Increased patient financial responsibility, the emergence of risk-based contracts, and tightened margins are a few of the many challenges driving medical groups across the nation to explore ways to optimize revenue cycle management.
This content is sponsored by Zotec Partners.
A healthcare organization's financial health is determined by how it manages revenue cycle processes, and dramatic changes in the industry are causing medical groups to change their approach to revenue cycle management (RCM) and patient experience. Many provider organizations lack the technology and/or staff needed to navigate payment models as healthcare makes the gradual shift from fee-for-service to a value-based care model, and they are looking for outside help.
In their quest for revenue cycle health, healthcare delivery organizations are increasingly interested in alternatives to a complete in-house billing solution. In fact, the U.S. market for physician and ambulatory RCM outsourcing/hybrid models and extended business office services most likely will continue to grow 42 percent beyond the fourth quarter of 2016 and the first quarter of 2019, according to a Black Book survey. Alternatives to outsourcing all or parts of RCM functions remains appealing to provider organizations, as it allows them to stay laser-focused on clinical care while an RCM partner efficiently manages revenue cycle processes.
Once a medical group makes the decision to outsource all or parts of the RCM process, the next step is to perform a thorough vendor assessment. During the vetting process, a medical group should look for a partner that adds value beyond simply implementing software to maximize revenue for services delivered.
1. Seek automation that increases top line revenue and reduces expenses. The revenue cycle process is becoming more complicated for hospitals and medical groups. These organizations are entering complex payment agreements, some of which involve taking on risk, and implementing changes to billing as required by new rules and regulations. The number of Americans with highdeductible health plans has also skyrocketed in recent years, which presents additional challenges for provider organizations as they try to collect payment for services rendered. About 26 percent of privately insured Americans aged 18 to 64 had a high-deductible health plan in 2011, and that number rose to 39.3 percent in 2016, according to a 2017 study by the National Center for Health Statistics at the CDC.
"As these reimbursement climate changes happen, as the high-deductible health plans continually ramp up … medical groups and health systems are having to hire expensive personnel to follow up on bad debt denials," said Jeff McHugh, senior vice president of enterprise solutions at Zotec Partners. "Human intervention presents a recipe for increasing error rates. The more you can automate the less likelihood for error, and the greater the likelihood of a claim being paid with a quick, clean turnaround."
Provider organizations should interview partners that can automate many of the RCM functions it takes to routinely follow up with payers throughout the life cycle of a claim.
It takes a member of a medical group's billing staff 10 to 20 minutes to manually follow up on a claim to determine if it was received or adjudicated by a payer. By automating these functions, Zotec Partners helps medical groups streamline claims management and reimbursement activities.
"They increase their top line revenue by increasing the amount they are able to collect on that dollar…and it's reducing the expense because they do not need as much manual labor to process the medical encounters and manufacture them into cash," Mr. McHugh said.
2. Seek out experts who can manage everything on the back end of the revenue cycle while providing transparency into the whole medical group. Medical groups should look for an RCM partner that can routinely use analytics to provide real-time data to drive revenue growth. "Big data and analytics are key to remaining independent or in business. They're key to critical decision making. They're pivotal to any move you make from an acquisition perspective. They're required if you want to understand the workflow efficiencies at almost every level," Mr. McHugh said.
With legacy platforms or in-house solutions, medical groups often wait weeks, maybe months, for actionable revenue cycle insight. This puts provider organizations at a disadvantage in today's healthcare environment, where proactive and real-time revenue cycle management is crucial.
"When you have the data in front of you … you understand from a revenue cycle perspective where to improve," Mr. McHugh said. "You have immediate access and control over how you manage patient balances and where to focus."
For example, a medical group armed with real-time data has instant insight into outstanding balances and, if needed, can act quickly to put a performance plan in place to drive down bad debt.
"Having that transparency immediately available allows you to make proactive business decisions and get ahead of it versus being in a reactive mode," Mr. McHugh said. "It very much is about keeping the health of your organization at the top of its game."
3. Look for an RCM partner that can seamlessly connect your EMR and practice management investments. Most medical groups today utilize one or more EMR systems and have also implemented practice management software to manage daily financial and administrative functions. Data from all of these systems is needed to effectively manage the revenue cycle, and medical groups should seek an RCM partner that can pull and combine all of this vital information.
Zotec Partners' RCM solution is EMR agnostic. "We fit into any healthcare IT environment, and we can wrap around without disruption," Mr. McHugh said.
By connecting with any EMR and practice management software, Zotec Partners helps medical groups produce a first pass, clean bill that includes all of the necessary data elements. It also allows Zotec Partners to determine if there was information that was not captured in the clinical setting or even at the front desk, according to Mr. McHugh.
4. Focus on patient care without worrying about the clinical data exchange between acute and ambulatory environments. Healthcare organizations across the nation are focused on population health management to improve patients' health outcomes and realize success under certain alternative payment The flow of data between acute and ambulatory sites of care is a key component to effectively managing patient populations.
