From the June 2022 issue of HealthCare Business News magazine

Medical coding
Medical coding is another commonly outsourced service that is part of the RCM process. This service is commonly outsourced due to the specialized knowledge and training required to perform coding. One of the challenges for medical coding companies is keeping up with the standards for the industry and continually training their coders. For example, in 2015, a shift was made from the old coding language, ICD-9, to the new coding language, ICD-10. Following this transition, pricing for coding services increased as the vendors attempted to recover their costs required to train their coders on the new, more complex, and specific coding language.

Notably, pricing for medical coding services tends to be measured on a “per chart” or “per hour” basis and is often segmented depending on the medical or departmental specialty (e.g., emergency medicine, surgery, inpatient care, outpatient, etc.). As with billing and collections, it is important to benchmark your rates for coding services to ensure they are competitive and reflect the appropriate type and fee structure.
Software solutions
Healthcare systems also use a number of software platforms for RCM. Most electronic health record vendors (e.g., Epic, Cerner, Meditech, and Allscripts) offer modules for RCM that can perform patient accounting (billing and account receivables), patient management (ADT), and general financials, and are priced based on an annual subscription fee.

Computer-Assisted Coding (CAC) software
CAC is a specialty software used for computer-assisted coding (CAC) and clinical documentation improvement (CDI), which aids coders by providing the grouping and coding of services. CAC software uses natural language processing (NLP) to analyze clinical documentations and produces appropriate medical codes for specific phrases and terms within the document. 3M’s 360 encompass platform and CDI solutions are market leaders for such solutions. Optum 360, Dolbey’s Fusion CAC, and EZDI CAC are other competing vendors in this market.

Pricing for CAC software is a subscription fee based on the number of annual inpatient days or annual outpatient visits. As such, it is important to have those metrics listed on any agreement.

Claims management software
Claims management software helps payers (insurers) manage, monitor, and evaluate the entire claims life cycle. By using it, agents manage the claims process with automated workflows. Change Healthcare’s Assurance Reimbursement Management, Experian’s ClaimSource, nThrive, Optum, and Waystar are examples.

June 2022 Magazine

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