Unlocking RCM Wins: Turning Setbacks into Success  

While healthcare providers in the country are hesitantly making a transition toward value-based care, hoping for an arrangement that could benefit them and their patients, their everyday struggles with revenue cycle management (RCM) are far from over. Their routine tasks turn into an uphill battle when they work claims endlessly without knowing the denial root causes or putting guardrails in place to prevent revenue leaks, repercussions of which are eventually seen on their bottom line. 

Stuck in this everyday grind amid challenges like shifting payer behavior, changing regulations, and growing staffing shortages, providers are now making a conscious effort to re-innovate their RCM strategy to keep the ball rolling. While some manage to sail smoothly through denial setbacks, for some, the journey is quite a challenge without actionable insights into their revenue cycle. The good news, however, is that with the right strategy, revenue cycle roadblocks can be turned into financial wins. 

Explore this blog to know the fix to five of the most common RCM challenges and how by addressing these bumps timely, you can pave the way for improved financial and patient outcomes. 

1. The “Recurring Denial” Loop

Imagine how frustrating it can be for your RCM team if they have to rework a claim multiple times, particularly if adequate insights into the root cause behind denials are lacking. Not to mention, it can eventually take a toll on the organization (denials costing hospitals nearly $20B yearly), having to put all time and effort into addressing such denials. But there’s a way out. 

Denial Prevention: Don’t Let Denials Drain Your Resources and Revenue 

Make denial prevention your best defense. Instead of appealing denials, focus on preventing denials in the first place. A smart use of technologies like artificial intelligence (AI) and analytics along with RCM expertise can help you achieve that. AI tools like machine learning (ML) can help identify and flag denial patterns before they hit your bottom line, while business intelligence (BI)-powered intelligent dashboards can help you track your critical KPIs and ensure your strategic interventions for denial prevention are successful in improving your outcomes.  

In addition, you can automate routine, error-prone processes like eligibility verification, charge capture, and claim status checks to minimize errors that frequently result in denials. These technologies help improve claims audits to ensure documentation accuracy, completeness, and compliance, further helping minimize denials, slash operational costs, and save a whole lot of time for your staff to focus on high-value tasks. 

2. The Manual Grind

How often have you found mundane tasks like insurance eligibility verification stealing away your valuable time that could be devoted to your patients? These tiresome, error-prone RCM processes not just overwhelm and drain your staff members but also cost your practice its revenue because of inefficient workflows causing delays and denials. 

Automation and AI: Let Technology Do the Heavy Lifting for You

Technologies like automation and AI can come into play as work agents for healthcare providers, taking administrative burden off their plate and helping save $25 billion annually by speeding up routine tasks and boosting efficiency. Envision a scenario where your staff members don’t have to manually verify patient eligibility, submit claims, and check claim status. With robotic process automation (RPA) bots and AI tools working in tandem, performing those tasks more efficiently and in a fraction of seconds, you can save your staff their time to focus on patient care and other high-value tasks requiring human intelligence. The outcome? Efficient workflows, more revenue generation, and happier patients, creating a win-win for you and your patients.  

3. RCM Insight Limitations

Navigating RCM without critical insights into process efficiency and efficacy is like finding the way through a dark maze. Without clear visibility into critical metrics like the cost to collect, the denial rate, days in AR, and the clean claim rate, you might end up doing a lot of guesswork, which would eventually cost you more than just your revenue. 

Intelligent Dashboards: See the Big Picture to Make a Big Impact 

Real-time KPI analytics on robust intelligent dashboards is what you need to steer your RCM strategy in the right direction to achieve your financial goals and high patient score. Think of these dashboards as a navigational tool, guiding you through your process efficiency—pinpointing the areas you need to direct your attention to in order to drive desirable outcomes. With easy-to-understand visualizations, you can benchmark your revenue cycle performance against industry standards, evaluate your financial health, and gain actionable insights into your workflows to optimize and improve your processes.  

These Power BI intelligent dashboards act as decision-enablers, empowering you to make informed moves to address revenue leaks, denials, and any other bottlenecks impacting the cash flow in your revenue cycle. With a clear understanding of what’s working and what’s not working for your RCM and where you should direct your efforts, you can turn the tide in your favor, driving dollars through data (analytics).  

4. Sluggish Collections

Probably the most challenging aspect of RCM every provider would agree on—timely payment collection (for the services rendered) is not a piece of cake, especially when payments must be collected from both patients (out-of-pocket) and payers (insurers). Moreover, the cost to collect a claim substantially increases for a provider with the number of touches a claim goes through if faced by rejections/denials, overwhelming all those involved in the process. Unaddressed AR further adds to the cost burden, increasing the probability of an account becoming bad debt (lost revenue) if untouched for a long time. 

Propensity-to-Pay AI Model: Prioritize Claims for Better Cash Flow  

AI tools like propensity to pay and intelligent dashboards can help you tackle this challenge by helping you to prioritize high-value, high-impact accounts or claims based on their likelihood of getting paid. The tool unburdens your accounts receivable (AR) team by streamlining collections through worklist prioritization, ensuring they do not drain their efforts chasing bad debt accounts or collections that have the least likelihood of getting paid. 

With insights into collections through intelligent dashboards, you can concentrate your resources on driving revenue through potential claims rather than wasting efforts on low-priority claims. This will help boost your collection efficiency, further strengthening your bottom line and keeping your AR days under control. 

5. The Compliance Conundrum

In the healthcare landscape, which is always evolving, ensuring compliance with payer guidelines and government regulations is a tricky affair for providers. Amid tight timelines for claim submissions and limited resources, their inability to keep up with payer rules often gets in the way of them getting properly reimbursed and, in some cases, even leads to them being heavily penalized for non-compliance. 

Bank on Experts: Keep Up with Changing Rules with Confidence 

RCM experts come in as guardians of revenue for healthcare providers in such scenarios, helping them navigate evolving guidelines with ease and ensuring their processes remain up to date. With RCM partners keeping tabs on shifting payer bahavior and regulatory changes and ensuring all functions of RCM, right from documentation for efficient prior authorization to claims filing and submission for timely AR collections, align with those guidelines, they scarcely leave any room for non-compliance, thus protecting providers from costly penalties and legal risks.