revenue Integrity (RI) became the talk of the town! 

The Importance of Revenue Integrity

As per the National Association of Healthcare Revenue Integrity, the goal of Revenue Integrity is to “prevent recurrence of issues that can cause revenue leakage and/or compliance risks through effective, efficient, replicable processes and internal controls across the continuum of patient care, supported by the appropriate documentation and the application of sound financial practices that are able to withstand audits at any point in time.’’ 

In simple terms, revenue integrity is critical to ensure no leaks by optimizing the revenue cycle, being compliant, and making the processes efficient. While the three - billing, operations, and compliance - have always been independent departments, getting these disparate entities to work together is the focus of revenue integrity. It creates a seamless experience in the clinic for patients, healthcare coding in the backend, and tying it with the revenue cycle.  

However, prioritizing revenue integrity is easier said than done, with diagnosis coding growing more complicated as time goes on. One of the most recent changes occurred in 2015, when the Centers for Medicare and Medicaid Services mandated the US healthcare industry to transition from the International Classification of Diseases Clinical Modification, 9th revision (ICD-9) to ICD-10. On top of that, coding, billing, and revenue cycle departments remain separated from each other, adding another layer of complexity to ensuring compliance.

With juggling compliance risks of inaccurate billing and managing accurate payments to prevent underbilling, providers are turning toward revenue integrity to help streamline the process. Providers are creating RI departments or looking to hire RI specialists to prevent compliance risk and revenue loss. 

Establishing an RI program or plan creates a bridge between the siloed sections of a hospital including operations, compliance, and billing departments. Not only can this improve the workflow, but it also helps to prevent any revenue leakage that may occur from inaccurate billing. By focusing on revenue integrity providers reduce the risk of external audits and help reduce payment denials. With an efficient RI plan in place, providers can achieve their financial margins while working within compliance.

Optimizing Revenue Integrity by Preventing Leaks

Some reasons for leaks:

1. Coding errors are the number one reason Medicare and Medicaid deny complex claims that can impact reimbursement. 
2. Manual transactions - the possibility of errors is always high. Data suggest providers end up paying $4.77 more per claim.
3. Patient accounting system - outdated systems can slow down the processes, and providers will lose crucial time. 
4. Rejected claims - rejections because of one or more errors take up critical time and multiple entries on the system. 

By being compliant in coding and billing practices, providers can automatically reduce the risk of possible payment denials - which saves both time and money. For healthcare where billing numbers are high, such errors and leaks can cost a lot. Also, it affects the experience for a patient and can become a problem in the longer run. 

Revenue Integrity Best Practices

Creating a plan is the first step to focusing on revenue integrity. This includes setting up guidelines and procedures that anyone involved in revenue will need to follow. Revenue integrity involves balancing the goal to increase revenue with the responsibility to comply with the rules. Here are a few steps to start an RI plan:

Access Current Workflows

Review each workflow and input involved in revenue integrity from operations to billing. Ensure that each workflow is efficient and compliant, paying particular attention to the claims workflow.

Implement Improvements

After doing a thorough sweep of workflows, consider what could be improved and how best to allocate resources. Make sure that all key processes are functioning efficiently and optimally including utilization review, coding, charge capture, and claim editing. If they're not, find the reason why and take steps to ensure processes function optimally. 

Managing Denied Claims

It’s no secret that denied claims contribute to revenue leakage. Ensure that the denials management process is efficient and accurate to confirm that denied claims are being handled properly.

Upgrade Technology

Technology and business automation are constantly improving and it's easy to continue functioning without realizing an antiquated system is slowing processes down. By looking at the technology the hospital uses with a critical eye, providers may find some inefficiencies. 

Business Solutions

Not all providers have time or resources to put together an RI program. Involving revenue integrity services might be the better option. Services such as Exela’s Revenue Integrity solution help providers maximize reimbursement from third-party payers, identify and recover underpayments, redistribute overhead related to in-house staff, and provide a more streamlined process. 

For more information on reducing revenue leakage and the importance of Revenue Integrity, read the latest PluggedIn edition.