In the rapidly evolving healthcare ecosystem, revenue cycle management (RCM) remains an important component of sustainability and productivity for health providers. As 2025 unfolds, Velan Healthcare Billing Services stands poised to spearhead the translation and support of emerging RCM trends, potentially influencing a whole new industry.

This step-by-step investigative exploration offers deeper insight into these trends, as well as tactics and best practices for effectively tapping their power.

Greater Investment in Managed Services

Rapid investment in revenue-cycle-managed services is one of the major trends out there. With labor shortages, payer complexities and increasing process complexities, healthcare organizations are employing these services to maintain competitive advantages.

Within the next five years, based on our research, over half of organizations will dedicate more than 50% of their RCM budgets to managed services, and this is statistically significant. We understand that strategic partnerships based on performance and results, rather than just price, will define the future of RCM.

Effects of the Customized Resolution

Customizable end-to-end solutions are essential for improving recovery rate management. Through seamless integration within existing workflows, healthcare providers can better manage payer claims and drive down administrative costs to accelerate cash flow.

These capabilities embody a revenue cycle management healthcare model that supports financial goals and patient care objectives, not just operational efficiency.

The game-changer: RCM technology

The year 2025 is an inflection point for RCM technology. Scalable and flexible end-to-end revenue cycle management healthcare technologies are enhancing billing, resulting in accurate coding and driving the highest levels of efficiency.

These technologies, AI and machine learning in particular, are not just tools; they are strategic weapons that help improve financial outcomes for practitioners by decreasing compliance risks as well as coding accuracy.

Costly Medical Billing Errors

Medical billing errors that affect finances are virtually hemorrhage-inducing. These errors, especially those caused by coding mistakes and typos, cost the U.S. healthcare system about $935 million per week! The repercussions of this extend deeply, as errors that went undetected resulted in 35% of late bills, and missed diagnosis information caused 44% inaccuracies.

Rectifying these errors will not only save you a ton of money but also improve the credibility and dependability of healthcare services.

Personnel shortages and the revised pay-for-performance model

Personnel shortages remain substantial in the revenue cycle management healthcare sector. Almost half of the hospital executives surveyed said ongoing remote work has further intensified an already significant outsourced revenue cycle management professional shortage. The shortages also make patient communication management much harder, slowing down invoicing process efficiencies.

Additionally, the growth of high-deductible health plans (HDHPs) calls for a more offensive payment collection process that involves new remedies for patient engagement and bill settlements.

Evolution of a Patient-Centric Approach

That financial burden extends to patients as well, who are bearing a greater portion of their healthcare costs across the board, which in turn is driving providers towards more patient-centric strategies. This shift represents the growing appeal for a customer-oriented, retail-like experience in healthcare.

If your providers offer online scheduling, mobile intake and price transparency, you are more likely to get insight into what will improve patient engagement. These tools greatly enhance the patient experience, drive revenue, and increase retention.

Various Payment Options and Financial Clearings

This fall, financial clearance tools (seen as a component of sophistication) became all the rage with hospitals and clinics looking to determine patients’ ability to pay for services. These types of tools include eligibility verification and price estimation, which are the underlying changes needed to help defend against administrative rework or uncollectible debt.

In addition to this convenient way of billing, other inherent qualities can all be considered when matching healthcare services over the counter, such as being able to make payments using online bill-pay or merchant service payment processing (in ways similar to how retailers accept deposits) and phone pay methods. This helps with better payment collections and a happier patient experience.

Revenue Cycle Segmentation: Unique Challenges at Each Segment

The sources of bottlenecks in the revenue cycle are varied, as the revenue cycle is composed to be a behemoth composite of interdependent pieces, each with its own set of hurdles. On the front end, they deal with things like patient acquisition, getting paid, and keeping down denials. The second cycle goes deep into value-based care, staff training, and revenue leakage intricacies.

Back Office: The process involves submitting clean claims within specified time frames, handling denials, and following up on payment. To address these segment-specific challenges, you need a bespoke approach that combines strategic insight with process optimization and technology.

Technological progress in RCM

Key technologies are reshaping revenue cycle management practices. AI-driven solutions improve clinical documentation and billing categorization, allowing for better accuracy and efficiency. Because of the complexity of charging rules, web-based infusion and injection coding tools help to minimize audit risks by providing clarity and consistency.

These BI tools also optimize workflow for healthcare providers, assisting them in maintaining their bottom line and adherence to regulations.

Omnichannel Platforms and Financial Participation

Financial engagement solutions are more prevalent than ever and, as such, have become the modern-day equivalent of the 1908 ‘tin lizzie,’ creating omnichannel platforms that can work in harmony within hospitals or clinics interactively with any patient’s financial life cycle.

These end-to-end solutions encompass various functions, such as document management systems and digital notifications, to help your practice facilitate the collection of patient payments, ultimately enhancing the overall patient experience.

Impact of Custom Solutions

Tailored end-to-end solutions are key to optimizing claim reimbursement management. At the core of Change Healthcare’s open architecture with over 300 APIs are a set of broader, next-generation solutions, including a claims lifecycle manager, that help healthcare organizations automate and manage payer claims for reduced costs and faster payments by fitting within existing workflows.

