How SSI Simplifies Revenue Cycle Management

Since the Affordable Care Act went into effect, healthcare revenue cycle management has overgone significant changes. While hospitals, health systems, and independent practices increase their focus on patient health, they also need effective processes and policies to maintain financial health.

That’s where healthcare revenue cycle management comes in.

Without revenue cycle management, providers can’t make a living and healthcare organizations can’t remain in operation. Keep reading to explore the foundations of healthcare revenue cycle management, what makes it so complex, and the solutions that healthcare organizations should implement to achieve an effective revenue cycle management process based on a real-world example.

What is Revenue Cycle Management?

Revenue cycle management is the financial process healthcare systems in the US use to track revenue from patients. Revenue cycle management starts with an appointment or hospital visit and ends when the provider receives full reimbursement for their services. The process unifies the business and clinical sides of healthcare by gathering administrative data like a patient’s name, contact information, insurance provider, and other personal details with their treatment information and healthcare data.

Revenue cycle management relies on clear communication from hospitals, health systems, and insurance companies to operate efficiently and accurately.

When a patient schedules an appointment, healthcare administrators will pre-check the patient’s reported insurance coverage. After an insured patient receives treatment and supplies any applicable copayment, the healthcare provider or coder categorizes the nature of the treatment according to ICD-10, a clinical cataloging system implemented in the US healthcare system in 2015. Current Procedural Technology (CPT) codes are then paired with the appropriate ICD codes and sent to the patient’s insurance company to see what portion of the care they’ll cover, with the patient billed for the remainder. 

Challenging Factors of Revenue Cycle Management

Billing and Collections Errors

Healthcare office staff spend significant amounts of time billing insurance providers and patients. Any inattention to that process can easily cause denials and innacurate payments into the millions of dollars. Errors also lead to complaints, patients choosing to go elsewhere, delays, and denials. All healthcare providers need a competent medical billing process to engage payers promptly and effectively to receive appropriate payment without delay. To offset the costs of maintaining in-house revenue cycle management experts, some healthcare providers outsource their revenue cycle management to an experienced and well-trained partner for consistent quality and data integrity.

Healthcare IT Demands

Information technology is an integral part of the modern healthcare revenue cycle management process for tracking the complete lifecycle of every claim. Healthcare IT solutions help ensure appropriate collection of payments and reduce denials. However, some healthcare providers struggle to implement IT and billing infrastructure successfully. Not all providers can afford to invest in new or even required technologies, such as EHRs, or necessary infrastructure. As a result, some providers consolidate, others turn to outsourcing, and some, unfortunately, don’t last.

Administrators face constant decisions about which technologies are suited for their healthcare organization and how much to spend. Knowledgeable healthcare IT consultants can help aid in decision-making, but it’s also highly beneficial for healthcare facilities to have an IT expert onsite at all times to handle any issues.

Lack of Training and Staff Turnover

Lack of training and staff turnover can lead to billing errors and incorrect or improper collection of patient data. Throughout the pandemic, the healthcare workforce has seen increasingly high turnover, making effective training a greater challenge than ever before. Healthcare staff responsible for billing need to know the correct way to capture patient demographic information on the front end and translate that data into an appropriate insurance claim. Getting accurate information at the very beginning of the patient experience provides the foundation for efficient and effective billing and collections processes.

While many coding methodologies have been in place for years, coders need to maintain their skills and stay updated on constant changes. Training is costly and time-consuming, but it can save a provider extraordinary sums of money by reducing potential coding and medical errors and helping to streamline the process.

End-to-End Claims Monitoring

In a well-functioning revenue cycle management process, claims are monitored closely at every point in their lifecycle. Without careful monitoring, any errors made may not be caught and can quickly become impossible to locate or identify, leading to lost revenue. Many providers opt to set up an exception-based workflow with automated alerts that specify why payers routinely deny claims for a given procedure. This type of practice is great for pinpointing and focusing on key issues while reducing the distractions of less critical tasks. Healthcare providers can spend hours researching issues without the right strategy, taking their focus from other essential duties. With a streamlined and efficient revenue cycle management process couple with the right software, healthcare organizations can run smoother and ensure their revenue cycle isn’t leaving cash on the table.

