Implementation best practices: Getting in the revenue cycle
Revenue cycle management technology is at the heart of the administrative side of business at every hospital and health system. It is key to daily operations.
As such, healthcare CIOs and other IT professionals must take great care when implementing RCM systems. Getting revenue cycle done right – and done right the first time – is imperative.
Here, five experts in the field of revenue cycle management IT offer Healthcare IT News readers their expertise when it comes to identifying and deploying best practices for implementing this all-important technology.
Making sure the tech is the right fit
Revenue cycle management isn’t just about increasing revenue. It’s also about how a healthcare organization identifies deficiencies in its process and then finds the right technology to improve efficiency and optimize workflow, said Jennifer Carlson, director of product management at ZOLLAR Boost, a revenue cycle management technology vendor.
“There are numerous technology vendors out there who will tell you that they can help solve revenue integrity issues – but how they are doing this, and at what cost to you, are the critical pieces to evaluate,” Carlson said.
“Move any new revenue cycle technology to the front of your workflow.”
Jennifer Carlson, ZOLLAR Boost
Carlson identifies five questions healthcare organizations should ask a revenue cycle management technology vendor:
- How many disparate systems does one need to contract for, implement and thoroughly train the billing team on to fully optimize the revenue cycle process? Look under the hood and fully understand all the various components of any revenue cycle solution.
- How easy will it be to get up and running?
- What is the true revenue impact expected and over what timeframe?
- Ask the potential technology vendor, and even the current vendor, how they compare in a head-to-head test of claims files for the various services one is looking to use. For example, demographic verification, insurance discovery, insurance eligibility, etc.
- Does the vendor have tools to help billers figure out which claims will result in the most revenue by analyzing the patient’s propensity to pay? What about deductible and claims status information? Is this information easily accessed and integrated into the workflow? Both are important when one wants to maximize revenue and gain tangible efficiencies in one’s process.
Understanding tech capabilities and limitations
When implementing cutting-edge technologies, including for revenue cycle management purposes, be sure to thoroughly understand their capabilities and limitations, said Eldon Richards, chief technology officer at Recondo Technology, a revenue cycle management technology vendor.
“Lately, there has been a lot of buzz around new technologies such as artificial intelligence, robotic process automation, natural language processing and deep learning,” Richards said. “We are starting to see these technologies applied to the revenue cycle. While these technologies may be capable of breakthrough gains in productivity for your organization, and may reduce maintenance costs, they also have limitations that may prevent your organization from taking full advantage of the benefits.”
“Use rules and traditional program logic where there isn’t sufficient data to train a robust machine learning model and use machine learning where sufficient data exists.”
Eldon Richards, Recondo Technology
One of the most common reasons that these technologies fail to provide full benefits is variability in data and processes, he contended.
The current wave of AI-enabled products primarily is built on machine learning. Machine learning algorithms are capable of finding patterns in data and making predictions and decisions based on what they see. This can reduce or eliminate the need for maintaining complex configurations and rule sets.
“However, machine learning-based algorithms often need very large quantities of data before they can make accurate predictions and decisions,” he added. “In cases where there is a lot of variation, the data requirements grow even larger. Many organizations simply don’t have enough data to effectively train machine learning models for real-world applications.”
There are several best practices to maximize an organization’s benefit from these new technologies, Richards said.
“One is to work with vendors who can securely pool data from many organizations to build robust models capable of handling high levels of variability,” he said. “Another is to use hybrid approaches – use rules and traditional program logic where there isn’t sufficient data to train a robust machine learning model and use machine learning where sufficient data exists. These approaches can be beneficial for robotic process automation and many AI-enabled technologies.”
Start with core systems
On another front, healthcare provider organizations must have one source of truth, said Scott Herbst, senior vice president and general manager of provider solutions at Availity, a vendor of a suite of technologies that manage clinical, administrative and financial data.