These options are the cornerstone of a revenue cycle management strategy and reflect a broader alignment of financial goals on the provider side with patient-care priorities instead of merely focusing on operational effectiveness.

The Function of Strategic Partnerships

 However, when it comes to strategic partnerships in RCM, they are not just about outsourcing services alone but also involve setting up an ecosystem where payers and providers can collaborate effortlessly.

These partnerships allow automated offerings to be integrated into existing workflows for streamlined availability of operational and clinical facts. This creates synergy for healthcare providers to better handle payer claims, giving them more resources to allocate towards high-quality patient care.

Things to keep in mind

The Future of Dental RCM in 2025: A landscape of dorm chaos and promises Velan HealthCare Services comprehends the obstacles that concern these trends and is dedicated to being your qualified guide through this transformative journey. And our approach is all-encompassing: uniting the strategy with technological innovation to enhance RCM outcomes!

Our non-negotiable goal as we address these dynamics is to create a health system rooted in patient-centeredness and value, connecting financial well-being with the care of patients. Velan stands out as a guiding light in the constantly transforming landscape of revenue cycle management and shines brightly upon where healthcare management is headed next on an efficient note, full of hope.

The 2024 Evaluation and Management (E/M) classification guidelines were revised and expanded by the American Medical Association (AMA) in collaboration with the centers for Medicare and Medicaid services (CMS) beginning in January 2024. This extension involved the ongoing selection of the code for outpatient E/M office visits under CPT 99202-99215, based on either time or Medical Decision Making (MDM). The same guidelines apply to the following services: Emergency Department (99281-99285), Hospital Inpatient and Observation Care Services (99221-99233), Inpatient and Outpatient Consultations (99242-99255), New and Established Home or Residence Services, and Initial and Subsequent Nursing Facility Care. This allows providers to determine their code level based on MDM or time. Numerous modifications will continue to endure in 2025.
What information is essential for physicians to be aware of regarding changes in E/M in 2025?

Initially, clinicians should bear in mind that they are adhering to a single set of guidelines for multiple locations. In this article, we will delve into all the changes that providers need to be aware of, which include:

For both new and established patients, the hours of office outpatient care have changed.
Hospital inpatient or observation care services encompass both admission and discharge processes.
Guidelines for Split-Shared Visits.

What Should You Know About E/M Changes in 2025?

One significant change in 2025, as outlined by the AMA, is that the time is now specified as “must be met or exceeded” rather than a start and end time for E/M codes in the categories mentioned above.

Example 2024: Dr. Jones observes an established patient in the office and intends to assign an E/M code after spending 36 minutes with the patient. For this visit, we would choose level 4-99214, which is based on the total time spent on the date of the encounter, between 30 and 39 minutes.

In 2025, Dr. Jones will encounter the same patient in the office and intends to assign an E/M code after spending 30 minutes with the patient. For this visit, we would choose level 4-99214, which is contingent upon completing or exceeding 30 minutes.

What Should You Know About E/M Changes in 2025?

The length of stay (including admission and discharge) will determine the choice of E/M codes for hospital inpatient or observation care services, with the AMA providing guidance in 2025. When the stay exceeds eight hours, the following grid assists clinicians, medical billers, and medical coders in reporting hospital inpatient or observation care services provided to patients admitted and discharged on the same service date. These services are exclusively used by the physician or qualified healthcare professional team responsible for providing initial and discharge services.

If Mrs. S was discharged within eight hours, Dr. X would bill her with E/M codes 99221-99223.

Reduce administrative difficulties, prioritize patient care, and stay ahead of E/M changes.

Points to Consider in 2025

History and examination are not included in the code selection process.

After the implementation of the E/M changes in 2024, it is no longer necessary to determine the extent of the history and physical examination. The provider will be responsible for conducting and documenting the history and physical examination that they consider medically necessary for the patient during the visit.

Comparison of Medical Decision Making and Total Time Spent

Medical practitioners and other competent healthcare professionals can now determine the suitable level of evaluation and management (E/M) service by considering one of the following criteria:

Each service has a defined level of medical decision-making (MDM).

The provided information states the overall duration of E/M services conducted on the specific date of the encounter.

Providers must select either MDM or time, but they cannot choose both simultaneously. The choice of method to use will be determined by the provider’s discretion.

Allow us to examine and assess each individual segment of the medical decision-making table. As per the initial modifications to the E/M guidelines in 2021, medical decision-making encompasses the tasks of establishing diagnoses, evaluating the condition’s status, and/or choosing a management option.

The definition of medical decision-making in the seven service code sets listed above is based on three key components:

During the evaluation and management encounter, the healthcare provider deals with a variety of problems that vary in their level of difficulty.

The magnitude and/or intricacy of the data require examination and evaluation.

Risks of complications, morbidity, and/or mortality are associated with the patient management decisions made during the visit. These decisions may be influenced by the patient’s issues, diagnostic procedures, or treatment.

Refer to the document titled “AMA Code, Definitions, and Guidelines Changes” on pages 8–9 of the 2025 edition of the Current Professional Terminology (CPT) book.

