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Hospitals outsource revenue cycle management to meet value based payment initiatives [infographics]

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The value-based care payment reform is a huge game changer. It has brought about vast changes in the way hospitals manage their billing and revenue cycle operations. This infographic tracks the changes brought on by the payment model that has drastically altered the way healthcare organizations handle their RCM process.

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Conclusion: All these statistics and facts point towards one trend- the emerging and burgeoning need for RCM providers to bail healthcare organizations out of this tricky phase. Please share out this infographic if you find it useful.

4 Thoughts on conducting a successful RCM Audits [Infographic]

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Regular RCM audits have become an absolute necessity to run a successful and compliant medical practice. This infographic explains in detail the four tips shared by healthcare administrative and revenue cycle expert Karen Bowden, to conduct successful RCM audits. Her thoughts were recently published in Becker’s Hospital Review.

Successful RCM Audits

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Medical practices should conduct regular RCM audits to mitigate financial risks in the future. Frequent audits helps in eliminating redundant processes and adopting best practices to achieve optimal outcomes. Please share this infographic if you found it useful and help us reach more people.

Cloud Computing for Optimal Revenue Cycle Management

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Cloud Computing Healthcare Industry

Viable Financial Options: Data Centers or Cloud Computing Services?

Outdated Revenue Cycle Management (RCM) systems are likely to make a big dent in financial viability of small and medium clinics and hospitals across the US. In such a scenario, these healthcare establishments face the bleak prospects of extinction or take over by larger hospital groups and lose their independence.

As a proactive action to preserve their independent healthcare business, these organizations are seriously considering two viable options, namely data centers and cloud computing based services, each with its pros and cons.

Data Center Versus Cloud

The data center is an onsite, high tech physical entity that houses a multitude of server banks. Data centers are experiencing a boom with an increasing demand. However, demand for data centers has outstripped their availability, mainly due to constraints of physical space.

Cloud storage, the virtual model, also utilizes many server banks with thousands of serves, although off-site. Usually, a third-party vendor incorporates an extensive network of servers located anywhere in the world. However, instead of electronic healthcare software or other applications downloaded on each computer, a central server in the cloud is accessed by the entire network.

The Winner !

Hospitals and clinics are evaluating alternative strategies of data management. They are analyzing relative financial and operation merits and demerits of data centers and cloud computing systems for storing and processing electronic health records, diagnostic images, email programs, and other healthcare applications.

The dice is heavily loaded in favour of cloud computing systems. Some of the reasons, out of the many, are :

  • 1. Lower cost for computer configuration.
  • 2. Decrease maintenance costs while freeing data storage capacity.
  • 3. Enable hospitals and clinics to better utilize their resources and focus on their core     mission – patient care.
  • 4. Ensure fool-proof backup and eliminate break down of hospital RCM services.

Be Cautious in Initial Crowd Approach

Rather than adopt an over-energetic posture and move over all healthcare workflows and processes in bulk on to the cloud, it pays to adopt a step-by-step process.

  • 1. Evaluate hospital/clinic-specific needs : Carry out an in-depth analysis of needs specific to the subcategory of the healthcare system.
  • 2. Assess existing cloud services vendors in terms of :
  • A. Proficiency in providing cloud computing services specific to the healthcare industry.
  • B. Financial and professional standing of the vendor.
  • C. Reliability of back-up facilities provided by the vendor in the event of major breakdown and disruption.
  • D. Ascertain the confidentiality and security of hospital/clinical data.
  • E. Willingness and ability of the vendor to scale up or scale down the services depending on increased/decreased fluctuations of healthcare business.
  • 3. Start cautiously on a small scale : If healthcare entities find that cloud concepts are enticing, they must be vigilant at the initial phase, to move some of the less complex healthcare systems such as email and payroll to the cloud, while leaving the more critical and complex software in their in-house setting.
  • 4. Be familiar with the cloud : The physicians and in-house IT personnel should use this opportunity to familiarize themselves with the cloud with lower risk.
  • 5. Conduct pilot trial : Once major applications such as RCM and Enterprise Content Management (ECM) services are moved up into the cloud, a pilot trial should be conducted to ascertain the functioning and performance of these services.
  • 6. Fine tune and incorporate enhancements : The pilot trial will highlight refinements to be made in the workflow processes to extract maximum leverage.
  • 7. Constantly review the cloud-based services.

