Imagine losing millions of dollars in potential revenue simply because of a classification error. For hospitals grappling with increasing financial pressures, this scenario is far too common. But instead of endless budget cuts, there’s a better path—strategically managing revenue.
Hospitals face immense pressure to cut costs, but focusing solely on reductions can compromise care and efficiency. True financial sustainability comes from balancing cost-saving with revenue optimization. By strategically investing across the clinical revenue cycle, hospitals can ensure every dollar spent enhances both operational performance and financial growth.
Mounting Financial Challenges
One major trend in recent years is the increasing number of patients choosing Medicare Advantage over traditional Medicare. While these plans offer benefits to patients, they introduce operational complexity for hospitals, particularly regarding reimbursement. In 2023, Medicare Advantage enrollments surpassed traditional Medicare for the first time, signaling a significant change in payer dynamics.
Meanwhile, the rise in payer denials is putting even more pressure on hospitals. Denials are growing by 26% annually, forcing hospitals to spend more time and resources defending their claims. The growing complexity and frequency of these denials make it clear that simply cutting costs isn’t enough. Hospitals need a more integrated approach—one that focuses on maximizing revenue and cutting inefficiencies.
Revenue Optimization: The Missing Piece in Cost Management
While hospitals have spent years trimming costs, this often comes at the expense of long-term financial health. To thrive, they must focus on optimizing revenue alongside cost reduction. The concept of return on clinical investment (ROCI) is key: How can investments in utilization management (UM), clinical documentation improvement (CDI), and denial management drive stronger financial performance?
Consider patient status determinations—deciding whether to classify a patient as inpatient or observation. These decisions can make or break reimbursement, even though the cost of care remains unchanged. Hospitals that invest in robust UM and CDI programs ensure compliance and accuracy, leading to higher reimbursements and fewer denials. Hospitals that self-downgrade in fear of denials often forfeit millions of dollars they could’ve successfully recovered through appeals.
For example, Northeast Health System secured $125M by partnering with CorroHealth, improving denial management and coding accuracy. Similarly, three large Midwest health systems reclaimed $66M annually by embracing payer friction and improving inpatient payment rates by up to 72%.
Breaking Down Silos: A Unified Approach
Many hospitals manage UM, CDI, and denials management in silos, each focused on its own metrics, leading to inefficiencies and missed revenue. Aligning these functions under a unified strategy is crucial to optimizing the clinical revenue cycle. By integrating UM, CDI, and denial management, hospitals can:
- Prevent costly errors by accurately determining patient status upfront. (Utilization Management)
- Ensure accurate DRG assignments for better reimbursement. (Clinical Documentation Integrity)
- Improve success rates for appeals with proactive, well-documented processes. (Denials Management)
This streamlined approach boosts both efficiency and revenue recovery.
Leveraging Technology for Financial Strength
Technology, particularly artificial intelligence (AI), has become essential for hospitals looking to optimize their revenue cycles. But technology should complement, not replace, strategy.
AI helps hospitals analyze vast amounts of data, pinpointing trends in denials and identifying opportunities for documentation improvement. For instance, CorroHealth’s VISION Clinical Validation Technology™ dramatically improved DRG integrity for a Pacific Northwest health system, boosting findings by 102% and driving a 6x return on investment. Using VISION, this health system increased revenue opportunities by 80%, achieving $500-$600 per chart while reviewing fewer cases.
These results underscore how hospitals can streamline operations without sacrificing financial gains. By adopting VISION, hospitals are seeing an average revenue increase of 10%, despite reviewing 39% fewer cases. This data-driven approach illustrates how AI, when strategically deployed, can recover lost revenue and improve compliance.
The Power of Strategic Partnerships
No hospital can navigate today’s complex healthcare environment alone. To stay competitive, hospitals benefit from partnerships with organizations specializing in the entire clinical revenue cycle—UM, CDI, and denials management.
CorroHealth’s success stories highlight the benefits of these partnerships. For example, Northeast Health System recovered $12.5M in missed revenue, while Northwest Health System significantly reduced denials. Across its hospital clients, CorroHealth has helped recover over $5.7 billion in compliant revenue, underscoring the value of long-term, tech-enabled collaborations that drive real results.
Are you fully leveraging the technology and partnerships needed to strengthen your hospital's financial health? If you're ready to explore how these strategies can transform your organization, we’re here to help guide the way.