Unlocking revenue potential through continuous insurance discovery
As financial challenges grow, healthcare providers are under increasing pressure to secure revenue. One key strategy in this effort is continuous insurance discovery, which has become essential in changing projected earnings into real returns while supporting patients on their financial journey.
“Continuous insurance discovery better positions healthcare organizations to realize more revenue and streamline operations from the moment a patient enters your facility until timely filing,” says April Wilson, vice president of product management for FinThrive. “With margins being as thin as they are for most providers, every dollar counts, and cash in hand is crucial.”
In the following conversation, Wilson explains how a comprehensive insurance discovery process can enhance the patient’s financial experience and help providers uncover more revenue opportunities. She also explores the benefits of proactive continuous coverage detection and key vendor considerations, such as seamless integration throughout the entire patient journey and flexible pricing, when investing in an insurance discovery solution.
Q: What is insurance discovery, and why is it important for providers to address throughout the revenue cycle?
Wilson: Insurance discovery is the process of helping providers find valid insurance coverage that might otherwise go undiscovered. It's crucial to know as much as you can about the patient throughout the entire revenue cycle, from pre-service through billing. Insurance discovery helps fill in gaps in the patient’s background and involves them in financial decision-making, which enhances satisfaction. Having this information readily available optimizes the patient’s financial experience, especially in cases where the patient is incapacitated or there’s confusion about their policy. It also helps ensure accurate billing and prevents eligibility-related claims denials.
Although often used for self-pay patients who present without coverage, insurance discovery is also highly effective in managing coordination of benefits (COB) issues. For instance, if a patient arrives with secondary coverage, insurance discovery can identify the primary coverage. By adopting automated insurance discovery technologies, providers can significantly reduce revenue leakage by capturing every possible coverage option and billing appropriately.
Insurance discovery has significantly evolved from its traditional post-service focus to a more proactive pre-service approach. By shifting this process to the front end, healthcare providers can streamline operations and enhance efficiency for their staff. Addressing insurance details before a patient is discharged reduces the need for post-appointment clean-up, allowing staff to focus on more critical tasks. Moreover, with increasing expectations for staff to collect payments upfront, pre-service insurance discovery offers patients a clearer understanding of their financial responsibilities, presenting an accurate picture of what is covered by their insurance. This proactive strategy not only simplifies operations but also fosters transparency and trust with patients.
Q:What are the advantages of continuous insurance searches prior to the point of service over other solutions?
Wilson: Continuous searches allow providers to stay proactive in managing patients’ changing insurance situations so no potential coverage is missed. This approach helps protect patients financially and enables providers to recoup all possible revenue. Continuous search enables coverage to be checked right up until the timely filing deadline, so no dollars are left behind.
For instance, the provider might enroll a Medicaid-eligible patient during their hospital stay, but it could take months for the policy to be issued and applied to the account. During this period, continuous monthly searches are essential to identify and apply that coverage.
The financial impact of not utilizing continuous insurance discovery is significant. For one, it helps prevent denials due to COB issues. Also, insurers typically reimburse claims within three to ten business days, providing crucial cash flow. In contrast, billing patients directly often results in delayed or partial payments, taking up to 90 days to secure payment. Continuous search solutions also reduce administrative burdens, saving staff from the time-consuming task of manually finding active policies, which can delay payment processing.
Q: How does insurance discovery fit into a best-practice patient access strategy?
Wilson: A world-class patient access strategy involves gathering as much information as possible before the patient arrives. This process includes sending appointment reminders, providing estimates, assessing payment ability and conducting financial screenings. When collecting any payment up front, you want to ensure it’s a reasonable amount that the patient can afford. Confirming patients have valid, active insurance for their visit is a significant part of the process. This proactive approach guarantees patients receive comprehensive financial counseling. Thorough preparation improves patient satisfaction and simplifies front-office interactions, reducing unpaid bills. Ultimately, fully understanding the patient and engaging in thoughtful financial discussions fosters loyalty and strengthens the patient-provider relationship.
Q:If organizations are looking for an insurance discovery vendor, what are the three most important things to consider?
