Revenue cycle management in specialty healthcare is getting an overhaul. The traditional fee-for-service model, which has largely driven healthcare for nearly 100 years, is based on volume. More services equal more revenue even though the care may not be the most appropriate or the best quality for that patient.
Revenue cycle management services exist mainly because organizations need to focus on the core business. This article looks at the top challenge in revenue cycle management, specifically focusing on specialty healthcare.
Timely payment of claims also poses a challenge to both providers and patients alike. Ambiguity in payment policies can delay reimbursement, even though claimed payments are actually out of date.
This can be devastating to the provider who is left to pick up the pieces. On the patient end, payment delays can result in cash flow problems that often lead to credit problems or reduced access to healthcare.
The problem with this traditional model is that it does not always provide incentives for quality medicine and patient safety.
What does quality medicine look like? Is it simply volume? How do we measure volume? These are great questions to ask, but the answers are less meaningful if healthcare providers cannot provide high-quality care economically.
Specialty providers face unique challenges when it comes to payment accuracy. Many issues that arise during the claims process can be traced back to a lack of clear and accurate reporting.
Often, there is no prioritization as to which claims should take priority instead of those higher up on the pecking order or those that may have an even greater impact on the provider to receive payment first.
There are many types of claims that can impact payment accuracy. The metrics that are being tracked are sophisticated enough to help providers better manage their RCM processes to improve payments.
The accuracy of a specialty provider’s payment processes may rise as high as sixty percent after implementing a more tailored and sophisticated RCM solution.
This can significantly influence their bottom line profit and profit margin, thereby improving their ability to invest in core competencies and intensify efforts to grow their market share.
Interoperability Between Departments
Revenue cycle management can be thought of as a series of checks and balances to ensure adequate revenue payment, timely payment for services rendered, payment accuracy, and to ensure all claims are properly processed.
Many specialty providers face challenges when trying to manage the interactions between multiple departments in their organization. They face a unique set of challenges that contribute to cost and quality problems.
There are additional inefficiencies that come into play when physician providers are working in an integrated healthcare system. A healthcare organization employs more than one payer (insurance) type to cover its employees.
Access To Capital
Access to capital is another issue that affects specialty providers. The traditional method of capital infusion relies on infusions from limited partners, such as banks and PE firms.
For the most part, these limited partnerships rely on relatively fixed terms and conditions, limiting the scalability of providers’ operations.
Access to capital also affects the speed at which specialty providers can implement new technologies and other operational improvements. These improvements often require a substantial upfront investment and long payment terms to make these purchases feasible.
Handling Prior Authorizations
Specialty providers are unique compared to other healthcare providers because they provide highly specialized services that are often not available in mainstream hospitals across the US.
One of the more notable areas of compliance for specialty providers is managing prior authorizations. Prior authorization is a procedure that requires a healthcare provider to get approval from an insurance carrier before rendering care to an individual under their plan.
Specialty providers have improved their prior authorization processes to improve their compliance rates in the past couple of years.
The Centers for Medicare and Medicaid Services (CMS), a government agency that oversees millions of claims that are submitted to Medicare, has been working with healthcare providers to improve these processes.
In recent years, providers have been tasked with providing higher quality care at a lower cost. While specialty providers may be uniquely challenged in the way, they deliver this type of care, a more sophisticated RCM solution can help them overcome these challenges and realize huge savings in the process.
A sophisticated RCM solution will analyze a provider’s current processes and provide actionable insights that can be used to improve payment accuracy and access to capital while improving payment within 30 days. This is an important metric for specialty providers.