Managing the hospital revenue cycle has become increasingly complex for myriad reasons, including the shift to value-based care models, dwindling reimbursement and talent shortages.
Here, five revenue cycle leaders in healthcare shared the issues that are keeping them awake at night.
Note: Responses have been lightly edited for length and style. Responses are in alphabetical order by last name.
Julie Deason. Director of Single Billing Office at Piedmont Augusta (Ga.). In healthcare finance and revenue cycle, I would say there are three major areas of concern:
- Human capital and talent is a major concern for healthcare systems right now. The pandemic had a paradigm shift in the workforce and as baby boomers retire, millennials really need to step up and have better succession planning.
- Reimbursement in general and the health insurer giants that continue to cut reimbursement for hospitals and physicians to beef up their bottom lines in particular are bothersome.
- The overall "health" of our healthcare system in the U.S. in itself is enough to keep anyone up at night, we are in need of another major reform.
John Groves. Interim Leader and Consultant at B.E. Smith (Lenexa, Kan.). The big issues facing revenue cycle executives are:
- Dealing with managed Medicare and managed Medicaid payers. They don't follow the contracts we agreed upon, they deny payment for services we provide without explanation and they just don't pay claims. I am dealing with an account where they denied the $500,000 claim as experimental. The patient had a life-saving surgery.
- Denials. Insurance companies are denying payment for hundreds of reasons. When denied, a formal appeal has to be completed in order to get paid. I am working on an account that was denied as "Not medically necessary." The patient gave birth. Another example is one account was denied because the payer needed a complete copy of the medical records. The records were 11,000 pages and the payer would not accept them electronically.
- The insurance companies are in the business to collect premiums and not pay claims. I am currently working at a hospital that employs 30 people just to contact insurance companies for payment. We bill electronically in the format the payer requires, the claim is accepted into the payer's system, and nothing happens until we call or go online and complain.
- Employee retention. Much of the work in the hospital revenue cycle is grinding, day after day. The younger employees are not challenged and find other employment. We "old-timers" lived to work. The younger ones work to live. Looking back on a 43-year career in healthcare, I believe the young ones are right.
Barbara Hayes. Regional Revenue Cycle Director, West Region at RestorixHealth (White Plains, N.Y.). I'd say point-of-service collections. Insurance companies offer low-cost plans with high deductibles and coinsurance. While the plans are affordable to lower-income patients, they typically can't afford to pay the required amount at the time of service toward the deductible or coinsurance. Some hospitals will not turn patients away for any needed care if they can't pay at the time of service, which results in account balances as hospital bad debt.
Patrick McDermott. Vice President of Revenue Cycle at Scripps Health (San Diego). High vacancies and leaves of absence — which may top 15 percent or more — are the top issue for many RCM departments. Given this exacerbation and difficulty to recruit and retain talent, we need to do more "smart-sourcing" and invest in digital workers to create overflow and redundancy capability.
Anne Rose. Vice President of Revenue Cycle at Lee Health (Fort Myers, Fla.). We are very focused on setting up processes to successfully navigate the increasingly complex processes, both regulatory and contractual, that we must follow in order to secure payments from third parties on behalf of our patients. We must balance this work inside the framework of creating an outstanding patient experience, where they are informed along the way of what to expect from a financial standpoint. We always want to put the patients at the heart of the work we do and make sure they are treated as family by us.