Wilson: First, accuracy is paramount. It’s essential to partner with a vendor who can identify patient coverage with precision, using robust systems and multiple layers of identity validation to avoid errors and ensure correct matches. A strong track record in delivering accurate, relevant coverage across all insurance types, including specialty areas like pharmacy or dental, is crucial. This level of accuracy ultimately saves time and confirms accurate billing on the first attempt.
Value is equally critical. You want a partner that understands your financial constraints and offers a solution that maximizes revenue recovery at a fair price. For example, features like continuous search, which is built into FinThrive’s platform at no extra charge, should be included as a one-time payment per record. If a person has applied for Medicaid, you shouldn’t be charged each time you check for that record to appear.
Finally, you want a partner focused on simplicity, flexibility and transparency. Embracing a subscription pricing model is essential in achieving this, as it allows you to leverage the full potential of your insurance discovery solution without budget constraints. Such a model helps you focus entirely on identifying comprehensive patient insurance coverage and uncovering revenue opportunities, maximizing your returns effortlessly. A great partner will offer advanced automation and intelligent systems to streamline processes while also providing options for manual reviews. The solution should be intuitive, allowing you to concentrate on the most profitable opportunities to recoup cash quickly. Transparency is key; the vendor should provide reports and access to advisors to help you understand the value you’re getting and to optimize your use of the product.
Additionally, Wilson notes that partnering with the right vendor can lead to a substantial ROI of 700% to 1,100% within the first year of implementing an insurance discovery solution. “A provider without an insurance discovery system, including manual processes, could be leaving six to eight digits of revenue on the table annually,” she says.
Adaptability and advanced data aggregation are critical as organizations gear up for future opportunities
Revenue cycle management (RCM) platforms are proving to be crucial in healthcare finance. By harnessing the ‘platform effect,’ they effectively reduce inefficiencies and data barriers while weaving in intelligence from the start. Cheryl Alden, chief marketing officer at FinThrive, points out that these platforms are tailored to navigate today’s revenue cycle complexities, offering data-driven insights for proactive decision-making.
In a recent conversation, Alden outlines the transformative role of RCM platforms in addressing both present and looming challenges within the revenue cycle. "In a climate where every dollar is scrutinized, the expansiveness and flexibility of our systems are crucial. Revenue cycle leaders and their IT partners must develop a reliable infrastructure that not only solves critical challenges today but also prepares the organization to capitalize on upcoming opportunities and innovation.”
Alden examines the factors driving the need for a new category of RCM platforms shaped by the aftermath of the pandemic. She discusses key elements providers should consider when choosing a platform and suggests careful evaluation due to the varied effectiveness of available options.
Q: What compelled the healthcare industry to carve out a new category for revenue cycle management platforms? How does this evolution reflect the changing needs in healthcare finance?
Alden: New categories often arise when an industry faces new challenges. After COVID-19, healthcare was forced to quickly adapt to new care delivery methods, workforce changes and patient expectations, all under tighter economic constraints. Organizations are now re-prioritizing investments in financial operations alongside clinical care, recognizing that strong revenue is fundamental to enhancing patient care and quality outcomes. Recent data shows RCM technologies are a top investment for health systems going forward. It’s in this context that the so-called “end-to-end” platforms have become increasingly relevant, offering advanced insights that connect all the dots.
Q: Can you discuss why not all end-to-end revenue cycle management platforms are created equal? What should providers look for when choosing a platform?
Alden: Absolutely. For starters, the definition of “end-to-end” is not standard and is something to pay attention to. RCM platform vendors have typically grown through a combination of building and buying, leading to a mix of capabilities across the category. At FinThrive, we believe a platform partner should not force their customers to choose between breadth and depth. Having to trade off best-in-breed point solutions for a single vendor system that is just “good enough” is thankfully becoming a thing of the past. Let’s face it, implementing new technology is disruptive. With this in mind, it becomes imperative for providers to select an RCM partner that has the breadth of technology options for both today and tomorrow while not sacrificing quality and capability. As my mother would say, do it once and do it well.
