In healthcare, providers at the bedside know the care team goes far beyond the nurse and doctor. Delivering the highest quality care requires an interdisciplinary model where experts are called on as needed, information is shared, collaboration and continuous performance improvement are part of the process.
Much like a patient’s care team, there are many players who must come together to ensure an organization’s revenue cycle is the healthiest it can be. Making this happen goes far beyond the billing and claims staff – or at least it should. In reality, it’s critical to involve not only front and back office team members, but those who are actually delivering (and documenting) patient care.
An often-overlooked key to success for RCM optimization is understanding the complexities of each payer contract throughout the organization. From providers to patient registration staff, to claims and billing teams and beyond – educating various team members on contract variances is a critical element of improving your revenue cycle. The nuances outlined in these often grueling contracts can have a significant impact on healthcare organizations of all sizes’ bottom line by helping staff avoid or respond to denials, catch errors in reimbursement, and much more.
Who Should Be On the RCM Care Team?
Here are some key team members to consider educating when trying to enhance your revenue cycle – keeping these key members of the team involved and engaged in understanding provider contracts is a critical step toward success.
Providers: While most providers have little familiarity with payer contracts, the truth is, it’s worth taking the time to educate providers on some of the highlights that may impact reimbursement. For example, depending on the contract, the way a provider documents can have a significant impact on RCM indicators. Some payer contracts reimburse based on quality metrics and/or adherence to evidence-based standards, which comes back to ensuring the provider accurately documents the care they deliver. Similarly, complexities such as risk adjustment scores and requiring alternate DRGs that proliferate some contracts can really have an impact on how or if claims are paid – both of which rely on provider documentation. Oftentimes, physicians think it’s up to the coders and RCM staff to ensure appropriate payment when oftentimes, it’s their documentation that can make all the difference. Having these frank discussions with providers is critical.
Preauthorization – Staff responsible for submitting preauthorization for a procedure or treatment to the insurance company should be well aware of the contracts to ensure a streamlined process without denial or delays, which could lead to cancelled procedures and lost OR time.
Patient Registration Staff – Varying contracts mean varying co-pays, co-insurance – as well as when these fees are expected from the patient. Registration staff who understand each contract will know how much needs to be collected at the time of service, which can significantly reduce the need for back-end collections.
Revenue Cycle Management Staff – While it may seem obvious that RCM staff should have an understanding of payer contracts, today’s healthcare organizations have so many contracts at varying levels (think ACA plans with metal levels) that it can get complicated. Ensuring RCM staff have access to reference all contracts in a centralized location can help ensure they have the information needed to verify accurate reimbursement, submit appeals, and the like.
With shrinking profit margins, all healthcare organizations are looking for ways to enhance their revenue cycle. While most organizations ensure members of the billing and coding staff are familiar with the specifics of a payer contract, getting the full interdisciplinary team on board is an important key to improving your revenue cycle.
GeBBS provides a comprehensive range of revenue cycle management solutions, serving thousands of hospitals and healthcare organizations nationwide. To learn more GeBBS technology enabled solutions, contact us today.