"You're moving — even though it's a slow move and a slow role — from fee-for-service to value-based care, and you have to take the patient as a whole," Mr. McHugh said. "You need access to all of the data about that patient."
Healthcare organizations must look for an RCM partner that provides a clinically driven revenue cycle solution that optimizes workflows and controls the cost to collect by aggregating data from acute and ambulatory care sites. Although the shift to value-based care is slow, medical groups need the ability to roll up data from various care sites to thrive in the next era of healthcare.
5. Look for an RCM partner that can eliminate disparate systems. It is common for a medical group to operate a different EMR system than its hospital owner, and this is unlikely to change in the near future given the rapid rate of medical group acquisitions occurring in the industry. Medical groups are facing a number of revenue cycle challenges, but these issues do not have to be exacerbated by disparate systems that cannot communicate with one another and increase the cost to collect, according to Mr. McHugh.
Regardless of which EMR system a medical group operates or how many feeds it receives from other systems, Zotec Partners is able to access and combine data from every source.
"Even if a medical group or health system uses four EMRs — or
10 or 15 — we don't care because we're agnostic to the clinical environment," said Mr. McHugh. "Once the provider is done with the patient encounter and they sign off, we're able to roll up all that data. They can then aggregate that data into a single source."
6. Find an RCM partner that allows you to keep some of your revenue cycle processes in place. Every medical group has different needs when it comes to choosing an RCM partner. Some medical groups want to outsource the entire revenue cycle function, while others want to maintain control over some parts of the process. Medical groups also have different goals they hope to achieve with their revenue cycle vendor partners.
"One size does not fit all," Mr. McHugh said. "It's really about understanding the goals and objectives of the medical group."
Zotec Partners works with each medical group to determine which partnership model will help the group meet its specific revenue cycle goals. Sometimes this involves outsourcing the entire revenue cycle function, while other medical groups opt for a hybrid model that allows them to maintain control over certain revenue cycle functions.
7. Put predictability at the forefront of your decision. With the rise in high-deductible health plans and reimbursement increasingly based on value, medical groups' revenue streams are less predictable today than in the past. It is imperative in this environment for medical groups to find an RCM partner that provides a predictable cost structure.
By partnering with an RCM firm such as Zotec Partners, medical groups can avoid labor costs related to the continual hiring of talent to manage claims. "The two things that an organization like a health system or medical group cannot control are infrastructure costs and people costs. Whereas organizations like Zotec Partners can scale because we built proprietary automation," Mr. McHugh said.
Zotec Partners incentives are aligned with the medical group's performance. A percentage of net collections is consistent, which means costs are predictable even as a medical group grows, according to Mr. McHugh.
8. Reduce the red tape. Purchasing new billing software may not be the best option for medical groups seeking to improve revenue cycle performance, as buying software usually involves paying for a support agreement year over year and purchasing upgrades when new government mandates come down.
As an alternative to paying for new billing software, medical groups should look for an RCM firm that allows them to pay for the results of the partnership, according to Mr. McHugh.
"Does anybody purchase Amazon? No. They have an application, and consumers don't pay anything for it. Consumers pay for the result of the application. I got the shoes I wanted off of Amazon. That was the result. That's what I paid for," he said.
When an RCM firm is paid based on results, it has a vested interest in ensuring a medical group does not miss out on potential dollars.
9. Make sure your RCM technology is future facing. As the healthcare industry transitions from fee-for-service, it is vital for medical groups to be able to work with multi-provider bundles, shared savings or other complex payment models and keep up with new rules and regulations. This is something Zotec Partners helps each of its medical group partners do.
"With future-forward technology, groups won't be behind when it comes to industry regulations," Mr. McHugh said. "Our partners are all on the same version … they'll never have to worry about paying for an upgrade for a government mandate that was dropped down that they may have forgotten about. They'll never have to worry about a support agreement to keep them up to date with industry standards. We proactively do that for them."
10. Keep patient satisfaction top of mind when making decisions. With the rise of high-deductible health plans, patients are shouldering more of the financial responsibility for the medical care they receive. This makes it more important than ever for provider organizations to ensure patients have a good experience, from the pre-visit to after care has been provided.
"The experience a patient has with a provider after the visit has occurred is probably more critical than even pre-visit because you have to treat the patient as a consumer," Mr. McHugh said.
Billing and payment processes are an important aspect of the patient experience, and medical groups that overlook this may see increases in patient complaints and bad debt. "In the high-deductible health plan world that we live in, the patient is one of the largest payers in the market," Mr. McHugh said.
From educating patients about their billing during the time-of-service to providing easy-to-read billing statements to offering patients multiple ways to pay their bills, it is crucial for an RCM partner to help a medical group effectively manage patients' expectations.
Zotec Partners offers several easy and convenient patient payment tools that help enhance the revenue cycle interactions patients have with medical groups.