But what is revenue cycle management? In short, revenue cycle management is the set of administrative and clinical functions related to capturing client service revenue. It begins when a consumer schedules an appointment and continues through point-of-service registration, charge capture and coding, claims submission, remittance processing, payer follow-up, and analysis. Crucial to revenue cycle management is clearly articulated workflows, sufficient staffing, integrated technology, and regular oversight.
“The revenue cycle management process is not going to change, the tools and info and detail to manage revenue cycle management are going to change, said Mr. Wawrzynek. “So, when I talk with people, the key is to have the basics done and nailed now, because when you bring in another variable, like outcomes, then it is going to be difficult to be successful.”
Here are some of the key revenue cycle management changes organizations will need to make in our evolving post-pandemic, value-based world.
Easily configurable billing and EHR systems EHR and billing systems should be easily configurable to accommodate value-based contracting specifics. For example, a value-based contract may require outcomes data that is not currently collected in the EHR. A billing system may also need to collect additional discreet variables to identify individual projects or contracts at the payer level and the client level. Ms. Lane did caution that it is important to manage the changes and updates being done to your system to control the complex variables that go into billing. Don’t let your vendor make a change to the system without completely understanding what they are doing and how it will affect your systems (see Beefing Up Your EHR To Beat The Competition).
Adding the ability to suspend claims Mr. Wawrzynek explained that many billing systems can suspend claims from being sent for payments if they do not meet certain regulatory compliance standards. Organizations may need to enhance their systems to suspend claims based upon contract specific requirements. Ms. Lane also added that it is crucial to have a compliance system in place that regularly audits your billing processes. By catching wrongly billed claims earlier, not only can organizations prevent claw backs later in the year, they can build trust with payers by voluntarily offering refunds for incorrectly billed services (see More Data Means More Risk).
Directly access data stored in billing and EHR systems A major part of managing revenue cycle management in a value-based contracts, is actively managing performance data. Therefore, provider organizations should begin developing data warehouses and data models that can be used to manage performance. Ms. Lane explained that Grafton regularly pulls data and looks at their performance. In cases where their performance isn’t what they expected or they are in danger of missing the targets in their contract, they will speak with the payer. She also said that payers like to see that they are proactively reviewing their contracts and are willing to problem-solve. It goes a long way in managing their relationships (see Data-Driven Care: Using Population Health & High-Utilizer Data).
Ms. Lane explained that managers need to take a more holistic approach to the traditional revenue cycle management process. While having the correct systems in place is crucial, managers should be actively using market intelligence and monitoring the data payers are putting out. Additionally, different revenue cycle staff members should attend meetings and conferences to network with payers. People with different specialties, often have different perspectives and may find a new way to solve a problem for a payer (see Addressing Social Determinants As A Path To Revenue Growth).
Finally, it is important to communicate across different revenue cycle management teams and the organization as a whole. Ms. Lane explained that the head of your revenue cycle management team should take their position broadly and sit in on business development meetings and strategy meetings. Value-based reimbursement requires organizations to sell their services, not just fill out contracting forms. Revenue cycle management should understand the different processes and components that are expected. Across the revenue cycle management team, it’s important to communicate new enhanced rates, changes in procedures due to a new contract, etc. As contracts become more complicated and individualized, teams need to be in constant communication to ensure they are billing at or above the negotiated rate and meeting the specified requirements.
As specialty provider organizations look to re-tool their revenue management cycle process for value-based reimbursement, they should stop focusing on whether they are billing and start focusing on relationship management at every level – the C-suite, clinical, and contracting.