Increasingly complex reimbursement methodologies, stringent healthcare reforms, and changing healthcare models are the top challenges for hospitals and health systems today. Hospitals spend more on revenue cycle and IT infrastructure but failed to achieve optimal outcomes.
Hospitals and health systems must focus on 7 areas in current value based care environment.
1) Automate pre-authorization, payer policy maintenance, and authorization acquisition to simplify patient insurance eligibility, coverage and benefits. Educate patients on their EOB. It will bring significant change in your patient experience and revenue cycle.
It’s the challenge of getting pre-authorizations, avoiding denials and managing the utilization of those patients. All these people suddenly have access to care, and we've got to make sure we can get them in and treat them effectively and get paid says Aaron Eichorn, CFO of the University Health System in Shreveport, La
2) Eliminating the complex billing process and outsource the weak part of your revenue cycle process to cut costs and invest on cutting-edge technologies to improve patient care. Focus more on front-end collections and patient satisfaction.
"Rising healthcare expenditures and the complex technology or staffing requirements to succeed under value-based care is creating the urgent demand for cost-effective, technically advanced business office outsourcing solutions in physician practices across the country," says Doug Brown, managing partner of Black Book
3) Deploy Patient advocacy program for empowering your patient’s financial experience to improve loyalty, cost-to-collect and net collections.
The large majority of my 15 years has been spent “geeking out” in the financial operation of healthcare delivery systems. This past year, I removed my finance hat and replaced it with a patient experience cap. As I navigate the halls of physician practices and health systems, I wanted to take a moment to share three challenges I’ve observed, but also, opportunities to transform the healthcare industry in the future says Vince Panozzo, Head of Enterprise Solutions at Outcome Health
4) Shift to performance based reimbursement as current health system is witnessing reduced inpatient volumes and increased outpatients. Though it is one or two percent of the net revenue of hospital operating margin, it will grow as the new government reforms forces organizations to shift from fee-for service to performance modal by focusing more on quality measures.
The shift to value-based reimbursement has also sparked an increase in provider-sponsored health plans. In these instances, providers inform a payer of their interest in being part of the payer’s network and may even request a particular rate says Steve Selbst, CEO of Healthcents
5) Current shift in payer mix from commercial payers to Medicare and Medicaid can also hit your bottom-line. Every Hospital should develop a unique revenue integrity program to align with top paying insurance regulations to stay compliant.
This dual risk—both financial and regulatory—will grow as Medicare moves steadily towards a MACRA/MIPS reimbursement model. Over the next few years, comprehensive revenue integrity has the dual benefit of not only contributing to additional reimbursement today, but shoring up cost capture to positively impact MIPs payment scores of tomorrow says Dan Ward, Vice President of ZirMed
6) Population health plans associated with patient demographic can impact your reimbursement and increase in claim rejections and denials. So if you consider choosing your RCM partner, make sure they are certified in compliance audits and managed care contracts. Most of the rural hospitals are facing bankruptcy due to continual ignorance of population health.
“Population health leaders know that health care delivery is incomplete without addressing the social determinants of health. But effective patient management cannot only include tasking care teams with addressing patients' social needs on top of their complex clinical needs. Instead, CMO’s should also partner with community-based organizations already providing quality non-clinical support for a range of needs, from healthy food access to stable housing, to scale patient management beyond traditional care settings” says David Bailey, CEO of Nemours Children's Health System
7) Pay attention to predictive analytics, physician productivity, clinical outcomes and patient experience using artificial intelligence and BI applications to make informed decisions and strategic planning.
"Data is powerful and can change behavior. In most departments, if you show them something quick and easily identifiable, it is most effective. Don't overdo the data; make it visual and easy to understand," says Ms. Bridget Walters, corporate director, Orlando Health.
Hospitals Executive teams should rethink and implement strategies on these seven areas for better outcomes in current value based care payment environment.
Nancy Lopez, a revenue cycle manager for the lost revenue recovery program at BillingParadise.
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