Technology has dramatically improved the speed and convenience at which both can operate. It used to be that all you needed to repair most car problems was a screwdriver and a pair of pliers. Modern vehicles, by contrast, are driven by so many on-board computers that you can hardly inflate a tire without first paying a mechanic to plug it in and check the diagnostics.
Perhaps the most closely aligned similarity between cars and the healthcare revenue cycle is the tumultuous industries in which they reside. Automotive manufacturers in recent years have been pinched between increasing labor and fuel costs and stiffening competition from foreign entities. Similarly, the U.S. healthcare system is front page news with increasing government spending, decreasing insurance payer reimbursement and the rising number of uninsured in the headlines.
But when you boil macro problems down to the perspective of one hospital, it all becomes the same fundamental challenge--figuring out how to get paid in the midst of everything going on around us.
In the past, healthcare providers had much simpler methods for collecting for their services. There were fewer payers and fewer rules by which they paid, and most collections were adequately handled by back-end staff. Today, a more complex revenue cycle yields an increase in the number and complexity of denials, and providers need the ability to collect at every corner of the hospital.
Industry analysts and other experts' research suggest that as much as 25% of all claims are rejected or denied on first submission. Most--90%--of those are preventable, and even after a rejection more than half are still recoverable.
Getting paid is no longer solely a function of the billing office and other back-end departments. In fact, back-end efficiency depends directly on front-end process efficiency, and successful providers are realizing that in order to capture as much revenue as possible as early as possible, they must consider a revenue cycle that begins at the first point of contact with every patient.
Fortunately technology has been developed to aid providers in this effort.
How? By first obtaining accurate patient insurance information and demographic data. Of course this is easier said than done in the fast-paced, high-pressured front-end environment. Most employees filling entry-level front-end positions are less educated and lower paid. Their daily responsibilities include managing patient access according to charity programs and Medicaid, Medicare and commercial payer rules and restrictions. Their performance is evaluated on registration time because it directly affects patient satisfaction. The expectations are high, and so is the turnover rate.
Still, the classic mandate from any CEO, CFO, or business office manager is, "I want each patient registration to be accurate and fast." And the classic response from registrars, although seldom stated out loud, "Pick one and call me back!"
Due to resource and time constraints, registration and admissions personnel cannot realistically meet the demands of today's revenue cycle using manual processes. Automation is required in order to close revenue cycle gaps.
Automated technology gives staff the ability to verify patient data at any and all points during scheduling, pre-registration, registration and admission. By confirming patient insurance eligibility, benefit types and levels, current address and co-pay and deductible amounts up front, providers are greatly increasing the likelihood that they will collect for each service performed.
But automation alone is not enough. To effectively and consistently close revenue cycle gaps, the ideal technology must have the ability to link patient inquiries. For example, if a patient presents in admissions as self-pay, then technology can automatically run his or her information against Medicaid to check for coverage, based on state of residence. If no coverage is found, then an address verification and credit score could be processed to determine the financial risks associated with treatment, particularly in non-emergent scenarios.
Automated technology can also aid front-end staff in a number of other critical functions, including:
- Pre-certifications for routine hospital stays or outpatient procedures. Pre-certification is usually done before admission for non-emergency care or shortly after admission for urgent or emergent care. It is increasingly required by some health plans for reimbursement.
- Validating procedures against medical necessity for accurate diagnosis codes. Validating medical necessity is the responsibility of the provider and should occur before services are rendered. If a Medicare procedure fails validation and the patient was not notified in writing in advance of providing the service, then the hospital cannot collect for that service. Medical necessity validation can be automated through technology to help hospitals avoid millions of dollars in potential losses.
- expedites the registration and admissions process, which improves patient satisfaction
- improves data accuracy by eliminating human error
- reduces claim rejections and denials, draws faster payment and minimizes re-billing in the back end
- improves registration staff efficiency
- dramatically boosts collections
Providers that implement the right technology will find that when their managers make the recurring mandate, "I want all registrations completed accurately and quickly," the staff response changes to "Not a problem--we have the tools to get the job done!"
Automation is the only sustainable approach that will effectively bridge revenue cycle gaps between the front and back ends.
Max Carter is vice president of sales for Passport Health Communications, Nashville. He can be reached at max.carter@passporthealth.com.
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