As the healthcare sector continues to struggle with the financial impacts of the COVID-19 pandemic and the mass job departures known as the Great Resignation, some providers and payers are finding renewed success through a comprehensive revenue cycle management (RCM) solution.
An optimum RCM solution allows organizations to do more with less. An end-to-end RCM platform helps organizations maintain regulatory compliance and improve workflow, coding accuracy, billing efficiency, reimbursement rates and patient experience through two key areas: automation adoption and staffing augmentation.
The pandemic contributed to more than $4 trillion in national healthcare spending in 2020, a nearly 10-percent jump over the previous year and the biggest increase since 2002.
Yet U.S. hospitals collectively lost more than $50 billion in revenue in 2021 due to higher operating expenses, fewer outpatient visits and increased lengths of stay among inpatients. And the financial forecast for providers is not good; a mid-year analysis of national hospital data found many hospitals reporting decreases in revenue and outpatient volume.
Meanwhile, more than 5 million U.S. workers have quit their jobs during the Great Resignation, many of whom have been in healthcare. The healthcare industry was already facing a staffing shortage before the pandemic and Great Resignation, but it has lost an estimated 20 percent of its workforce since 2020.
And the exodus is likely not over. According to a COVID-related stress and work intention study published by the Mayo Clinic, 1 in 5 physicians and 2 in 5 nurses intend to leave their current practices within two years.
In addition to tight operating margins and a workforce shortage, providers and payers face the challenges of evolving regulations regarding value-based care, telehealth use, reimbursement methods and interoperability. An RCM solution that deploys technology-driven automation and healthcare-specific staffing augmentation can help on all fronts.
The effective automation of healthcare revenue cycle management processes stems from three critical components:
- Industry standardization
- Robotic process automation (RPA)
- Artificial intelligence (AI) and machine learning
When part of a fully integrated RCM solution, these elements streamline productivity and the patient journey by elevating medical data accuracy and improving data security and access.
Of the approximately $391 billion spent on administrative complexity in U.S. healthcare, about 11 percent — $42 billion — is devoted to nine common transactions, according to the 2021 CAQH Index produced by the Council for Affordable Quality Healthcare.
Of that $42 billion, the healthcare industry could save about $20 billion by transitioning to fully electronic transactions for standard activities, including:
- Eligibility and benefits verification (ASC X12N 270/271)
- Prior authorization (ASC X12 278)
- Claim submission (ASC X12 837)
- Attachments (ASC X12 275)
- Acknowledgements (ASC X12N 277CA/999)
- Coordination of benefits (ASC X12N 837)
- Claims status inquiry (ASC X12N 276/277)
- Claim payment (EFT/ACH)
- Remittance advice (ASC X12N 835)
Automating those nine everyday transactions industry-wide could lead to 48 percent savings on the annual spend for administrative complexity.
The purpose of RPA is to augment staff with process automation.
Robotic process automation utilizes software “robots” to standardize and automate repeatable business processes. Think of RPA robots as virtual assistants that can handle repetitive tasks previously performed by valuable human resources.
RPA provides healthcare organizations benefits that include enhanced:
- Accuracy: RPA minimizes human errors and the costs associated with them.
- Compliance: RPA follows regulatory guidelines with precision and creates transparent audit trails.
- Speed: RPA can complete tasks up to 5 times faster than a human, which improves efficiency and gives crucial human resources more time to devote to patient care.
- Reliability: RPA robots are always available and work around the clock, regardless of patient flow or staffing fluctuations.
The advantages of RPA aren’t limited to direct revenue cycle functions. RPA can also boost employee morale. Long hours, heavy workloads and high stress are the driving factors in healthcare turnover; an RCM solution that incorporates RPA and strategic automation frees employees from repetitive tasks so they can focus on high-touch endeavors.
At its core, AI is the capacity of a computer system to understand and simulate human intelligence. AI grows its knowledge through machine learning, the computer science that enables AI to comprehend tasks and improve performance through experience rather than direct programming.
These processes include acquiring information and contextual rules for certain data, using the data and contextual rules to reach conclusions, and advancing AI learning through successes and failures. AI is essential to interoperability and an end-to-end RCM system because it complements and furthers RPA’s merits.
Where RPA uses structured inputs and processing logic, AI develops its logic from unstructured data. In conjunction with robotic process automation, AI allows the performance of far-reaching functions with complete autonomy.
Because healthcare organizations generally have structured data (field-based numbers and values) and unstructured data (a mix of text, speech and other files), RPA and AI are intrinsic to complete automation. Together, they also help improve automated processes after deployment.
The healthcare workforce has reached a crisis point. A solution that amplifies AI-enabled technology with professional outsourcing can keep up with the demands of vital revenue cycle processes, including coding operations and accounts receivable management.
Two healthcare workforce augmentation options are:
- Onshore labor
- Nearshore/offshore labor
Each has its unique benefits. To ensure accuracy and regulatory compliance, GeBBS Healthcare Solutions works with credentialed auditors and professional coders certified by the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).
Onshore labor is beneficial for conducting complex and high-value transactions that drive revenue.
Onshore staffing is ideal to ensure automation delivers at a high level, especially during a technology transition. Onshore staffing can also monitor analytics to identify opportunities for workflow improvements and revenue enhancement.
Expert auditors help ensure payers and providers meet applicable standards established by the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), the American Hospital Association (AHA) and AHIMA.
Nearshore/offshore labor is a low-cost and easily scalable staffing augmentation solution.
As robotic process automation is being implemented for repetitive tasks, nearshore/offshore labor can support the technology more cost-effectively than additional internal or temporary staff. Small-balances AR and professional fee coding by certified coders are just two areas where nearshore/offshore resources can assist during the technology transition.
These resources can be increased or subtracted according to workforce attrition, patient volumes or other needs.
GeBBS Healthcare Solutions is a leading provider of technology enabled RCM and Risk Adjustment services.
GeBBS is dedicated to helping our partners find the optimal automation and staffing solutions to meet immediate demands and foster revenue growth while sustaining compliance. We support our clients’ success with advanced IT, certified medical coders, experienced audit professionals and electronic medical record experts.
GeBBS is proud to be recognized as a Leader by Everest Group’s Revenue Cycle Management Operations, one of Black Book Market Research’s Top 20 RCM Outstanding Services, one of Inc. 5000’s Fastest-Growing Private Companies in the United States, one of Market Research’s Top 20 RCM Outstanding Services and one of Modern Healthcare’s Top 10 Largest Revenue Cycle Management Firms.
Connect with GeBBS today at gebbs.com to request a consultation and free demonstration.