Revenue Cycle Management – The Road to Maximized Profit

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RCM Workflow

Effective and efficient Revenue Cycle Management (RCM) is bread-and-butter for survival and prosperity of any medical practice business. RCM is not limited to medical billing and collecting reimbursement claims. It involves tightly integrating all the clinical workflow steps, commencing with patient’s registration at the front desk, diagnosis, treatment, discharge, recovery of dues from the patient and the insurance company, and follow up on denied claims.

For ensuring financial viability of the business and before initiating implementation process of RCM, it would be prudent to carry out an in-depth assessment of the current position of the practice.

In-depth Self-examination :

There is a need to evaluate the present standing of the practice with the following posers :

  • 1. Does it take unduly a long time to collect reimbursement claims and patient payment?
  • 2. Is the denial rate for the first submission of reimbursement rate more than 4%? (For best  practice standard the rate should be less than 4%)
  • 3. Are write-offs and adjustments of pending reimbursement money very frequent and high?
  • 4. Is percentage of accounts receivable, which are more than 120 days old, higher than 10%? (For best practice it should be less than 10%).

If answer to any one of these posers is in the affirmative, then the financial viability of the practice is jeopardized.

Critical Post-evaluation Measures :

Patient Reporting-in :

On receipt of a phone call for an appointment from the patient, the front desk should ascertain medical problem and insurance coverage of the patient, and then guide the patient to provide information for registration by going online on the hospital’s/clinic’s website. Any incomplete information should be followed up before the appointment, so that the insurance coverage of the patient can be verified. An alternative process involves a kiosk for patient check-in at the clinic or hospital for collection of patient’s demographic data and automatic verification of insurance coverage.

Charge Entry and Capture in the Superbill :

As a basic requirement, physicians should ensure that the correct code with appropriate modifier is recorded in the clinical document of the patient, to ensure correct billing and preparation of claims. The billing should be timely and close to the date the patient has been provided with the medical services to avoid delay and piling up of pending claims.

Bill Clearing House :

Bill clearing house checks whether all the required data are included in the bills transmitted to the clearing house by the clinic/hospital.

Follow-up with Insurance Company :

Once the claims are transmitted to the insurance agency, follow-up is a must to ascertain the progress on submitted claims. When the claims are passed, in full or partial, the insurance company remits the payment automatically to the practice account.

Patient’s Portion of Payment :

Ascertain and recover patient’s payment contribution for diagnosis and treatment through aggressive AR callers.

Denied Claims and Follow up :

Correct and resubmit denied claims to the insurance company and follow up till receipt of payment.

Complete End-to-end RCM :

RCM encompasses all the workflow of the clinic or hospital, with each step linked to the next step as under :

 

Infographics: Eradicating Impediments In Medical Claims Reimbursements

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Physician Reimbursement Facts For 2014

Existing turbulent healthcare industry scenario :

In the current turbulent economy-ridden environment healthcare providers and physicians are not able to precisely and correctly claim the actual reimbursements of expenses incurred for  diagnostic and treatment purposes from the insurance agencies, resulting in loss of revenue, profitability, incorrect claims, delayed claims, missing out on claims, the main reason being that they are not fully equipped to provide precise diagnostic and treatment documentation, backed by capturing the correct medical codes for medical billing. The physicians do not have the time to oversee capturing the correct medical codes and medical billing procedures as they have to focus on their core competency of diagnosis and treatment as first priority.

Vital issues compounding the problems :

Healthcare professionals are constantly under pressure due to increased patient/financial constraints and regulatory pressures, forecasting a doomsday for medical services.  This situation is worsened further due to federal regulations that advocate improved, affordable healthcare services without comprising on quality issues even under the present economic scenario where the inputs for provision of healthcare services are experiencing spirally increased costs. To further complicate the issue, in-house administrative personal are not inadequately trained, inexperienced and lack the requisite expertise in medical coding and billing, as well as thorough and accurate clinical documentation.