One of the key differentiators to look for is the potential to achieve the ‘platform effect’— the “1+1=3” benefits that are associated with consolidating vendors to leverage more technology from a single source. The ability to aggregate data for enhanced analysis and decision-making is becoming a “must-have” capability for platforms. Analytics are crucial; they transform a platform from a mere set of tools into one that delivers actionable insights, especially in critical areas such as denial prevention. To pull data from multiple solutions into a single enterprise view offers a unique vantage point for RCM leaders, helping them understand both gaps and opportunities in their revenue operations.
Finally, partnership is key. Revenue cycle teams want systems built by revenue cycle professionals. A partner should have a deep understanding of the revenue cycle and a commitment to a long-term relationship. Many providers want to avoid the complexities and limitations of excessive customization. They’re turning to those who offer a consultative approach to advise them on a standardized solution that allows data to flow more easily. An experienced partner provides guidance in this area, helping customers navigate common pitfalls and deploy best practices for successful outcomes.
Q: Do RCM platforms require providers to take an “all or nothing” approach, or is there flexibility in how they can get there? If so, how?
Alden: RCM platforms are commonly referred to as “end to end” or “E2E,” which can be misleading for providers thinking they have to buy the entire portfolio all at once. In reality, the path to RCM platform adoption is not one-size-fits-all. Few providers are in a position to wipe out their existing RCM technology stack and deploy a full replacement despite some of the advantages. Given that dynamic, it’s important vendors offer flexibility to meet the specific needs of each customer. While the benefits of a platform are becoming more widely acknowledged, the pathway to actually ‘getting there’ is less clear for providers currently working with numerous vendors.
To aid in this transition, FinThrive and HFMA created the industry’s first company-agnostic Revenue Cycle Management Technology Adoption Model (RCMTAM) inspired by the HIMSS EHR adoption model. It’s a complimentary, five-stage assessment model that offers benchmarking insights drawn from healthcare finance leaders. Encapsulating over 30,000 data points, the model helps providers determine their current maturity stage, identify what’s mission-critical to address now and begin to plan for the future. Presently, almost half of providers are at stage one of RCM maturity, partly due to vendor limitations.
Our benchmarking data guides providers on improving financial performance and increasing efficiencies by linking specific technologies to business processes at each stage in a personalized analysis. It identifies under-optimized areas, helping to drive focus toward their technology investments and adopt best practices more effectively.
Q: How do you envision a revenue cycle management platform influencing revenue optimization strategies in the future? What potential transformations could these platforms trigger in the industry?
Alden: One of the big promises of RCM platforms is empowering people with better information to make informed decisions so they can focus on things that truly require human intervention. At FinThrive, we’ve shifted the narrative of this concept to ‘Revenue Management,’ moving away from the idea of a ‘cycle’ that suggests constant reworking and information chasing. The future lies in efficiently processing and compensating accurate claims, placing the focus and attention on revenue optimization and improving the patient experience, not managing elements of the revenue cycle that can and should be automated.
The right RCM platform has the potential to break the cycle of inefficiency, going beyond just facilitating payments. It can dismantle data silos across organizations, empower comprehensive analytics and help providers better understand trends impacting their business and patients. Instead of retrospectively considering what could have been done better, this strategic approach positions organizations to preemptively avoid mistakes by leveraging the intelligence that modernized technology can deliver.
Alden urges the industry to keep the spotlight on empowering the financial side of healthcare through technology innovation. “Revenue is the lifeblood of our industry. Without it, investment in better patient experiences, improvement of patient outcomes and the modernization of tools to achieve greater efficiencies can’t happen. For healthcare to reach its true potential, we must continue to push the industry to advance and mature its approach to RCM.”
For more information on the industry’s first Revenue Cycle Management Technology Adoption Model, visit finthrive.com/RCMTAM.
Selecting the best fit in a landscape of diverse offerings
Revenue cycle management (RCM) platforms are proving to be crucial in healthcare finance. By harnessing the ‘platform effect,’ they effectively reduce inefficiencies and data barriers while weaving in intelligence from the start. Cheryl Alden, chief marketing officer at FinThrive, points out that these platforms are tailored to navigate today’s revenue cycle complexities, offering data-driven insights for proactive decision-making.
