An effective Revenue cycle management begins with a set of well trained professionals and a proficient work flow practice. The RCM community must be aware of the emerging strategies to provide with excellent outcomes for clients. The procedure starting from fixing the individual’s appointment to the final claim settlement must be managed with a holistic approach with 99% accuracy by the staff members.
All of the demographic and medical data must be gathered from the individual prior to the consultation. The collected data validation in the first stage helps in handling the most critical parts of the progress, that include billing and clinical coding which helps in the reduction of denied claims.
Here is a quick checklist of pitfalls to avoid in revenue cycle management to provide better results.
PITFALL 1: LACK OF KNOWLEDGE
RCM involves various teams, interconnected to one another in order to manage the RCM operations. Each team must work together as a group to ensure that the patient’s data is accurate right from the initial stage of registration till the claim is processed. A small mistake in any one task may cause a delay or denial for the entire claim.
With the rise in number of patients, it becomes all the more difficult for employees to carry out their duties. The people involved in the process should be updated with the latest additions/changes in the procedure and rules. This will help in getting accurate results. In most of the cases it is the lack of knowledge which results in claim errors and issues So it is critical to know whether the RCM team have sufficient knowledge and training to handle the entire claim process.
PITFALL 2: FAILURE TO CHECK PATIENT DATA
Authentication of data and eligibility during the initial stage is a crucial part of an effective RCM. It is essential to verify individual’s eligibility prior to the appointment, as it helps in determining the charge that is to be paid even before the treatment is given. By verification the concerned person may receive a EOB (Explanation of Benefits) or ERA (Electronic Remittance Advice), which states the eligible amount covered of by the insurance team and the bill that is to be paid by the concerned person, if any.
Many staffs don’t fully check the eligibility and limit allowed. A study claimed that 25% of providers never verify individual’s eligibility or deductible amounts, while another 25% check the data only after discharge.
If the claim is processed without the authentication of data, there is a greater chance that it will be denied, leading to an unexpected bill falling on the shoulders of a patient who may or may not be able to make the settlement and may even lead to unpaid bills.
This is one of the most vital pitfalls to avoid in revenue cycle management, especially since deductibles and patients are increasing day by day. The RCM companies should make sure that their staff inquires about eligibility and collect the deductible amounts at each and every encounter of patients.
PITFALL 3: NOT FOLLOWING UP WITH DENIED AND RESUBMITTED CLAIMS
The staff must continuously monitor the status of the submitted claim and identify any error in it. Rejected claims must be resubmitted with the valid reason for progression. Any mistake made by a specific department must be corrected as soon as possible in order to close the denied claims.
Many of the staffs forget to settle the resubmitted claims. Forgotten claims may lead to a huge loss to the hospitals. Like wise, unpaid claims by individuals must also be made a priority to be taken care of. The individual must be made aware on the available payment options and steps must be taken to close the settlement.
No claim should be left open, the longer it is left unattended, the higher the charges. So it is important to check whether the team is following up claims properly.
PITFALL 4: LESS NUMBER OF ACCOUNTS RECEIVABLE EXECUTIVES
It is indeed a difficult task to find the right group of professionals with the relevant skill set to manage the RCM process. Due to this reason most of the health providers try to maintain the RCM with the existing number of staffs.
As there is an increase in population, technology, etc., the number of people visiting health care facility has also increased. This leads to increase in accounts. In order to manage these challenges, effort should be taken to modify the staffing systems to meet the demands of accounts.
Accounts receivable staffs work on managing the accounts of both the insurance claims as well as the follow up with the patients. They are also liable for filing of settled claims, handling resubmitted claims, and unpaid bills. The AR team goal is to attain the maximum level of remuneration and payments.
By the help of a well trained and sufficient set of AR staffs, the estimated amount of denied claims can be reduced. Regular training and updates to AR executives will make them gain more knowledge.
PITFALL 5: NOT FOLLOWING ICD UPDATES
ICD stands for “International Statistical Classification of Diseases.” It is managed by the World Health Organization (WHO) and was originally a classification system, providing a set of unique codes for distinguishing diseases.
The ICD codes are modified each year. They are deleted or changed and the updates are expected to be followed by the health care companies. Ignoring these updates may lead to claim denials and a broken revenue cycle. ICD is currently in 10th revision also known as ICD10 and The next revision of the ICD11 will come into effect in 2022.
According to a report, error and faults in use of ICD codes have led to a numerous number of denied claims in the recent years causing more payments from hospitals, patients, and other care providers. This is one of the most common pitfalls to avoid in revenue cycle management to reduce the number of denied claims as well as to save the revenues of clients.
PITFALL 6: NOT UPDATED WITH LATEST TRENDS
Since the people involved in the Revenue Cycle process is quite busy dealing with billing, coding and claims, no one is able to notice that the health care industry is evolving each day. It is important to notice the trends that are developing which may seem like a challenge for the RCM team to keep up with.
The policies are reformed, new ideas and modern technologies are implemented each day in the health care domain. Effort must be made by RCM staffs to adapt to the changes that are reforming the health care sector.
Future trend analysis can be analyzed by some following up researches and case studies in medical departments. One of the major advancement in the sector is the use of AI (Artificial Intelligence) and RPA (Robotic process automation) in the field. Weekly reviews can be done and monitored to learn about the emerging trends in RCM.
These common pitfalls can be avoided by monitoring at each stage of the RCM. If these mistakes are continuously made, it may lead not only to delayed payment but also create revenue loss to the hospitals.
The people involved in RCM process must be well trained professionals who are completely aware of the system flow and are able to adapt to the changes that they are challenged with. Measures must be taken to see to that there are prior validations of data, minimal denied claims, no shortage of staffs, following the set rules of ICD and future trends.
Pitfalls to avoid in revenue cycle management: But how?
With the ever-evolving healthcare industry, you should keep a tab on required changes in your organization to make a difference. Here are some steps that you can follow:
- Take a note of your denial rates. A greater denial rate for a long period of time indicates that you are making repetitive errors. That might be incorrect coding or redundant billing methods.
- Once you identify the issue, work on it with your staff to make sure it does not happen again.
- Analyze data reports frequently. Data reports will give you clear insights into where you are going wrong with your billing methods.
- You can take the help of AI tools or get an outsourcing medical billing company to give you a detailed analysis.
- Make sure you perform regular staff training programs. This will help your staff to stay updated on the latest modifications of the billing industry.
- They can also adapt to the best practices of the industry and fasten their working methods.
- It would help if you also listened to any concerns that your team might be having on the billing front due to a lack of efficient technology. Keep them in mind and invest in proper tools that will increase organizational efficiency.
We hope that this blog helped you understand the pitfalls in revenue cycle management about which you should be careful. If you have any queries, please comment down below, and we will definitely reach out to you. For more such updates on healthcare management and technology, please subscribe to our blog. Follow us on Twitter, Facebook, Instagram, LinkedIn, and YouTube to get regular updates!