The physicians would like to spend most of their time and efforts by focusing on core issues of diagnosis and treatment, rather than diverting their resources and energies over the nuances of managing and monitoring their   to maximize revenue. Rather than have in-house medical coding and billing services, it pays to opt for outsourcing or right sourcing the billing services to established and experienced vendors. There is a dire need for in-house analysis of existing problems, solutions, future trends, and remedial measures.

The situation will further worsen in the near future since presently health care reforms are under way with focus on affordable health coverage and quality. 

Medical Reimbursement Problems faced by Health Providers :

  1. Insufficient knowledge or experience in medical coding and billing
  2. Lack of training in medical coding and billing
  3. Physicians using In-house medical coders and billers have to feel the consequences by struggling with inexperienced coders straight out of college
  4. These billers and coders fail to cope up with evolving coding and billing guidelines, for medical procedures, and stay abreast with the latest procedures
  5. Nightmares of lost revenue and unpaid bills 

Lost revenue opportunities :

  1. Physicians tend to miss opportunities to maximize medical reimbursements from the insurance companies.Lost revenue due to various factors includes:
  2. Undercoding level of treatment,
  3. Omitting modifiers,
  4. Submission of medical reimbursement claims without the requisite documentation required to support the reimbursements.
  5. Wastage of resources in determining and tracking reasons for claims rejected, besides finding out claims missed or under claimed.

The pathway to maximum reimbursement :

  1. Out sourcing or better known as “Right sourcing” the medical billing and coding, clinical documentation, claims processing, EMR services to professional one-stop third party vendors  results  faster, precise and complete reimbursement of medical claims, boosting up revenue and  profits.
  2. Besides assigning the right codes for medical services the outsourcing vendor provides specialty specific coding services using experienced and AAPC credentialed coders on board. 
  3. The vendor is conversant with the significance of coding for the technical and professional components of a medical service, place of service codes, e/m codes, revenue codes, and when claims need to be bundled or unbundled.Compliance with all medical coding systems such as ICD, CPT and HCPCS ensures that working with such vendor is a smart option.

Remedial Measures :

  1. Wise,prudent, and strategic to partner established third party vendors such as MedicalBillingStar who have long-standing expertise, experience in dealing with state-of-the-art coding and billing services to a wide range of categories in the US medicare industries.
  2. Healthcare and medical units, irrespective of whether they are small, medium, or large, stand to experience hassle-free boost-up of medical reimbursements, without the nightmares of returned claims, missed-out claims, and piling up of rejected claims, and efforts to resubmit claims.
  3. MedicalBillingStar closely follows the on-going trends in medical coding and billing and medical insurance claims processing methodologies.

The AMA Suggests That Physicians Should Focus On Billing. Are You?

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clinic medical

Are you losing out on billable dollars ?

This is not the best time to be a healthcare provider! Financial constraints and regulatory pressures are giving physicians, sleepless nights.   Doomsayers have crawled out of the wood works to proclaim that medical practices are going to fold up and die.

It is certainly not like healthcare is circling the drain hole. But it is essential that medical practices up their game to stay afloat.

Still stuck with a payment contract that is five years old ?

The major mistake that healthcare practices make is to get paid much lower than the services they provide. Nobody likes getting on the phone and haggling with insurers. But what has to be done has to be done! Frequently negotiating reimbursement contracts will go a long way in increasing revenue.

Thorough claim analysis and evaluation of top paying CPT codes every three months can prevent and clot the bleeding.

It is okay to discuss money with patients !

Do you feel delicate when discussing about money with patients? Instead of dillydallying be forthright with your patients about treatment costs and payment options. Give them a lowdown on what and how much the insurer will cover.

A lot of patients promptly sue their doctor the minute they receive a bill. Discussing about payment prior to a medical procedure will prevent heartaches and heated arguments.

Don’t rely on straight- out of a- can solutions…

Most EMR/EHR systems come with coding and billing features. But no matter how loaded your system is, don’t lean on it completely. There are certain factors such as duration of treatment or the extent of injury that play a crucial role in increasing reimbursement. Middle of the road coding isn’t going to cut it anymore.

