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The new value-based care reimbursement environment is changing healthcare revenue cycle management (RCM) and forcing healthcare providers to adopt new and unique RCM strategies. New value-based care models, whatever The Affordable Care Act (ACA) ends up being, and the transition to ICD-10 have added complex challenges to an already burdened reimbursement system. Patient volumes are rising and the newly insured’s high-deductible plans are putting added pressure on revenue cycle managers to bill and collect for the monies they are owed.

To overcome these challenges, a deep understanding of the revenue cycle is required, in conjunction with solutions that cut through RCM complexity and are tailored to individual provider’s revenue cycle management needs. RCM solutions should work with a provider’s legacy systems to build efficient workflow processes that provide higher output through the use of a hybrid model of in-house staff knowledge, outsourced expertise, automated technology and manual solutions.

“Right Sourcing” includes a combination of outsourced expertise and in-house knowledge. “Right sourcing” allows healthcare providers to take advantage of outsourced industry expertise, while leveraging their in-house staff’s knowledge base. These outsourced experts will be well versed in all Medicaid state plans, managed care plans, government-funded programs, third-party insurance, and Medicare billing rules. By leveraging their in-house staff and skilled outsourced people, in conjunction with the appropriate technologies, providers can reduce operating and capital costs, recover revenue, improve patient satisfaction, and increase productivity.

What is needed to survive and thrive in this new reimbursement environment is a suite of end-to-end, comprehensive revenue cycle management solutions, including:

Extended Business Office — Using a combination of advanced technology resources, along with qualified and knowledgeable outsourced billing professionals, this type of solution can improve first-pass rates, and provide an accuracy level of up to 97 percent with significantly improved turnaround times.

Charge Capture and Payment Posting – This solution can automate the receipt, processing and posting of all RCM paper documents, including charges, demographics, insurance payments, patient payments and correspondence.

Claims Management — Understanding the components of how the different aspects of claims management affect reimbursement are critical to ensuring that claims are paid promptly.

Denial Management — Experienced analysts adept at trending denials and looking for patterns of deficiency will increase cash flow and reduce aging A/R. Most healthcare organizations do not have enough of this expertise on staff.

Accounts Receivable (A/R) Management — It is critical to any provider’s success to have access to qualified resources that understand how to quickly and correctly analyze account history, appeal denied claims, and get timely turnaround to recover and close out A/R.

Credit Balance Resolution – This aspect of RCM carries with it real and serious financial and compliance risks. It is a provider’s fiduciary responsibility to manage these real risks. Industry data shows that over 55 percent of credit balances are a result of incorrect posting of allowances.

Health Information Technology (IT) — IT automation tools can increase providers’ visibility into their data, automate their processes, streamline workflow, and provide business intelligence to enhance the decision-making process.

This kind of RCM will not only help healthcare provider’s survive in today’s reimbursement environment, but will also help them cope with the new value-based care delivery world.

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