In today’s fast-paced healthcare landscape, changes in regulatory demands, increasing pressures from payers, and on-going market consolidation have all contributed to a myriad of revenue cycle challenges and considerations. From coding and patient access to compliance and consolidation– as value-based care and ACAs penetrate deeper into the industry, RCM teams must hone in on these various complexities in the revenue cycle, and identify new cost-efficient opportunities to optimize their medical workflows.
Increasing Attention to RCM
The increased focus on RCM will lead many providers to outsource revenue cycle management to companies who can offer expertise and optimize the revenue cycle. Healthcare providers will increasingly need to find third-party help to remain compliant with complex and changing healthcare legislation. With outside help handling the mechanical aspects of compliance, providers will shift attention to training and educating staff to act as necessary to uphold compliance. In addition, hospital staff and providers must learn and implement new coding practices or risk slow or foregone reimbursements. Updates to the ICD-10 will require more demanding clinical documentation for coding purposes and a lengthy learning curve for those learning the codes.
Further complications in RCM have risen in recent years. In an attempt to optimize billing and payment collection, providers are starting to use technology to offer a more user-friendly experience for patients. With everything from kiosks to price estimates and flexible payment plans, providers are hoping the improved customer service leads to higher rates of payment collection. To mitigate financial risk, some providers will merge and direct attention toward reducing losses in emergency care and extended hospital stays. Moreover, the newly formed organizations will need revenue cycle analysts to manage the added workflows and merge the influx of data into existing systems.
While providers are faced with mounting operational challenges, in this article, we will focus on the RCM challenges associated with compliance and their implications for the changing healthcare landscape
RCM Challenges and Implications
To comply with the Advance Beneficiary Notice of Noncoverage (ABN) required by Medicare, providers must give patients an ABN form if they believe a patient will be denied coverage on the basis of lacking medical necessity. Failure to comply with the ABN can prohibit a provider from charging patients for elective procedures. To prevent this outcome, staff who first interact with patients must have a protocol in place to notify providers of patients who use Medicare and have not been pre-authorized for a service. In addition, giving providers and staff education in ABN requirements, as well as determining official responses to various questions and topics relating to it, can minimize a provider’s risk.
If applicable, Medicare demands that patients receive a Medicare Secondary Payer (MSP) questionnaire to determine whether they have alternative payor priority status. Repeated failure to identify these instances exposes providers to the threat of criminal and legal ramifications and the withdrawal of the ability to collect Medicare funds. Avoiding this outcome is possible when checkpoints for MSP questionnaire verification are implemented into the patient registration and billing processes.
To ensure the security of patient data and individually identifiable health information (IIHI), HIPAA regulates the way a provider records, stores, and transmits that information. If a healthcare provider electronically transmits IIHI during claim submissions or other administrative inquiries, the HIPAA Privacy Rule requires that provider to keep that data safe from breaching. Regardless of whether a provider outsources their billing, anyone handling sensitive information must comply with HIPAA. The consequences of failing to comply with HIPAA, or using a non-compliant service, can include harsh fines and prison time. Preventing this outcome can start with requiring all healthcare professionals who interact with IIHI to be trained and undergo continuing education on HIPAA compliance procedures. Conducting due diligence on any third-party billing companies a provider uses, as well as sporadically checking sites for compliance, will help mitigate risk.
In an attempt to prevent claim denials in the future, utilization review can help providers give extra attention to cases at risk for potentially objectionable claims or care. The presence of faulty cases can incite Medicare to issue a Civil Monetary Penalty (CMP) or prohibit a provider from collecting reimbursements. A good way to avoid this problem is to use real-time analytical data to identify issues and ensure proper communication between monitors and medical professionals, and sync that information with the electronic health record (EHR) of a provider. Furthermore, making it a priority to be up-to-date with reimbursement expectations can help staff manage workflows accurately.
The time to minimize risk and avoid penalties related to patient-centered compliance is from the first contact staff has with the patient. Instituting careful systems for collecting and processing patient data can be the best way to maintain compliance with Medicare and HIPAA requirements. By staying on top of compliance, providers can ensure they receive payment for their services and protect patient privacy. Partnering with eReceivables can give providers access to high quality, regulation-compliant billing services that will increase collected provider revenue. With our patented automated appeals software, denied claims can be resubmitted and monitored, and allow us to pursue every claim. We will help you maximize income and act in accordance with official regulations.