Why work just eight hours ?

As pressures mount and operational costs skyrocket, outsourcing has become a viable option. It makes a lot of sense to work with a billing company that works 24 hours. You not only process claims faster you can clear revenue backlogs.

Furthermore it is a nice feeling to walk in to your practice the next day knowing fully well that your biller has transmitted your claims to the insurer. And that now, finally, the accent will once more be on patient care.

ACO Wars – Pioneer vs Shared Savings Programs

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ACO

Well, it is not a war in the strictest sense of the term, but it does denote the recent developments in the ACO or Accountable Care Organization scene where many Pioneer ACOs have been opting out of the program due to difficulties in meeting the targets and the high risks involved.  About 25% of the Pioneer registered Accountable Care Organizations are in the process of exiting the program and joining the lower-risk option, the Shared Savings Program.   CMS had this to say about the fallout :

 “We’re encouraged that these organizations want to continue in programs that promote better care at lower costs, we fully anticipated that as these programs get up and running, some organizations would shift between models.” 

Health Reforms & ACOs

 For those of you, who have been too busy to register what an ACO exactly is, it is a category of CMS program, which is part of the government health reform, which includes others like Patient Centered Medical Home, Medical Neighborhood, Health Home, etc.  The reforms themselves consist of three main components, which is a superset of any practice models.  They are :

a. Care Delivery Reforms.

b. Payment Reforms.

c.  Health and Healthcare Community Reform.

 ACO is a model which is, to quote a popular definition, “an organization, virtual or real that agrees to take on the responsibility for providing care for a particular population while achieving specified quality objectives and constraining costs.”

 As the above definition clearly points out, an ACO platform is expected to stimulate more integrated care for the patients, which would ultimately result in quality improvements and healthcare cost reduction.  Also, in these programs the ACO gets a share in the costs ultimately saved.

Pioneer vs Shared Savings Programs

 SSP and Pioneer were two landmark ACO programs created by CMS.  The latter has a slightly complex format, which takes into consideration organizations that already have some experience in providing coordinated care.

 The Main Differences between the two are:

 1.  SSP has two payments tracks and it is upto to the ACO to choose either the non-risk sharing one (which has less cost savings share) and the risk-sharing track (which has higher cost savings share but at the same time there are possibilities of losses upto even 60%).

 2.  The Pioneer utilizes a trending methodology that, all other things being equal, produces a slightly higher benchmark than the SSP for high-cost areas.

 3.  The SSP will need to cater to at least 5,000 Medicare fee-for-service beneficiaries, whereas the Pioneer needs to service 15,000.

 4.  The Pioneer program importantly includes a clause that 50% of Pioneer ACOs revenues should come from participating in “risk” contracts with other non-CMS  (private) payers.

 The Significance of events such as the above

Republicans have been ardently opposing the health reforms (which is really an attempt for universal healthcare).  The recent refusal by the National Football League to team up with the government to promote ObamaCare has been touted as some sort of vindication for their stance.  Also, the refusal of some states to adopt the Medicaid expansion plan and the setting up of online HIE, to realize the goal of “healthcare for all” , is seen as further supporting evidence.   And the above developments in the Pioneer ACO scene is construed by some health reform detractors as the “straw that will break the ACO camel’s back”.

 MedicalBillingStar :  A Voice of Sanity

 With a decade of hands-on experience in servicing over 500 clients when it comes to the RCM Cycle, MedicalBillingStar always endeavors to float above the cacophony of healthcare gossips and half-truths, to provide their medical billing and coding clients with information that is relevant, besides of course catering to their entire RCM workflow.   We are aware of the impact that ACO’s will have on payment models, the changes from which ultimately have to be incorporated into the RCM process.  Thus, we keep abreast of the latest happenings in the payment model scene.  Meanwhile you may call MedicalBillingStar at 877-272-1572 or visit our website at www.medicalbillingstar.com if you any questions about any of the above or the Medical Billing/Coding processes in general.

A Few Survival Strategies For Healthcare CFO’s To Handle 2014

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Time for healthcare CFO’s to step up their plate !

