Revenue Cycle – Back to the Basics

Ensuring that critical revenue cycle fundamentals are strong can improve healthcare organizations’ chances for success amidst a sea of change and reform.

This slideshow requires JavaScript.

Just like in sports, it’s important to have a strong core set of skills or players to build around. As the healthcare industry pitches curveballs at us all with market reform, insurance mandates, pricing transparency, bundled payments, coding overhauls, etc., the key to success and mitigating potential risk for healthcare organizations may lie in maintaining a strong foundation of critical revenue cycle fundamentals.

What are some of the key fundamentals that healthcare providers must pay attention to in order to ensure the core of the revenue cycle remains strong and focused?

Effective and streamlined front-end services.

Perhaps one of the most important stages of the revenue cycle is the time prior to delivering any care or treatment to the patient. It is during this time that critical information is either captured or lost, directly impacting the success and timeliness of creating a clean claim, and thus collecting payment for service. The people, processes, and technology across the organizations’ patient access areas must work seamlessly together to maximize the organization’s likelihood of capturing its potential net revenue. Centralized scheduling, insurance and benefits verification, point of service collections, and case management play a vital role in capturing accurate patient data as early in the revenue cycle as possible.

Documentation, documentation, documentation.

Changes in the healthcare industry may have no larger impact on a single group of people than our professionals in the Health Information Management (HIM) arena. As electronic health records (EHR) are continually refined and integrated across the spectrum of care, clinical documentation is as important as it has ever been. HIM professionals, including certified coders, will play a vital role in reviewing clinical documentation and assigning the appropriate codes. The acuity and complexity of services must be accurately represented, not only to ensure proper reimbursement, but to also meet guidelines set forth through value-based purchasing, patient satisfaction, and other critical metrics.

A strong denials management program.

At the core of any successful revenue cycle department is a robust denials management program. From identifying and utilizing meaningful denials metrics to creating a cross-departmental denials steering committee, this program can prove invaluable in identifying trends and strengthening operations across the organization. Clinical resources play an increasingly important role in a successful denials management program as the healthcare industry shifts its focus from quantity to quality and value rather than volume.

Focusing on what you do well and playing to your strengths.

We’ve all heard the saying “I can’t be everywhere all the time,” and the same adage holds true for the revenue cycle and its limited resources. Organizations must play to its strengths and develop those skills that provide the most significant return on investment. Conversely, organizations must take a deeper look at their revenue cycle objectives and capacity to determine what they cannot effectively accomplish. For many organizations that may mean outsourcing or co-souring things such as Medicaid eligibility screenings, self-pay collections, or medical coding. No matter the task, determine if your organization can effectively and efficiently handle the responsibility with internal resources or if it makes more sense to partner with someone that can provide that service for you.

Significant change is happening in the healthcare industry and approaches must be tailored to account for the reforms and “curve balls” that are being thrown our way. Tweaks must be made and processes refined, but in order to give ourselves a better chance at success, we must stay true to our fundamentals and continually strengthen those tasks at the core of the revenue cycle.

Adam Shewmaker, FHFMA, is director of Healthcare Consulting Services at Dean Dorton. He can be reached at 502.566.1054 or ashewmaker@ddafhealthcare.com.