Resolving Revenue Cycle Challenges Without Risky Tech Investments

RCM is ripe for tech innovation but harnessing its value requires the right talent, innovative technology, partnership, and collaboration.

Hospitals and health systems face significant bottom line pressure, from inflation and escalating costs to supply chain issues and staffing shortages. The shortages are not only among nurses and physicians, either. One of the hardest-hit areas involves staff who manage revenue cycle processes. A recent poll of medical group leaders found that coders were the most challenging positions to hire for, followed by billers, schedulers, and authorization specialists.^[i]

Another labor cost challenge is the inordinate amount of time physicians and other clinical staff spend on largely administrative duties such as completing prior authorizations, appealing claims denials, and composing the growing amount of documentation required for a payer-approved claim. While providers want to focus on clinical care, they must ensure accurate and complete documentation to support compliant reimbursement.

Innovative RCM Technology is Essential

Several new and advanced technologies, however, can help hospitals and provider groups overcome revenue cycle challenges amidst a historic shortage of qualified professionals. Here are a few examples:

Payer compliance and prior authorizations (PAs)

Problem: Complying with payer prior authorization requirements consumes valuable staff time and can lead to care delays.

Solution: Automation, along with an AI and rules-based approach, can help improve patient satisfaction while easing the staff burden by identifying PA documentation requirements in advance. Use of technology-led solutions can significantly reduce appointment cancellations due to lack of authorization, helping prevent delays in care while reducing PA-related denials.

Coding and Clinical Documentation Improvement

Problem: Poor coding and clinical documentation lead to costly and time-consuming claims denials and payer audits. 

Solution: Computer-assisted coding (CAC) and autonomous coding solutions use natural language processing (NLP) to choose the appropriate medical diagnosis, procedure, and phrases from the patient chart. The technology then matches them to the ICD-10 and CPT codes. AHIMA (American Health Information Management Association) suggests that CAC can increase coder productivity by 20%.^[ii] Based on a “before-after” assessment across various clients, Omega Healthcare noticed that an AI-assisted clinical documentation improvement solution with a “human-in-the-loop” approach can help increase physician revenues by 2%-5% while improving their overall coding compliance.

Claims denials

Problem: In a recent survey by Omega Healthcare and Eliciting Insights, 67% of healthcare leaders said “denials, audits, and takebacks” were their top revenue cycle concern. Another survey found that nearly 70% of medical groups experienced an increase in denials, with the average increase being 17%.^[iii]

Solution: Advanced AI and machine learning solutions can conduct root-cause investigations of denials, analyzing payer adjustment codes from remittance forms and creating denial reports for providers to improve documentation. While predictive AI solutions help identify the claims that are likely to be denied and address the potential issues during pre-submission, generative AI solutions can streamline denials correspondence through automated letter generation that supports the original claims.

Outsourcing RCM Yields Benefits

Selecting, implementing and integrating all these technologies, however, can be costly and disruptive for provider organizations. That is why more hospitals and providers today are outsourcing to revenue cycle management partners for a comprehensive range of solutions, including prior authorization/benefits verification, coding, claims management and billing, payment posting and reconciliation, A/R management, and collections, denials and appeals management, and underpayment recovery.

Ideally, RCM partners should offer flexible technology-led delivery models regardless of location—onshore, nearshore, or offshore—and modular or end-to-end solutions aligned around outcomes.

Leading RCM partners offer expertise with advanced technologies such as AI, machine learning, and NLP to automate repetitive tasks, reduce turnaround time, and increase accuracy. Partnering with such companies alleviates providers from risking a large investment in new solutions and integration that could impact productivity.

Some RCM partners also offer fully credentialed clinical teams licensed in the U.S. to reduce clinician burnout and improve retention. Utilization review nurses, authorization specialists, and other clinical staff can play a vital role in identifying systemic issues leading to claims denials. Additionally, these clinical teams can review patient charts before service to identify prior authorization and medical necessity documentation requirements.

The best RCM partners have a reputation for leading innovation in revenue cycle management and helping improve financial performance such as 10-20% improvement across collections and denial rates. They are known by their clients for being trusted partners who deliver scalability, quality service, accuracy, regulatory compliance, and integrity.

[i] Bottom line impacts from revenue cycle staffing challenges,” MGMA, March 23, 2023 (https://www.mgma.com/mgma-stats/bottom-line-impacts-from-revenue-cycle-staffing-challenges)

[ii] “United States Medical Coding Market Analysis Report 2022: A $32.6 Billion Market by 2030 – Increasing Automation and Development of New Technologies for Faster and More Efficient Medical Coding – ResearchAndMarkets.com,” Business Wire, September 6, 2022

[iii] “6 keys to addressing denials in your medical practice’s revenue cycle,” MGMA, March 18, 2021 (https://www.mgma.com/mgma-stats/6-keys-to-addressing-denials-in-your-medical-practice-s-revenue-cycle)