2014 is going to be a year of change. Federal mandates, financial constraints and heavy penalties for non –compliance is going to make 2014 a challenging, tumultuous year. It is time to up the game to ensure medical practices don’t crumble under pressure. And as always it is the man at the helm who needs to up the game!

Focusing on wellness programs can help you save on taxes !CFO

The PPACA requires all healthcare organizations to review the wellness plans of all full time employees. Choosing a wellness plan that is highly deductible can be a major tax saver. CFOs will have to examine the current coverage plans.

And freeze in on a wellness plan that works both for their employees and also saves on taxes. This could well be the major priority of healthcare CFOs in 2014.

Systems to record the quality of care…

The healthcare landscape is undergoing a period of transition. From volume based payments. To a model that is based on the quality of care and patient outcomes. It is essential that CFO’s implement systems and upgrades to report and measure clinical variations. Maintaining, longitudinal health records that are detailed and contain data across the care continuum, is important.

Will your clinical documentation cut it ?

Do you maintain pristine clinical documentation ? If yes you are lucky. If, like a majority of health care providers your answer is, no, then it’s time you upped the ante. Review your revenue cycle that coordinate with coders and physicians to ensure more accurate and updated clinical documentation.

Analyze every phase of the RCM to see where you can reduce costs. Have your billing team give a detailed report of key financial metrics.

Outsourcing can be a huge cost saver !

Reducing the number of full time employees can help you cut back on costs. But this is a move that has to be taken after weighing in the pros and cons. 

Here’s a quick presentation for CFO’s to handle the practice.

Can Healthcare IT Help Physicians In Increasing Patient Collections?

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Are you neglecting patient collections? Technology to the rescue !

Adopting technology can help physicians not only stay in compliance but also collect more.patient-collections Patient collections have always been neglected by physicians. Getting a patient to pay is one of the toughest tasks a physician faces. The delicate doctor physician relationship means the doctor has to tread on eggshells to get paid.

With hundreds of patients walking in and walking out collecting reimbursement for every visit is an unenviable task. With latest technologies and electronic tools can help physicians increase their patient billing collection ratio.

Here is the presentation from Angomark on Are Physicians Losing Revenue? Concentrate On Patient Collections. 

Want To Save $ 23,000 ? Switching To E-Billing Will Improve Your Practice’s Financial Health

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Still Stuck With Paper ?

What is your carbon footprint ? If you are still sending out paper claims, you are felling more trees. Agreed, this is an argument that is as old as fossils. Apart from saving trees there are a lot more advantages to using e bills ! It helps to track claims easily and lessens the amount of time your insurer takes to sign your check.

ebilling-infographic

Save More Dollars !

According to the American Medical Association submitting claims electronically can save a practice 55% of its claims submission costs. The AMA further states that physicians stand to gain above 23,000 dollars a year by switching to electronic claims.

Electronic billing also reduces the TAT of insurers. The overall efficiency and cost effectiveness of the process is just what overworked medical practitioners need. Paper claims are time consuming to generate, transmit, and maintain a record of. Electronic bills are quite simply put, the smarter way to bill !

Joining The e-club !

According to a recent survey of America’s health insurance plans the usage of billing electronically has doubled. From a measly 44% in 2002 to 94% in 2012 there’s been an exponential increase in providers who are switching to e billing.

Almost 79% of claims are now automatically adjudicated without manual support. Physicians are finding e billing helpful as it helps their staff to focus on patient engagement.

A Huge Relief For Billers…

What is the biggest headache of a medical biller ? No. It is not getting claims paid. The bigger headache is finding out which claim is in what stage of processing. An average medical office sends out dozens of claims per day. Keeping tabs on each one of them can trip up the most determined of medical billers.

ERA’s and EFT’s help medical billers to hasten the pace of the billing process. And make it easier for them to maintain a clear cut billing record.

Ask Your Insurer To Move On From The Stone Ages !

It is time for insurance companies to stop working with paper claims. Physicians need to put their foot down and ask insurers to accept electronic claims! Concerted and continuous effort across the continuum will ensure that the healthcare industry functions a lot more smoothly and efficiently. And yes, save a billion trees in the process !