Work must be done in one system so it can be used to the maximum degree, Herbst contended. Many organizations live with a hodgepodge of practice management, hospital information system and electronic health record systems combined with multiple revenue cycle management IT vendors, which can cause significant interoperability and workflow issues, as well as data silos, he added.
“It’s best to start any revenue cycle management implementation with core information systems.”
Scott Herbst, Availity
“It’s best to start any revenue cycle management implementation with core information systems,” he advised. “Whether your organization is upgrading an EHR, embarking upon a net-new build or consolidating systems across multiple facilities, CIOs should make revenue cycle management a high and continuous priority because a significant indicator of a successful go-live is a provider’s ability to effectively manage payments and claims.”
By focusing on revenue cycle management early, provider organizations – regardless of the facility – can establish a performance baseline for claims and revenue management and ensure that the hospital or practice can seamlessly administer payments and claims and maintain financial performance during a transition, he added.
“Revenue cycle management prioritization also helps the organization focus on detailed integration points and workflows, such as submission of claims, electronic attachments, converting paper claims, eligibility, remittances, claim status and payment auto-posting,” he said.
Further, a vendor that knows an organization also helps new vendors get acclimated, provides guidance and ensures everyone stays accountable, he added. A positive and fruitful collaboration allows an organization to establish claim benchmarks and ensure that work-queue configurations are optimized to mitigate missing or lost claims, he said.
All about the use-cases
Brian Robertson, founder and CEO of VisiQuate, a revenue cycle management technology vendor, insisted that implementing revenue cycle management IT is all about the use-cases.
“The U.S. revenue cycle is one of the most complex ‘invoice/payment’ processes to ever exist,” Robertson said. “From pre-service to zero balance, there are many silos of information from system of record, third-party data sets, data from bolt-on niche platforms and more.”
“True innovation versus ‘incrementalism’ is the key to success.”
Brian Robertson, VisiQuate
While it is critical to have a centralized and longitudinal revenue cycle management data model designed to capture all information across the silos, he advised, the more important task when implementing technology to drive revenue cycle management performance improvement is user profiling and business problem framing.
To reinforce the point, he said, the early emphasis of the Certified Analytics Professional (CAP) exam, where one can become a certified analytics expert, is as follows:
- Objective 1 – Receive and refine the business problem.
- Objective 2 – Identify stakeholders.
- Objective 3 – Determine whether the problem is amenable to an analytics solution.
- Objective 4 – Refine problem statement and delineate constraints.
- Objective 5 – Define an initial set of business benefits.
- Objective 6 – Obtain stakeholder agreement.
- Objective 7 – Reformulate the business problem statement as an analytics problem.
“By putting a laser beam focus on the above, prior to any discussions of platform, database or tools, will ensure a compelling ROI and avoid the ‘If you build it, they will come’ trap that often occurs with bottom-up technology builds,” Robertson stated.
Changes to the workflow?
In the billing department, workflow is key. And it’s not to be toyed with.
“The number one question we get is, ‘How will this change the workflow for our team?’” said Ron Wince, CEO of MyndShft Technologies, a vendor of prior authorization, eligibility and benefits verification, and patient financial responsibility technologies. “Billing and revenue cycle teams are wary of new technologies because they are usually on the receiving end of technologies that have been chosen for them but are now their responsibility to adopt.”
“Billing and revenue cycle teams are wary of new technologies because they are usually on the receiving end of technologies that have been chosen for them but are now their responsibility to adopt.”
Ron Wince, MyndShft Technologies
Healthcare CIOs and other leaders should make sure the implications of adopting revenue cycle management technology at the point at where the work gets done are accounted for when selecting a technology, Wince added.
“It can mean the difference between achieving the return that was anticipated or just becoming an expensive notepad where work continues to happen outside the system under the old workflow and then information is entered into the new system at the tail end of the process,” he explained.
Strong alignment of processes and technologies
Another best practice suggestion from Richards of Recondo Technology is to gain maximum benefit from revenue cycle management technology by deeply aligning processes and technologies.