In a recent conversation, Alden outlines the transformative role of RCM platforms in addressing both present and looming challenges within the revenue cycle. "In a climate where every dollar is scrutinized, the expansiveness and flexibility of our systems are crucial. Revenue cycle leaders and their IT partners must develop a reliable infrastructure that not only solves critical challenges today but also prepares the organization to capitalize on upcoming opportunities and innovation.”
Alden examines the factors driving the need for a new category of RCM platforms shaped by the aftermath of the pandemic. She discusses key elements providers should consider when choosing a platform and suggests careful evaluation due to the varied effectiveness of available options.
Q: What compelled the healthcare industry to carve out a new category for revenue cycle management platforms? How does this evolution reflect the changing needs in healthcare finance?
Alden: New categories often arise when an industry faces new challenges. After COVID-19, healthcare was forced to quickly adapt to new care delivery methods, workforce changes and patient expectations, all under tighter economic constraints. Organizations are now re-prioritizing investments in financial operations alongside clinical care, recognizing that strong revenue is fundamental to enhancing patient care and quality outcomes. Recent data shows RCM technologies are a top investment for health systems going forward. It’s in this context that the so-called “end-to-end” platforms have become increasingly relevant, offering advanced insights that connect all the dots.
Q:Can you discuss why not all end-to-end revenue cycle management platforms are created equal? What should providers look for when choosing a platform?
Alden: Absolutely. For starters, the definition of “end-to-end” is not standard and is something to pay attention to. RCM platform vendors have typically grown through a combination of building and buying, leading to a mix of capabilities across the category. At FinThrive, we believe a platform partner should not force their customers to choose between breadth and depth. Having to trade off best-in-breed point solutions for a single vendor system that is just “good enough” is thankfully becoming a thing of the past. Let’s face it, implementing new technology is disruptive. With this in mind, it becomes imperative for providers to select an RCM partner that has the breadth of technology options for both today and tomorrow while not sacrificing quality and capability. As my mother would say, do it once and do it well.
One of the key differentiators to look for is the potential to achieve the ‘platform effect’— the “1+1=3” benefits that are associated with consolidating vendors to leverage more technology from a single source. The ability to aggregate data for enhanced analysis and decision-making is becoming a “must-have” capability for platforms. Analytics are crucial; they transform a platform from a mere set of tools into one that delivers actionable insights, especially in critical areas such as denial prevention. To pull data from multiple solutions into a single enterprise view offers a unique vantage point for RCM leaders, helping them understand both gaps and opportunities in their revenue operations.
Finally, partnership is key. Revenue cycle teams want systems built by revenue cycle professionals. A partner should have a deep understanding of the revenue cycle and a commitment to a long-term relationship. Many providers want to avoid the complexities and limitations of excessive customization. They’re turning to those who offer a consultative approach to advise them on a standardized solution that allows data to flow more easily. An experienced partner provides guidance in this area, helping customers navigate common pitfalls and deploy best practices for successful outcomes.
Q:Do RCM platforms require providers to take an “all or nothing” approach, or is there flexibility in how they can get there? If so, how?
Alden: RCM platforms are commonly referred to as “end to end” or “E2E,” which can be misleading for providers thinking they have to buy the entire portfolio all at once. In reality, the path to RCM platform adoption is not one-size-fits-all. Few providers are in a position to wipe out their existing RCM technology stack and deploy a full replacement despite some of the advantages. Given that dynamic, it’s important vendors offer flexibility to meet the specific needs of each customer. While the benefits of a platform are becoming more widely acknowledged, the pathway to actually ‘getting there’ is less clear for providers currently working with numerous vendors.
To aid in this transition, FinThrive and HFMA created the industry’s first company-agnostic Revenue Cycle Management Technology Adoption Model (RCMTAM) inspired by the HIMSS EHR adoption model. It’s a complimentary, five-stage assessment model that offers benchmarking insights drawn from healthcare finance leaders. Encapsulating over 30,000 data points, the model helps providers determine their current maturity stage, identify what’s mission-critical to address now and begin to plan for the future. Presently, almost half of providers are at stage one of RCM maturity, partly due to vendor limitations.
