The health system revenue cycle only continues to grow more complex, time-consuming, and demanding. With evolving regulations, changing payer policies, and the intricacies of medical billing, healthcare organizations face mounting challenges in managing their revenue effectively.
Meeting these demands requires innovative strategies, advanced solutions, and a commitment to optimize revenue processes. At Becker's 14th Becker's Annual Meeting, Terry Russell, VP, Implementation and Optimization with Conifer Health Solutions, emphasized the significance of technology to optimize and standardize health systems' revenue cycles.
Mr. Russell highlighted three central pathways for automation and patient access in the revenue cycle, each of which involves its fair share of change management, continual improvement and updates, and strong communication with patients and payers.
Below are summaries of those three pathways, which Mr. Russell discussed in detail with hospital and health system executives gathered in Chicago in April 2024.
- Eligibility. Conifer Health Solutions has the capability to not only to leverage service codes, but to mine for the 271 transaction set for problem accounts, Mr. Russell said. He emphasized the importance of identifying limited benefit plans or insurance that may not provide adequate coverage for patients.
"We don't want anybody coming into our hospitals without some sort of idea as to what their insurance covers and having that conversation with them," Mr. Russell said. "Timing is everything."
Mr. Russell shared one example related to Texas Medicaid, where providers must bill the most appropriate evaluation and management with a modifier "FP" visit procedure code. Without identifying this code, patients may not have hospital benefits. When these coverage shortfalls are mined and detected ahead of time, health systems can proactively work with patients to determine the extent of their coverage. - Automated estimates. Conifer Health Solutions' automated estimates are swiftly generated, typically within a minute of a scheduled encounter, according to Mr. Russell. This capability, which the company has offered for years, continues to expand its scope.
However, this capability presents challenges due to the dynamic nature of estimated charges in healthcare appointments. "It's not like they go to the store, pick a can of peaches, and know exactly what that's going to cost," Mr. Russell explained. "A physician or provider of care can change the treatment plan at any time." Conifer has dedicated significant efforts over the past five years to address this challenge. Mr. Russell highlighted the development of algorithms and synchronization of timing around eligibility confirmation to enhance the accuracy of estimates. - Authorizations. "I would say authorizations are the number one pain point for patient access in general," Mr. Russell said. "We want to make sure that authorizations are a non-issue for the patient and that the hospital receives the revenue for the services that they're providing."
One critical aspect of authorization management is rules management, which is determined by payers and dictates the necessity of authorizations for specific CPT codes. These rules can vary even at the group health plan level, resulting in health systems and organizations dealing with thousands to millions of fragmented rules and policies related to authorizations. For instance, Conifer Health Solutions manages about 2 million rules across its enterprise.
Moreover, maintaining these rules is a continuous effort, as Mr. Russell highlighted. His team regularly reviews authorizations for rules-related discrepancies on a weekly basis to ensure the viability of rule sets.
For hospitals & health systems, physician groups and employers & unions. Conifer Health is your partner in care – providing revenue cycle and value-based care solutions that optimize financial performance, improve business outcomes and elevate the healthcare experience.