“When implementing any new revenue cycle technology, it is important to ensure that the new product will integrate well with your organization’s existing processes and technology platforms,” Richards advised. “Today’s provider organizations and their technology platforms are quite complex. This complexity derives from the large number of technology platforms, teams and partners involved in running a provider system.”
A single organization may employ hundreds of people to manage the revenue cycle, partner with dozens of technology vendors and interact with hundreds of payers, he said. Successfully running such an operation requires tight integration between technologies and strong alignment of processes and technologies, he added.
“Successful technology integration requires platforms that not only handle industry standards such as EDI and HL7, but can also adapt to nuances required to support your business,” he cautioned. “Be sure that your team fully investigates what information needs to be passed between platforms and whether the standard protocols can handle that information, and what are the triggering events to ensure the information is available when needed to support a process.”
Involving current and future users of a new platform will help one identify process details that existing technologies must support, he added.
“Be sure to plan not only for the main processes – the ‘happy path’ – but also for the more difficult exception cases,” he said. “It is also important to include review of processes to maintain your new systems, such as custom rule updates or updates to reflect upcoming changes in your organization.”
The human equation
Herbst of Availity adds another revenue cycle management technology best practice, and that is to remember that software supports people. Despite some automation of claim submission and other transactions, many administrative transactions are still largely driven by costly and inefficient manual processes, he said.
“Automation and training can help with one of the most common challenges hospitals face when implementing revenue cycle management solutions – finding skilled human resources,” he said. “Better automation and better software coaching will open up a broader labor pool and help those employees do a better job.”
One of the most important things healthcare organizations can do is help employees understand the goals of the organization and how their specific role fits in, he added.
“Most people want to do good work and want to be in a situation where they feel good about the organization they work for,” he stated. “With automation, every person has the same knowledge, so your least efficient employee can work as efficiently as your best employee.”
Although it’s easier to automate standard operations, exception handling – when the same error crops up over and over and is always corrected the same way – is also a great opportunity to introduce automation,” he explained. “And if you don’t have the information you need to address it, you can automate the process of driving it to the person who can.”
Things that should not occur
Don’t wait until the claim is back in your hands to correct it, warned Carlson of ZOLLAR Boost.
“Move any new revenue cycle technology to the front of your workflow,” she said. “Back-end denials due to incorrect demographics, ineligibility, incorrect coverage or low likelihood to pay shouldn’t occur in today’s technology-enabled revenue cycle. They are preventable.”
Healthcare provider organizations should use the revenue cycle management technology supplied by its vendor as close to the front of the claim lifecycle as possible, Carlson added.
“This results in time savings, less rework, lower costs to collect, greater claim throughput, and heightened efficiency in your billing department,” she advised.
Think beyond commodity use-cases
In the healthcare provider landscape, there has not been a breakthrough, game-changing innovation or technology leapfrog in 20-plus years since the conversion from paper to EDI, contended Robertson of VisiQuate.
“Industry whitepapers from over twenty years ago relayed the tremendous waste and inefficiency citing more than $30 billion dollars of waste and inefficiency,” he said. “And how much has really changed? Not much. But things like robotic process automation, artificial intelligence and machine learning have the potential to change the game. Think beyond commodity use cases.”
To achieve optimal revenue cycle management yield, velocity and cost optimization, healthcare providers need to think beyond the traditional areas of centralized reporting, KPIs, dashboards and ad-hoc queries, and consider how technology will drive automation, he insisted.
“Which technology stack is required to ‘demonstrably automate the revenue cycle?’” he asked. “Areas such as advanced exception processing, robotic process automation, automated anomaly and pattern detection, and continuous artificial intelligence and machine learning have the potential to substantially improve revenue cycle management outcomes while bending the cost curve.”
An average of 2-4% to collect on the business of healthcare is simply no longer sustainable and will become less tolerable and less acceptable in the coming years, Robertson said.
“True innovation versus ‘incrementalism’ is the key to success,” he concluded.
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Healthcare IT News is a HIMSS Media publication.
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