As hospitals evolve to provide care to vast swathes of patients, the healthcare industry is in the midst of a struggle to remain financially healthy as well. An effective healthcare revenue cycle is crucial in ensuring that patients get their treatment and hospitals can pay their bills on a timely basis.
The modern healthcare revenue cycle evolved as a result of the shift away from fee-for-service to a value-based-care reimbursement system. While this accelerated a substantially more engaging and efficient patient care process, it also made managing and monitoring administrative and clinical functions a financially critical task. And this is where the importance of effective revenue cycle management (RCM) comes in.
To drive overall value in today’s current healthcare landscape, it is important to understand the revenue cycle itself, the challenges that stand in the way, and the solutions that can be implemented to overcome these hurdles.
Understanding the Healthcare Revenue Cycle
One of the guiding principles behind a successful healthcare revenue cycle is the reduction and prevention of errors. While there are a number of contributing factors that contribute to the prevalence of errors in the healthcare systems, an agile healthcare revenue cycle management framework will be able to face these challenges up front. To do this, hospitals must emphasize the enhancement of certain RCM components and enablers, which include:
- Documentation: Clinical documentation (CD) refers to digital or analog records that maintain the details of a medical treatment, clinical test, or a medical trial. Accurate documentation is an imperative to ensure proper reimbursements.
- Claims submission: The process of submitting details outlining the care provided to determine the amount of reimbursement.
- Remittance processing: An explanation of the payment towards one or more claims submitted by a provider.
- AR management: The handling of Accounts Receivable (AR) or the amount owed to providers or medical billing companies for the care provided to patients.
- Analytics: Healthcare analytics refers to the process of analyzing current and past healthcare data to better manage ailments, improve outreach, and predict trends in order to generate actionable insights for a provider.
By optimizing these key factors, healthcare centers can build a strong and efficient revenue cycle management framework and reap several tangible business benefits such as:
- Increased revenue and practice collections
- Increased paid claims after first submission
- Enhanced focus on quality care
- Better patient experience
- Lowered administrative burden
RCM Challenges in 2021
Maintaining a healthy revenue cycle, in an increasingly over-burdened healthcare sector (especially in the light of the COVID-19 pandemic), is a daunting prospect for several providers. In addition to communication issues, inadequate data flow, human error, technical failure, and other exacerbating issues; errors in the coding/billing and documentation process are the hurdles that can often cause the most damage to the revenue management cycle.
The introduction of the ICD-10 guidelines has presented a fresh layer of complexity to an already onerous coding process. For hospitals, failure to comply with the guidelines could result in incorrect coding and billing, revenue leakage, as well as harsh penalties in the event of any mishaps. Additionally, not maintaining specialty specific AR benchmarks pose additional challenges.
Secondly, documentation errors can put further strain on the management process as a whole. A recent review by a medical liability insurance provider reveals that documentation errors make up 72% of all EHR risks. This starkly outlines the impact that documentation errors have on care quality and provider reimbursements, as they can affect all other processes on the outpatient chain as a result.
Technology as the Solution – The EZDI Initiative
In an increasingly digital world, leveraging cutting edge technological offerings to simplify processes and streamline revenue is an absolute necessity. And this is where EZDI’s cutting-edge solutions can offer marked benefits across multiple aspects of the revenue management cycle.
EZDI’s Computer-Assisted Coding (CAC) tool uses AI and NLP to maintain coding guidelines and suggest accurate codes. This in turn reduces coder workloads significantly and mitigates human errors in coding. At the same time, EZDI’s Clinical Documentation Improvement (CDI) solutions automate query suggestions to maintain coding accuracy and improve document quality.
Additionally, EZDI’s Analytics engine provides visibility over the entire coding function along with granular insights to aid in continuous improvement of processes and people. With real-time tracking of clinical, CDI, and audit performances, the engine helps providers identify issues and implement fixes in a proactive manner.
EZDI’s solutions strive to surpass the benchmarks of outpatient coding quality and accuracy with rapid and consistent CAC and CDI solutions and learning models; with the fundamental objective being the enablement of healthcare centers to provide the best possible value and receive the best returns on investment in the current value-based health-care landscape.