Managing revenue cycle in consumer-based healthcare

July 18, 2022
by John R. Fischer, Senior Reporter
Healthcare is becoming consumer-centric, with patients demanding more choices in the entire care process, from scheduling appointments to how they pay their medical bills. New technologies like Apple Pay and shifts to value-based care are giving them a greater say here and making them feel more in control of their healthcare journey.

But for providers, this has introduced new challenges that have added pressures on their already tighter budgets and dwindling reimbursements. Additionally, they are facing higher labor costs, shorter staffing and the ongoing effects of the pandemic, all of which have forced them to reevaluate their care delivery models, including for revenue cycle management.

“Hospitals and health systems are struggling to keep the lights on because the cost of labor is going up and margins are going down. How can they invest in the future? How can they invest in programs to help define the patient population across the continuum with a longer return on the investment rather than an immediate one,” Dr. James Fee, co-chief executive officer of Enjoin, told HCB News.

Fee says that moving forward, providers will need to be more strategic in how they handle their expenses, revenue streams and patient demands. He and other experts sat down to discuss how providers can do this, while investing more in and enhancing their RCM operations.

The consumer experience
In the past, revenue was based on one encounter, which made reimbursement easy and immediate. But replacing fee-for-service with value-based care has made this more complicated with an exponential number of factors to consider, resulting in longer wait times for compensation. This has proved difficult during the pandemic, with budgets and margins waning more and expenses going up. Also increasing costs is the great resignation of workers nationwide, including nurses, doctors and staff at hospitals.

Meanwhile, consumers are thinking about expenses differently, seeking to pay medical bills retail style with their phones and iPads. They also want more flexible payment plans, billing transparency before care, and more effective communication with clinicians.

Casey Williams, senior vice president of patient engagement and payment applications for RevSpring, says meeting these demands is crucial to holding on to a customer’s loyalty. “Organizations are perfecting those experiences, so that you continue to walk back in the door and use their businesses. Healthcare is starting directly or has started to recognize that over the last two or three years.”

Choosing the right partner
Changes in regulatory requirements have forced providers to adapt their processes. For instance, value-based care has them now factoring in readmission rates, comorbidities and social determinants. And the hospital price transparency rule has them publishing prices for procedures on their sites to give patients a more informed healthcare shopping experience.

As a result, more are turning to outsourcing companies who are made up of experts with specialized know-how about these tasks and how best to facilitate them. Outsourcing also potentially enables providers to focus more on patients, scale operations, and bring in extra staff while saving on costs.

The downside is a loss of control and portability, according to Williams. “If you're outsourcing your revenue cycle, you've outsourced your labor on that too. So to be portable, meaning that if you want to make a change or decision within that partnership, there is going to be a lot of friction if you want to change from one outsourcer to another. If you insource, you're more portable and can more freely make decisions about how your experience is changing because you're in control of it.”

Many factors must be considered when deciding between in-house and outsourcing, including the type of provider, patient demographics, and infrastructure and resources. If an organization outsources, they must ask the right questions to find the vendor best suited for their needs. A good RCM partner, for example, should understand the workflow and consult with the provider about what experience their patients want, according to Sandy Coffta, vice president of client services for Healthcare Administrative Partners.

She says that providers should look for a company with credentialing and a robust charge reconciliation process that captures every service carried out. “With a good RCM company, you should have a good level of communication and serviceability to make you feel the same comfort level you would if billing were in-house.”

Investing in the right technology
In March 2022, Northwell Health, the largest care provider in New York State, signed a 10-year agreement with Clinithink to use its CLiX revenue solution to integrate natural language processing into its RCM operations. These automated capabilities can help it process millions of documents in hours instead of days and extend revenue cycle review without increasing staff costs.

As patient volumes continue to increase, solutions like this will continue to become more desirable to help process growing numbers of claims more quickly and accurately, as well as automate manual tasks. “Physicians should spend 80% of their time on the 20% of the tasks that require their full attention; the rest can be automated,” said Joey Cavanaugh, chief operations officer at Zotec Partners. “This paves the way for more in-depth and meaningful patient-doctor interactions, and it’s a significant asset for combating physician burnout.”

Artificial intelligence and machine learning are also helping providers facilitate patient preferences, such as how they would like to communicate, whether it be by phone, text or in person, so as to improve their experience. Cavanaugh says that as machine learning becomes smarter and analyzes more data, it will find new ways to cut costs, save on time and help with filing accurate claims.

Coffta says automation is also helping to check eligibility and direct claims, denials and other tasks to people best equipped to take care of them. Meanwhile, Williams is seeing AI and machine learning help patients and doctors come up with effective payment plans. “I can look at their actual ability to make payments and know if they should pay in full versus, on a prescribed payment plan, versus if they qualify under a financial assistance policy. AI and machine learning allow empathy to be infused in those interactions. It goes back to value-based care in interactions and ensuring the patient comes back through our doors.”

Prepping for the future
Today, RCM is influenced by hundreds of variables that will only grow in number as care continues to become more value-based, with factors like price transparency, shorter staffing and higher expenses weighing in. Whether an RCM team is in-house or outsourced, it should have the most up-to-date expertise to properly account for these factors, says Coffta. “The biggest challenge is making sure you're staying aware and educated about the changes that are coming. Make sure that whether you use an outsourcing company or in-house staff, that they are up to speed with the latest regulations.”

In addition to AI and automation, Fee says that providers also should look for solutions that expand interoperability, as hospitals seek out data both in and outside their walls to personalize care. “It's a siloed approach as we move towards value-based care. We need to invest in technology that looks beyond the hospital setting and infrastructure. That’s a sort of a larger, longer term investment as we look at the longer term horizon in revenue health.”

Cavanaugh says conversations with patients must be clear and concise and give them a thorough understanding of what to expect regarding care and payment. “With patients as payers, providers will need to meet them where they are at by listening to feedback and implementing enhancements quickly before referrals decrease and negative reviews increase.”

Additionally, the future of RCM is just as important as the present, says Williams. "It's important to choose a partner that is solving today's challenges and innovating for the challenges of tomorrow. It's paramount to constantly evolve how we engage with patients."