Transforming Healthcare Revenue Cycle Management
By ClearCycle Team

The Healthcare sector is witnessing large scale technical reforms as data analytics, AI, and automation become more mainstream. More and more industries are utilizing these technological advancements in their current business processes to address challenges. This transition not only helps them to gain a competitive advantage in the market but also presents multiple opportunities to drive transformation in the industry.

Healthcare Revenue Cycle Management: An Overview

The healthcare Revenue Cycle Management (RCM) is a complex financial process for healthcare providers. It deals with the billing lifecycle of a patient that commences from the treatments, includes patient registration, claims generation, and the final submission of a claim to the payer and revenue collection for offered healthcare services to the patient. It is a crucial revenue management activity in a hospital or health care provider unit.

Healthcare Revenue Cycle: Components and Management

As healthcare makes a transition from fee-for-service to value-based care reimbursement, it has seen changes in the traditional revenue cycle management. A general revenue cycle proceeds as follows:

  1. Patient Appointment– This includes the schedule and patient account creation with the correct details.
  2. Verification for Insurance Eligibility– Information about a patient’s insurance coverage, deductibles, and insurance registration information
  3. Upfront Collection– This includes payment collections of co-payments and deductibles and any payment plan presentations in case of overdue credits.
  4. Clinical Documentation and Coding- This is where the patients’ examinations and treatments are done. This step involves collecting and correct documentation and management of prescriptions, reports, diagnostic tests, and other documents and assigning the right claim codes.
  5. Claims Management– This includes the charge capture responsibilities, like converting medical and physician services into billing charges. These charges are then submitted to the claims payers. Some of the submitted claims may get rejected at times. Reimbursement management of the revenue is also an integral part of this cycle.
  6. Medical Billing and Final Collections- After claims settlement or something not covered by the insurance, any remaining balance on a patient account is sent to collections. Medical billing staff should create and send bills to patients and make responsible payment collections.
  7. Reporting- This step involves the final reports generated, for the patients, doctors, the hospital and the clinical staff, and the accounts staff as a whole

All these steps in the regular healthcare system’s revenue cycle need to be streamlined to get the maximum output. Most practices only collect 60% of their accounts receivable, which leaves 40% of potential revenue in limbo. The various services are carried out by different front-end and back-end teams. A significant first step towards transforming the healthcare revenue cycle management would be reducing the segmentation in the various departments to bring them together on a common platform. This step will enhance collaboration among multiple staffing levels and expedite payment collection.

Using Technology to Unlock Opportunities in the Revenue Cycle Management 

Let us explore how the revenue cycle for a healthcare system can use technology like AI and analytics, and automation at each step of the process to witness a positive transformation.

Patient Registration and Scheduling– This is the first place in a healthcare unit to handle patient data and has the maximum chances of manual errors. Efficiency can be enhanced by using these techniques:

  • RPA or Robot Process Automation can be used to simplify manual data entry systems. Repetitive, routine tasks can be supplemented with RPA techniques, and human robots can be used for data entry, which provides cost and time savings, and improved business processes.
  • Similarly, ICR-based solutions for document scanning, i.e., using Intelligent Character Recognition to read hand-written or scanned documents, will considerably improve data accuracy.

Insurance Eligibility Verification and Pre-Authorizations- This step of the cycle involves several laborious and time-consuming tasks not done in real-time. Here hospitals can use E-verification of insurance eligibility, which is enabled by payer APIs.

  • This allows the use of authorized software programs called web crawlers. They can log in to the website of the payer using the provider’s credentials to make an authorization query on behalf of the patient. 
  • The same web crawlers can also retrieve and check status on several requests at once. They can standardize the answers and transfer this information to the hospital’s system.

Medical Coding and Charge Capture– This step of the RCM can use medical coding solutions powered by data analytics, like, CAC, or Computer Assisted Coding. Companies can benefit from the use of machine learning and Natural Language Processing (NLP). These techniques will automatically recognize and extract data from medical documents and assist in proper coding and billing.

Payment Posting- Patient payments and plans can be streamlined by Automated Payment Plans and allowing patients to pay through an automatic payment portal.  AI-based ICR (Information Collect Request) solutions for payment posting and automated data reading from EOB (explanations of Benefits) and ERA ( Electronic Remittance Advice) driven by Machine Language can be utilized to improve accuracy and speed. Patients should get the facility of Automated Finance plans with options to make payments upfront or over time.

Payment Collections – The manual collection of patient payments and follow-ups becomes hectic and prone to errors. At this stage, RPA-based solutions can be employed for manual tasks. Analytics-driven process optimization can be used to drive transformation. Third-party payment gateways can be incorporated into invoices and viewed in real-time. Better still, contactless payments can be substituted as a clean method of payment.

Reporting– The reporting part is the most critical section of the revenue cycle. With robust automated reporting tools, companies can analyze accounts and invoices, and make reconciliation statements and end-of-day reporting quick and hassle-free. Nowadays, several fully customizable reporting tools are available that integrate with the management systems to provide detailed reports and statements.

Summing Up:

Automation in the right direction and correct solutions can go a long way in simplifying and enhancing the Healthcare Revenue Cycle Management. Automated services not only reduce administrative costs and processing time but result in an overall increase in revenue for the healthcare system. This further leads to more fulfilling patient experience and quality care administration by the healthcare unit.

Get in touch with Clearcycle today to know more about how you can automate your processes and enjoy lower operational costs.


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