5 Revenue Cycle Challenges (& What steps to take to remove the barriers)

Posted by InSource Revenue Management Innovations, Vice President of Revenue Cycle Operations

In every practice from start-up to robust ASC, there are inevitably obstacles within the revenue cycle process. Although differences may be seen across your locations, some of the common challenges remain consistent prior to partnering with InSource Revenue Management Innovations, LLP.

Let’s review 5 of the common challenges we have seen within the revenue cycle, and our tips for combatting each.

Denials causing havoc!

In any practice-even the ones with the greatest levels of efficiency have denials. But not all Denials are bad-in fact, some denials are just letting you know your contracts in place are processing correctly. However, most denials are ways to see improvement upon your process. (Did you know that the industry standard is 5% or less for denials?) The truth behind denials are that they create disruption to multiple facets of your practice. These disruptions create interruptions in your revenue which could ultimately lead to an increase in more denials.

The best way to get ahead of the denials, is to be proactive. Understanding what types of denials you are seeing by tracking and trending. Next, understand your payer mix and how the payers are processing your claims. At this point you are able to be knowledgeable about the denials and if payers are just being creative in creating delays for your revenue. When you start understanding the denials, start improving upon the denials up-front, stay on-top of those denials you are untangling the havoc to create a path to bringing in your revenue faster, while reducing your denial rate.

Where is the follow-up!!

In today’s RCM world follow-up is being done through varies methods, but the often times payers want you to go through their portals. But let’s be honest – still picking up the phone is the best way to truly know what’s happening with your claim and utilize the portals where you optimize your time. Following-up is critical, whether it is with your payer or patient follow-up is essential to ensuring all revenue is being collected. Being able to understand the nature of the practice and payer contracts, and member benefits, along with being able to work through those awkward conversations takes experience.

Training your team is essential to the successfulness of any practice. Training is not a one-time event, there is a need for frequent training to ensure your team is working with the most up-to-date knowledge accessible. Equipping your team with resources, policies, and access to all payer portals is critical. When you train your team to ensure patients understand their insurance benefits and what the patient is financially responsible for up-front only helps the patient and your practice. Don’t forget about those payment plans- being able to offer your patients options to pay the balances along with giving more opportunities to hold patients responsible for their member portions. Stay firm and work as a practice to ensure your patients know you expect them to be accountable for their financial responsibility according to their insurance.

Best Practice consideration: Creating a tiered payment plan structure which accounts for smaller balances versus the larger balances. Consider creating a tired payment plan along for balance of $250 for a set period of time. In contract to that- consider creating a payment plan along with requiring a deposit for services that will inquire a balance greater than $1500. It is important to smaller balances should not have the same structure as a service that will have a larger balance. Keep in mind the length of time you want to grant patients to pay off a balance while still receiving treatments. The over goal of payment plans is to create a per-month payment that is fair for all patients.

Inconsistent audits

Consistent Audits are incredibly essential to any practice. It is important to not only look at the frequency of your Audits, but also what are the audit parameters. There are some practices that do not audit, but have some other form of validation. Regardless of how you audit, in most all cases you should be. The frequency of your Audits should be subjective as not all practices operate the same. At a minium, we recommend at least, an annual audit to catch errors, omissions, or other discrepancies, and implement feedback based on the findings. When practices audit more frequently, errors will be caught earlier on, and there will be less room for falling off of benchmarks.

We recommend using a 3rd party auditor, inquire about our coding audit solutions.

Up-front Patient Financial Discussions!

Having a financial consultation prior to a procedure is an important discussion that can help both the patient and provide avoid those awkward moments. Equipping your team with various methods to help the patient take accountability for their copay, pre-arranged payment plan, or setting up a payment plan can create an improved relationship between your patient, front-desk staff, and “billing”. However, it is important to keep in mind, that not every patient is not going to be over the moon happy to give up thousands of dollars. Some patients may get upset for being asked for a possibly large amount of money, for a surgery they may already be less than thrilled about. Ensure your team is properly trained to have those difficult conversations along with call escalations in place when your team needs to be supported. .

Best Practice Recommendation? It is a best practice to ensure your financial consultation team members are not entry-level. This specific role requires someone with a kind and compassionate personality along with a customer-service mind-set.

Prior Authorization Hurddles.

In the prior authorization world change is inevitable. Change occurs with the payers updating their guidelines, providers changing the procedure, patients being rescheduled, or canceled and moved after an approval is obtained. The best way to be proactive in prior authorization is to stay organized. Know how far out in advance the payer requires the procedure to be to avoid the denials, understand the clinical guidelines, and ensure you have access to all the payer portals. W

Remember – RCM is everywhere. Do not panic if you are facing one or all 5 of these barriers. It is possible to overcome them all with time, patience, and consistency. We recommend choosing one area at a time that is creating the largest bottlenecks. Implementing a solution before moving on to the next is critical in staying successful in creating change. Being able to effectively implement a change is challenging but communicating throughout the process will yield better success than sticking to just dealing with the problem and hoping for a better outcome.