By Monica E. Oss, Chief Executive Officer, OPEN MINDS
As the health care field shifts from fee-for-service reimbursement to performance-based and value-based reimbursement (VBR), there are process and cultural changes in how services are delivered. But there are also changes in how organizations get paid. he challenges of this shift are reflected in a recent survey of health care provider organization leaders, with 59% identifying the transition to VBR among their top concerns—and 32% citing it as their most difficult issue. The survey results, reported in Realizing The Promise Of Tech-Enabled, AI-Driven Revenue Cycle Management (RCM): Outsourcing In The New Era, also found that 71% of executives identified the lack of real-time data on claims status and payment processes as their top concern.
For the year ahead, these executives identified top priorities for improving revenue cycle management (RCM)—with cybersecurity topping the list at 63%. Enhancing payer collaboration was the second priority cited in the survey—with the goal of aligning on outcome measures and quality metrics as well as investing in data-sharing solutions. The final priority on the list was investing in automation and artificial intelligence (AI) solutions to improve RCM.
Among the investments in technology to improve RCM, 23% of organizations are looking at predictive denials management solutions—with real-time risk scoring and recommended corrective actions. Twenty-two percent were considering revenue leakage solutions and 16% were looking at accounts receivable optimization.
The increasing complexity of RCM requirements and solutions was one of the areas of focus in my recent interview with Bob Bates, the Chief Executive Officer of ContinuumCloud: Getting The Data In Their Hands – A Discussion On Revenue Cycle Management, Workforce, Outcomes & Automation With Bob Bates, Chief Executive Officer, ContinuumCloud. In our discussion, Mr. Bates identified three ways that technology and good tech planning can help improve financial performance. His advice to provider organization executives is to focus on evaluating changing RCM needs and workflows, considering RCM across the service delivery system, and determining how to leverage data to maximize the revenue derived from VBR contracts.
A first step in optimizing RCM is an evaluation of how reimbursement models and contracts have changed. This includes assessing new billing requirements and performance measurements that affect payment. In addition, executive teams need to look at how these changes affect the workflow of the teams responsible for everything from prior authorizations to billing.
“Many times, executives take a short-term approach, and then they realize that maybe they saved money, but in the long term, they don’t have the tools they need,” said Mr. Bates. “It really comes down to acquiring or finding help—the search process, the tracking of those employees, their training, their productivity, and how their time is allocated. Everyone wants to be productive. They don’t want to have a hard time working on a system. They want tools that make their jobs easier. And with AI coming, automation, better workflows, mobile apps, and remote work aren’t just wants—they are requirements.” Another key issue is taking a systems view of RCM—from consumer intake and eligibility verification, to treatment planning and prior authorizations, to billing and collections. To be effective, executives need to take a holistic approach to planning RCM systems. “For performance and optimization, there has to be as much automation in that system as possible,” said Mr. Bates. “Underneath it all, you need to have a data lake where the people can run those dashboards. It needs to be quick. The objective would be to give people tools where they can grow, operations can be scaled, and you don’t lose productivity. Productivity is everything.”
Finally, there is the issue of maximizing revenue from VBR contracts. Revenue maximization requires the entire system to move away from thinking about units of service to specific outcomes and performance measures. The right tools are essential for meeting new contract requirements and driving more revenue from contracts.
“Proving quality and outcomes will be everything,” said Mr. Bates. “We’re already seeing that contracts are awarded to those who can demonstrate superior outcomes. It’s mission critical that you run the analytics. But it’s also workflow. You have fewer workers, and you have a whole lot more people in need. We have to be a whole lot better at driving outcomes and a whole lot better at driving greater efficiencies.”
In closing, Mr. Bates had some advice for executives planning for managing revenue in an era of increasing VBR and the growing influence of AI: “Make sure that you’re investing in data-driven decision-making. You need to have the dashboards and the reporting tools to run that organization… Those that operate better generally have greater margins, and they are around to invest in other things.”