Our benchmarking data guides providers on improving financial performance and increasing efficiencies by linking specific technologies to business processes at each stage in a personalized analysis. It identifies under-optimized areas, helping to drive focus toward their technology investments and adopt best practices more effectively.
Q:How do you envision a revenue cycle management platform influencing revenue optimization strategies in the future? What potential transformations could these platforms trigger in the industry?
Alden: One of the big promises of RCM platforms is empowering people with better information to make informed decisions so they can focus on things that truly require human intervention. At FinThrive, we’ve shifted the narrative of this concept to ‘Revenue Management,’ moving away from the idea of a ‘cycle’ that suggests constant reworking and information chasing. The future lies in efficiently processing and compensating accurate claims, placing the focus and attention on revenue optimization and improving the patient experience, not managing elements of the revenue cycle that can and should be automated.
The right RCM platform has the potential to break the cycle of inefficiency, going beyond just facilitating payments. It can dismantle data silos across organizations, empower comprehensive analytics and help providers better understand trends impacting their business and patients. Instead of retrospectively considering what could have been done better, this strategic approach positions organizations to preemptively avoid mistakes by leveraging the intelligence that modernized technology can deliver.
Alden urges the industry to keep the spotlight on empowering the financial side of healthcare through technology innovation. “Revenue is the lifeblood of our industry. Without it, investment in better patient experiences, improvement of patient outcomes and the modernization of tools to achieve greater efficiencies can’t happen. For healthcare to reach its true potential, we must continue to push the industry to advance and mature its approach to RCM.”
For more information on the industry’s first Revenue Cycle Management Technology Adoption Model, visit finthrive.com/RCMTAM.
Why analysis has become so complex and how tech is delivering deeper insights
Amidst an evolving landscape, hospitals and health systems grapple with a myriad of escalating business challenges, including surging denials, diminishing patient volumes, reduced payments, the pursuit of revenue recovery and the quest for sustained profitability. For healthcare finance leaders, the task at hand is not just about navigating these choppy waters but also interpreting essential revenue cycle metrics to get better visibility into performance across the revenue cycle. John Yount, chief innovation officer for FinThrive, points out that the complexity of healthcare operations is exacerbated by intricate processes, a multitude of stakeholders and the existence of data silos that keep essential information just out of reach. “Data typically originates from a single source, a best-of-breed solution, preventing a comprehensive view of the revenue cycle and the ability to stay on top of critical areas such as payer performance.”
Yount advocates for the adoption of a unified system that creates a 'platform effect,' streamlining data sharing across the organization to drive enhanced revenue cycle outcomes. Here, he examines the benefits of end-to-end (E2E) platforms, revealing strategies that have effectively bridged revenue cycle management gaps and boosted reimbursement rates.
Q: What are the primary challenges faced by healthcare revenue cycle management (RCM) leaders when analyzing revenue cycle metrics?
Yount: There are three key areas where roadblocks are most prevalent in revenue cycle performance evaluation. The first lies in leaders having difficulty efficiently monitoring their performance, primarily due to data silos. Currently, the RCM landscape is quite fragmented, with data scattered across multiple niche systems. Most health systems rely on 30 to 40 different RCM vendors. There's an increasing need for consolidation through a unified platform. The second challenge is figuring out ways to increase net revenue. With so much dispersed data, leaders often grapple with evaluating data from multiple sources in one view to get a complete understanding of an issue. As a result, they are challenged to identify effective steps required to impact revenue growth positively. Another significant problem is the slow access to data, which restricts the ability to act swiftly on corrective measures. It’s not uncommon for revenue cycle departments to spend days or weeks compiling essential data, which delays interventions and affects desired results.
Q:Which one of the challenges mentioned stands out most and why?
