How to Tackle The Top Revenue Cycle Management Challenges of 2019

2019 will undoubtedly be an eventful year for healthcare, but it won't come without its challenges. Every new idea, technology and innovation presents a new risk that providers must face, both financially and at an organizational level. A new report by Crowe shows the top risk areas of physician revenue cycle management in healthcare this year. In this blog post, we will explore the parts of the revenue cycle that pose the biggest challenges while addressing how to tackle each in ways that is beneficial to your employees, patients and bottom line.

We focus on every step of the healthcare revenue cycle so you can focus on patient service.
btnLearnMore orange

Parts of the Revenue Cycle

For the purpose of this article, we will cover five parts of the revenue cycle, along with the challenges and solutions of addressing each. Those parts include: billing and collections, charge capture, coding, denial management, and patient access. These five parts are by no means comprehensive but are a good starting point for forming a picture of the overall revenue cycle.

Billing and Collections - The Challenge

Because there are so many moving parts throughout the billing and collections processes, the smallest inefficiency can lead to costly rework, denials and lost reimbursement. Many providers look to outsourced billing to handle these functions, but even then, oversight of third-party vendor relationships must be managed to ensure operational and financial success.  According to Crowe, the major risks relating to this area include completeness and accuracy of billing, lost revenue, inadequate denials management and lack of third-party control visibility.

Billing and Collections - The Solution

  • Use an analytics tool to track key performance indicators and areas for improvement - Tracking key performance indicators (KPIs) plays a large part in tracking the financial health of your business, both operationally and financially. KPIs help physicians and management understand the strengths and weaknesses of their revenue cycle to help guide future decisions. They also help prioritize resources and help recognize key success drivers. These 8 medical billing KPIs are a great starting point for organizations looking for quality KPIs that heavily impact financial performance. To make sense of this data, using a business intelligence reporting and analytics tool will improve your ability to identify trends and patterns, as well as increase awareness around what variables impact your practice.
  • Automate patient registration - Collecting accurate patient information upfront sets the groundwork for efficient billing. Without it, denied claims and lost reimbursement typically follow. Each unique visit should be validated by staff under the patient billing system and the patient’s demographic information and insurance eligibility should be determined upfront. This can be done manually, but it’s laborious, time intensive and leaves room for human error. Supplement staff workflow with as much automation as possible to improve billing registration accuracy. Software solutions like ImagineAI validate when a patient is eligible for primary insurance listed on the visit and/or your list of top payors before the claim is sent to insurance. Once you receive the positive eligibility response, the AI solution will add a note to the visit with the patient’s identified payment information.
  • Communicate clearly with patients - Never underestimate the importance of being transparent. It’s necessary for providers to train their billing staff to answer questions about pricing over the phone and in person. Billing staff must learn that communication with patients is not a “soft skill” but something that must become second-nature. This is especially crucial during time of service, when staff is face to face with patients and must think on their feet.  Explain financial policies right away, follow up with the patient if there is any confusion and be sure to use an appropriate tone. It’s something that can easily be overlooked, but how you engage in conversation with a patient is just as important as what you say.
  • Third Party Visibility - Outsourcing parts of the revenue cycle process has its benefits, but lack of visibility can lead to micromanagement, which defeats the purpose of outsourcing. Medical billing companies and other third-party vendors should be able to supply you with performance reports automatically or upon request. This will give you much more visibility into your billing operations.  Most vendors will provide it even if it’s not automated.  Some go a step further and provide ad hoc or customized reports to their clients, you need only ask.

Charge Capture - The Challenge

Managing charge capture and maintaining an accurate charge description master (CDM) serve as the starting point for billing patients and payers and form the heart of a healthy billing cycle. Providers must accurately load and regularly update pricing for services while also billing in accordance with the charging and billing guidance provided by Medicare and other payers. Without the correct training on documentation and metrics put in place, the accuracy and completeness of charges becomes a major risk.

Charge Capture - The Solution

Hopefully, your medical billing software automatically flags incomplete charges.  Aside from that, there are several strategies that providers can adopt to ensure that charge capture is accurate and complete.

  • Proper training - Educate staff on existing rules and regulations including payer-specific rules, CMS rules, and your current procedural terminology codes. These change frequently so it’s important that employees are continually trained to ensure charge accuracy.
  • Work with what you have - Before jumping the gun and implementing new policies, leverage what you already have.  Use your EMR to identify missing and inaccurate charges and alert your team. Try setting up work queues to flag patterns of missing charges and high-quantity errors.
  • Review lag times - It’s good practice to review both lag times for date of service to billing/coding and from service date to posting date and claim submission. Compare to industry benchmarks to identify areas for improvement. Build the billing team and physician relationship - Improving charge accuracy can’t be accomplished by just the billing team alone. Establishing a strong relationship between the team and physicians will ensure more collaboration to correct the process in a way that’s mutually beneficial for both teams.
  • Perform charge capture audits - If your practice management system has the proper reporting functionality, it will be incredibly helpful here.  Charge-capture audits are necessary to ensure that internal procedures have been implemented and carried out properly. The information included is up to the practice, the key is to perform audits consistently.

