Financial challenges and market conditions are prompting healthcare organizations to redesign legacy revenue cycle management (RCM) workflows, remove costly steps and optimize claims for accelerated, data-driven, real-time settlement.
This was a major theme in an executive roundtable sponsored by Optum at Becker's 9th Annual Health IT + Digital Health + RCM Conference. Two Optum leaders — Cindy Klain, general manager and senior vice president for administrative software, and Sunay Shah, executive director for product management and strategy — facilitated a discussion on common pain points in RCM workflows and the strategies healthcare organizations are deploying to address them.
Here are the three key insights from the session:
1. The front-end, middle and back-end processes of RCM workflows are rife with challenges.
- Front end: What happens at the front end has a domino effect on the rest of RCM. Common front-end issues are grouped into three key buckets, each with multiple touchpoints that cause friction due to inherent inefficiencies:
1) patient acquisition; 2) financial clearance and 3) payments.
"One wrapper you can put around this part is how we are strategically engaging with patients, proactively across digital, telephone, and mail in a personalized approach, ensuring they feel part of the entire journey within the organization," Mr. Shah said. - Middle: Two big friction points here are around ensuring revenue integrity (coding, clinical documentation integrity, audit and compliance, appeals and denials) and providing clinical decision support (including utilization management, admission and second-level review, authorization submission, concurrent review and discharge planning).
- Back end: Three big pain points here occur around: 1) AR management (insurance liability, coverage detection, over/underpayment management, denials management and appeals process); 2) patient responsibility management (third-party coverage, early out, billing and statements, payment collections, financial counseling); and 3) contract and claim management (contract modeling, adherence, reimbursement integrity).
2. Revenue cycle breakdowns and inefficiencies can no longer be ignored.
Technology solutions to these widespread RCM challenges are emerging but are often applied sporadically or are incomplete.
"We're trying to automate the prior authorization process and come up with a comprehensive product versus piecemeal opportunities," one roundtable attendee said. Another participant said his organization is building bots to reduce human-driven administrative costs, which are often just shifted externally when contracting an outsourced solution.
The roundtable discussion highlighted proven solutions that can be applied throughout the revenue cycle. On the front end, healthcare organizations might consider enhanced insurance verification, enhanced payment collections personalized to patient preferences, digital access (like self-scheduling and self-pay), conversational AI and patient registration automation.
In the middle or mid-cycle, bringing forward payer-specific edits for more efficient claims processing, automation for clinical documentation integrity (CDI), point-of-care ambient documentation and autonomous coding are being prioritized.
On the back-end processes, enhanced claim edits and gathering intelligent insights becomes important.
Automation can play a role in appeal resolution, autonomous AR follow-up and managing underpayments.
3. Vendor management is key to successful solution implementation.
Whatever RCM solutions organizations end up investing in, sharing feedback from pilots with vendors is crucial to getting value out of those solutions and partnerships.
However, because pilots do not usually represent a full integration workflow, implementing a solution in one department first to see how it goes before deploying it across multiple functions is another good way to assess options and refine as needed.
Regardless of the approach healthcare organizations take, it is important they "think about managing the change and building the trust of the people who will have to use the technology," one attendee said.