Yount:The most significant challenge is undoubtedly the data silos. The core issue is that data often comes from a variety of niche solutions that aren't naturally aligned. This means there's a need for additional tools to consolidate this data, which is a complex task for providers. In practice, organizations have traditionally monitored key performance indicators (KPIs) across distinct categories, such as patient access, pre-billing, claims, account resolution, financial management and productivity. These categories have been quite compartmentalized, which makes it difficult to compile a comprehensive data view. In many cases, a leader only has a picture of the KPI that's specific to the work they're doing. To illustrate, consider pre-billing, where the KPI 'discharged, not final bill' (DNFB) is typically monitored. But what we want is to enable an executive to look at DNFB in conjunction with other critical metrics, such as denial write-off percentage, all in one place. Ultimately, this provides insights specific to pre-billing but also encompasses broader financial management metrics.
Q:What are the advantages of using an E2E platform for KPIs or metrics over point solutions?
Yount: An end-to-end platform excels by centralizing scattered data, which allows for a comprehensive and contextual analysis of both payer and provider performance. For example, with denials increasing, it’s critical to accurately assess your top payers by examining collections, denials, underpayments and the payer mix together for a comprehensive understanding of trends. This unified view extends to provider performance, bringing together productivity and revenue data into one platform. With the ability to compile diverse data into one unified interface, we can overlay different data sets for a more complete analysis. This not only enhances our understanding of performance but also informs the actions needed for improvement.
Q:Have any of your customers successfully overcome these challenges, and can you share the outcomes?
Yount: The concept we have championed, known as the 'platform effect,’ is all about leveraging a shared data environment to drive efficiency and action across a health system. It is the effect that has enabled our clients to realize substantial improvements in key areas. Specifically, in overall reimbursements, there's been an uptick of about 5% in revenue. Additionally, having access to benchmark data has empowered them to identify and close gaps in revenue cycle management outcomes, leading to boosts in performance by 10% to 15%. This all circles back to our core objective: transitioning from metrics derived from single data sources to a more integrated approach where data from multiple streams converges and brings end-to-end intelligence. This approach doesn't just pool data—it adds a layer of context, enabling comprehensive analysis across the entire revenue cycle for more predictive and proactive revenue management.
In conclusion, Yount emphasizes the urgency of resolving fragmentation within healthcare finance systems. "Unresolved, we're going to continue to see organizations struggle from a margin perspective," he states. He foresees a market shift towards comprehensive, end-to-end solutions that cover the entire revenue cycle, from patient access to revenue recovery. "Opt for a partner that can deliver these essential capabilities to truly harness the platform effect," Yount advises.
Wilson: Insurance discovery is the process of helping providers find valid insurance coverage that might otherwise go undiscovered. It's crucial to know as much as you can about the patient throughout the entire revenue cycle, from pre-service through billing. Insurance discovery helps fill in gaps in the patient’s background and involves them in financial decision-making, which enhances satisfaction. Having this information readily available optimizes the patient’s financial experience, especially in cases where the patient is incapacitated or there’s confusion about their policy. It also helps ensure accurate billing and prevents eligibility-related claims denials.
Alden: New categories often arise when an industry faces new challenges. After COVID-19, healthcare was forced to quickly adapt to new care delivery methods, workforce changes and patient expectations, all under tighter economic constraints. Organizations are now re-prioritizing investments in financial operations alongside clinical care, recognizing that strong revenue is fundamental to enhancing patient care and quality outcomes. 
Yount: There are three key areas where roadblocks are most prevalent in revenue cycle performance evaluation. The first lies in leaders having difficulty efficiently monitoring their performance, primarily due to data silos. Currently, the RCM landscape is quite fragmented, with data scattered across multiple niche systems. Most health systems rely on 30 to 40 different RCM vendors. There's an increasing need for consolidation through a unified platform. The second challenge is figuring out ways to increase net revenue. With so much dispersed data, leaders often grapple with evaluating data from multiple sources in one view to get a complete understanding of an issue. As a result, they are challenged to identify effective steps required to impact revenue growth positively. Another significant problem is the slow access to data, which restricts the ability to act swiftly on corrective measures. It’s not uncommon for revenue cycle departments to spend days or weeks compiling essential data, which delays interventions and affects desired results.