Revenue Cycle Management

What Factors Contribute To The Complexity Of The Revenue Cycle In Health Care?

What Factors Contribute To The Complexity Of The Revenue Cycle In Health Care?


Revenue Cycle Management is a vital aspect for all healthcare providers. The quality of the revenue cycle outcomes influences every part of care for patients. The ability of a practice to maintain quality care is dependent on precise clinical documentation and transparent communication between providers, payers, and patients to ensure prompt reimbursement. Over the past years, the majority of healthcare institutions and practices have begun to automatize the RCM processes, resulting in higher efficiency and improved customer experiences for patients. However, a variety of significant issues remain, especially for healthcare professionals. Medical specialties need to address various financial and administrative challenges that are harming financial performance compared to their counterparts.

In this blog, we will examine the most significant challenges to effective revenue cycle management within specialty healthcare. Because healthcare services are specific to a particular area, the revenue cycle process requires specialist resources with specialization-specific capabilities. RCM is required for Specialty healthcare and is a challenge to many healthcare institutions due to the frequent modifications to regulations. Furthermore, it could be challenging because it demands attention to administrative and financial difficulties, which usually negatively impact the stability of its finances.

Top Hospital Revenue Cycle Management Challenges and Solutions


  • Billing and Collections Mistakes

A poor process for billing could result in millions of dollars of loss. Because patients are more than ever before liable for the cost of their out-of-pocket expenses, hospitals need to ensure that they complete all required collections without placing too much pressure on patients so that they aren't forced to seek out a new health facility. If they don't have a streamlined and efficient procedure for collection, hospitals might not be able to collect the maximum revenues at the time of service. To ensure stability in their finances, regardless of the constantly changing revenue cycle market, hospitals need an efficient process for medical billing staffed by a competent team. It's an excellent idea for any service to have a proficient medical billing system, ensuring that the payments are processed quickly. It's also advantageous for a service to hire an experienced, appropriately trained medical billing staff that recognizes the importance of accuracy and reliability of the information they work with daily.


  • Enhancing Interoperability between the Financial and Clinical Systems

 Data interoperability is the keystone for success in the current healthcare setting. When you have a unique healthcare visit, one patient could access more than half a dozen health IT platforms. All of these platforms record an enormous amount of clinical data. Interoperability among systems is crucial in assembling a comprehensive and up-to-date picture of the patient's health status and a complete account of any reimbursement services offered.

Specialty practitioners must create an infrastructure that facilitates the integration of clinical activity data, provides a complete picture of the status of patients to healthcare professionals, and ensures that financial information related to the patient is appropriately integrated into work processes for business offices. This seamless interoperability approach can assist in several crucial aspects that specialty care providers must fulfill, like assessing the need for prior authorization when designing the treatment plan or predicting future appointments with patients dependent on the achievement of prescribed clinical milestones.


  • Strong Prior Authorization Process

Prior authorization is getting the payers' approval before the provider provides any service to the patient. It can help reduce costs and allow providers to deliver evidence-based care to patients. In healthcare, specialized prior authorizations are vital because specialists can develop a treatment plan that meets the unique requirements of different payers. So outsourcing your authorization procedure to an RCM firm aware of the specific requirements for prior authorizations in specialty healthcare will increase the clean claims rate, decrease the number of denials, and boost reimbursements.


  • Collection from Patients

One of the most significant Revenue Cycle Management challenges for healthcare companies is collecting payment from patients before or at the point of service. While managing the cost before patients leave the office could save time and energy when ordering, most healthcare providers agree that it's challenging. Collections at the point of service have become increasingly complicated as most patients can't afford to pay medical bills upfront, and the deductibles of many patients have increased. Hospitals should improve their understanding of patients' responsibility and develop more straightforward methods to collect payments from their customers to ensure financial stability in an ever-changing world.


  • Maintaining Regulatory Compliance 

Compliance with regulations is an issue for every provider; however, specialists might face additional challenges. Specialists spend more time working with the policies and procedures related to referral agreements and prior authorizations to care. Of course, the absence of critical regulatory requirements can tremendously cause problems in the revenue cycle. Simple things like placing a single patient's health data at risk can result in various issues that can affect the revenue. For instance, the HIPAA breach penalty imposed on "unknowing" violations can mean an amount of $100 in penalty for a civic offense.


  • Monitoring Drug and Treatment Pricing and Payer Contracts 

It's common for professionals to offer services that include the latest treatment and medications. However, more modern and advanced standards of care could lead to higher costs across the spectrum of costs. To ensure your practice receives the proper reimbursement for specific services, it is crucial to be aware of the current treatment and drug prices following specific contracts for payers. Since treatment changes continuously in medicine and reimbursement rates are re-adjusted by the payers on an ongoing basis. For instance, CMS Centers for Medicare and Medicaid Services (CMS) adjusts its pricing for the reimbursement of drugs every quarter.


  • Inappropriate management of A/R

Your Revenue Cycle Management team should know the accounts receivable benchmarks used by various specific services and follow them. Failure to adhere to these benchmarks could hurt your revenue. Therefore, it is essential to develop proper routine operational procedures and guidelines to reduce the days of account receivables and prevent and control denials. 


  •  Tracking Claim

Another major challenge for Revenue Cycle Management is tracking the claim throughout its life cycle. Healthcare professionals must be watching the process of submitting claims closely to determine where mistakes occur. Revenue may go unclaimed if companies fail to find out the cause and fix the issue quickly. Providers typically receive automated alerts that explain why payers frequently deny claims for specific methods or codes.


  • Employee Training

If healthcare staff members aren't adequately trained, they may not be able to bill or collect the correct patient data accurately. Healthcare personnel charged with billing should know how to effectively manage a patient's demographic data on the front end and convert that information into successful insurance claims later on. Most claims-related issues are human errors like incorrect code, defective items in the patient's account, or concerns about insurance eligibility. Healthcare companies should invest in ongoing employee education programs that emphasize appropriate coding practices, thorough chart documentation, and financial reminders of policies. The training sessions are connected to a better ROI, including lowering employee turnover and decreasing medical mistakes.

As a healthcare services organization, you need to be aware of these challenges and have the appropriate tools and strategies to deal with these challenges. Enhance your facility's financial well-being by outsourcing your revenue cycle management to Houston's dependable RCM services provider with specialized knowledge.