Coding - The Challenge

Because of growing compliance standards, it’s becoming more and more challenging for providers to code accurately. ICD-10-CM requirements for diagnosis documentation often lead to insufficient diagnosis codes and increased workloads, both major coding risks as outlined by the Crowe report. Other frequent coding errors are using non-specific diagnosis codes or incorrect modifiers, upcoding and undercoding.

Coding - The Solution

  • Provide ample training - Especially for inexperienced coding staff that may lack the proper knowledge to accurately code for the highest possible reimbursement. Provide up-to-date training on the most recent Centers for Medicare and Medicaid Services (CMS) guidelines. Physicians should also be included in training. Physician’s Practice suggests having a coder shadow and scribe a visit in addition to the physician’s documentation to compare what each person documents.
  • Claim scrubbing - Medical billing software solutions with built in claim scrubbing improve coding accuracy and remove manual workflows for coders.
  • Conduct regular audits - The word “audit” is typically held with a negative connotation, but auditing coders on a regular basis will bring any issues to light in a timely manner. If done with the right intentions and frequency, it’s something that doesn’t have to be painful for anyone involved. For example, instead of auditing regularly on productivity or speed, audit for quality instead. This may be an obvious tip, but it makes a big difference.
  • Subscribe to CMS updates - CMS sends quarterly updates on modified codes. It’s a good idea to subscribe to these updates so that you always have the latest medical codes. If not that, check the CMS website on a regular basis for updates.
  • Provide better documentation for physicians - Better documentation and coding-decision support for physicians can drastically improve coding accuracy, especially for highly compensated encounters that require more rigorous documentation.

Denial Management - The Challenge

Denied claims can be caused by numerous departments and workflows, including all risk areas we addressed above. Denied claims are three times costlier to rework than submitting a clean claim, and the challenges only compound as organizations grow.

Denial Management - The Solution

  • Track KPIs for denial and third-party payer reimbursement - Tracking key performance indicators (KPIs) like claim submission performance, charge period revenue analysis and procedure reimbursement will identify areas for improvement in denial management and help establish a payment variance process that helps determine whether your payers are paying correctly based on the contracted rate. Receiving these reports on a daily, weekly and monthly basis will improve your ability to monitor financial reporting by leaps and bounds. Learn more about those reports in our ebook, "A Future-proofed Revenue Cycle: Prepare for 2019 with Automation."
  • Break down denials by category - Breaking the various steps of your revenue cycle down will help identify specific processes that could be causing the greatest revenue loss.  Track areas like credentialing, registration, preauthorization and charge entry.
  • Automate manual processes - According to a recent HIMSS survey, nearly a third of providers in the US are using manual denial management processes. Preauthorization, electronic remittance, auto coding and auto charge posting are areas that can be automated to help staff save time and increase accuracy in claim submission.  If your current medical billing software vendor or billing company doesn’t allow for this kind of automation, consider switching to a partner that does.

Patient Access - The Challenge

From financial standpoint, the lack of control over patient registration is a major risk area for providers in 2019. There are a lot of scenarios where this goes wrong, from inaccurate collection of patient information to failure to collect copayments or coinsurance in advance. Providers need a solid strategy and ample training on the front end to minimize the risk of billing issues and increase patient satisfaction.

Patient Access - The Solution

  • Leverage tools for estimation - Adopting an estimation tool gives patients a snapshot of how much they owe out-of-pocket.  If you can inform patients about their financial responsibilities upfront, there’s a higher likelihood that they will pay their bill.
  • Perform a data clean up - While this is time intensive, performing a data clean-up can prove to be incredibly effective in wiping the slate clean and improving the accuracy of patient information.
Intermountain Healthcare performed this process by identifying the patient, detecting the lacking demographic data, and manually editing that data to improve accuracy.  While this improved Intermountain’s patient matching rate to 60-70%, it was also done manually.  The process of updating and standardizing demographic data is laborious and expensive but certainly effective, so keep this in mind.
  • Give patients the ability to pay through an online portal - An online portal that’s integrated into your billing platform (or a medical billing company’s platform if you outsource) is beneficial for both patient and provider. Patients are given more control over their payments and have the option to pay bills in one place from anywhere. The patient’s responsibility is clearly communicated, making it easier for the patient to pay faster. It reduces follow up on co-pays, deductibles, and co-insurance balances, which translates into improved A/R.
  • Offer payment plan choices - Offering payment plans can be life changing for many patients, giving them the ability to make small payments over time without forcing themselves to choose between receiving the care they need and other necessities.  For you, it’s another step to streamlining your collection process while obtaining more patient payments.


If you enjoyed this post, you'll love our email updates!

Receive content on industry topics, upcoming webinars, current healthcare trends, and more!