Financial Policy Documentation

Some healthcare facilities lack properly crafted financial policy documentation for employees. Clear financial policies are important elements of revenue cycle management that should be reviewed by legal counsel and made available to employees digitally or in writing. Financial policies should also guide patients on copayments, unpaid balances, patient responsibilities regarding insurance requirements, and financial arrangements for outstanding balances, charity care, or other payment arrangements.

A financial policy is a helpful tool for healthcare professionals involved in billing as well. A financial policy could include processes for analyzing a patient’s financial capabilities and steps for determining a patient’s balance. Financial policies can also contain information regarding denied claims and how to address them. It’s best to have a process for tracking and resolving denied claims.

Overcoming the Challenges of Revenue Cycle Management: A Real-World Example

It can be difficult to visualize exactly how hospitals and health systems develop and implement effective strategies to overcome these types of complexities, so let’s look at an example.

In 2020, Anderson Regional Health System (ARHS), a two-hospital system in eastern Mississippi, decided to integrate their patient access and patient financial clearance processes to improve continuity in their financial care. What would typically be a challenging undertaking was made even more complex by the COVID-19 pandemic. At the time, many revenue cycle management staff shifted to working from home, and many patients were apprehensive about reentering a medical environment, leading to limited opportunities for in-person financial counseling.

Before the fall of 2020, ARHS worked with a vendor for estimation, collections, and eligibility. But with the price transparency rule set to take effect in January 2021, revenue cycle leaders knew that the health system would need to bolster its financial estimation capabilities to meet one key component: posting charges for 300 shoppable services online in a searchable, consumer-friendly format.

ARHS chose to partner with SSI, specifically for our suite of access management tools and revenue cycle management platform. Functionality for SSI’s proven patient access management solution comprises:

      • Address Validation
      • ID Validation
      • Eligibility
      • Medical Necessity
      • Admission Notification
      • Estimation
      • Financial Clearance
      • Patient Payments

ARHS and SSI worked together to implement the tool, adopting the full suite of patient access functionality—from eligibility to medical necessity, patient data validation, and patient payments—and augmenting its existing eligibility and admission notification tools with our solutions. During the implementation process, ARHS met with staff to explain the tool’s purpose and importance and how it could address patients’ desire for greater transparency around costs of care while bolstering patient engagement and collections efforts.

Kevin Adams, director of revenue cycle services at ARHS, said of the project, “Getting staff comfortable with the tool was the most important piece. One aspect that appealed to staff is the ability to provide price estimations internally, at the point of contact, and externally—via our website—for both commercial and self-pay patients. By looking up the shoppable services we offer, consumers can not only see the list price for these services but also gain an accurate estimate based on their insurance plan, and the amount of their deductible met to date. It’s a service that ensures consumers are highly informed at each stage of the care decision-making process.”

Read the full case study here.

Take Steps to Optimize Your Revenue Cycle

In the example above, SSI’s access management solution was a perfect fit to help ARHS fill gaps in expertise and capabilities in their revenue cycle’s front-end. Still, that’s just the tip of the iceberg for many hospitals and health systems. SSI’s RCM solutions touch every aspect of the revenue cycle, including:

      • Access Management
      • Claims and Denials Management
      • Compliance Management
        • Contract Management
        • Audit Management
      • Remit Management
      • Clearinghouse
      • Predictive claims and remit analytics
      • Payer Solutions
      • Professional Services

The healthcare revenue cycle is a highly dynamic aspect of the US healthcare system that continues to evolve. ICD-10, MACRA, accountable care, and other regulations mean that providers often struggle to handle the financial pressures these regulations cause without an effective revenue cycle management process in place. As a result, hospitals and health systems often face a wide range of revenue cycle management challenges, ranging from billing errors to lack of documentation to outdated policies and procedures. In the modern healthcare billing landscape, it’s vital for providers to explore smart ways of improving their organization’s revenue cycle.

Talk to an expert from SSI today to discuss your hospital or health system’s current healthcare revenue cycle situation, and learn how we can help expedite time-to-payment and ensure your organization and providers are paid timely, efficiently, and fairly for essential services.