Providers were previously required to document medical decision-making (MDM) at one of four levels: straightforward, low complexity, moderate complexity, or high complexity, according to the previous E/M guidelines. We have modified the MDM table of risk to focus on activities that have an effect on the management of a patient’s condition, while still including the four types of medical decision-making categories. It is important to understand that the overall MDM level only necessitates two out of the three MDM elements. 

Number and Complexity of Problems Addressed During the Encounter

During the encounter, the physician or other qualified health care professional reporting the service addresses or manages a problem, also known as our diagnosis.

To receive credit for the problem or treatment, the provider must demonstrate that they have evaluated the issue. It is important to note that simply recording stating that another professional is handling the problem without any additional assessment or coordination of care does not meet the criteria for the physician or qualified health care professional to be considered as “addressing” or “managing” the issue. 

Key terms to consider

Minor or self-limiting problems

Stable chronic 

Acute, uncomplicated illness or injury 

Undiagnosed new problem with uncertain prognosis 

Chronic illnesses characterized by severe exacerbations, progression, or treatment side effects

Quantity and intricacy of data to be examined and analyzed

This dataset comprises medical records, tests, and/or other information that must be acquired, requested, examined, and analyzed for the patient encounter. These cannot be the provider’s own notes. The provider must review and analyze his or her notes without simply copying or pasting them into the medical record. 

Data is divided into three categories

Tests, documents, orders, or independent historian(s). We count each distinct test, order, or document toward a threshold number.

Independent interpretations of tests.

Discuss management and/or test interpretations with an external physician, another qualified healthcare professional, or a suitable source.

Data encompasses information acquired from various sources or through interprofessional communication that is not reported individually. For instance, this section cannot use data from an office-based EKG provider who billed for it.

On the other hand, if a provider receives an MRI report for a diagnostic center and then reviews images or interprets that report during or just before the patient encounter, then the provider will receive credit only if images are reviewed and the provider states they did their own interpretation. If the provider orders the test and only reviews the report on a second visit, he/she is not able to count in the data. The first visit counts both the order and the read.

Risk of complications, morbidity, and mortality

This includes the risk of complications, morbidity, and/or mortality associated with patient management decisions made during the visit that relate to the patient’s problem(s), diagnostic procedure(s), and/or treatment(s).

This encompasses the management options that were chosen, as well as the options that were deliberated but ultimately not chosen, following a collaborative process of medical decision-making involving the patient and/or their family. 

The American Medical Association (AMA) has supplied the following examples for reference: The AMA defines “a decision about hospitalization or escalation of hospital-level care.”

Examples may include

a mentally ill patient who has adequate support in an outpatient setting or a decision not to admit a patient with advanced dementia who has a severe condition that would normally require hospitalization but whose purpose is to provide palliative care.

Risks Associated with “Social Determinants of Health” are also Addressed

You may be familiar with SDOH from ICD-10-CM coding, specifically categories Z55.- to Z65.-, which refer to persons with potential health hazards related to socioeconomic and psychosocial circumstances. It is important to note that the AMA has supplied a table for CPT E/M office revisions. You can assign the correct CPT code with the help of the level of medical decision-making (MDM) chart, fully updated for E/M changes in 2025. 

Documentation Considerations

The nature of the event under consideration determines the assessment of the level of risk.

For instance, a stable, chronic illness occurs when a patient’s treatment goals determine whether the illness is stable. Even if their condition has not changed and there is no immediate threat to life or function, a patient who has not reached their treatment goal is not stable.

Risk definitions are based on the typical behaviors and thought processes of a physician or another qualified healthcare professional in the same specialty. For the purposes of medical decision-making, the level is based on the consequences of the problem(s) addressed during the encounter when appropriately treated. Risk also encompasses medical decision-making regarding whether to proceed with or abstain from additional testing, treatment, or hospitalization. Be aware that the documentation must still demonstrate medical necessity.

Duration of Time Spent 

The second option for choosing the correct CPT codes relies on the overall duration of the encounter on the specific date, excluding emergency room services, for the aforementioned service levels.

For coding purposes, time for these services is the total spent on the date of the encounter, face-to-face and non-face-to-face, with the patient. The medical note must document the time for each activity to accurately reflect the actions taken. The total time will encompass all the time that the physician and/or other qualified healthcare professionals personally dedicate to the patient’s care on the date of the encounter. 

If time is used to specify the appropriate level for E/M service codes, be aware that time is defined by the service descriptors. 

The following are examples of timed activities you could perform

Engaging in pre-consultation activities such as reviewing test results in anticipation of the patient’s visit.

Obtaining and/or reviewing separately obtained history. 

Performing a medically appropriate examination and/or evaluation 

Counseling and educating the patient, family, or caregiver. 

Ordering medications, tests, or procedures 

Interacting and exchanging information with other healthcare professionals (without reporting it separately)

Recording clinical data in the electronic or other health record

Analyze findings autonomously (without being reported separately) and effectively convey the results to the patient, their family, or their caregiver.

There is no separate report for care coordination.

Shared/Split Visits

Split or shared evaluation and management (E/M) visits are medical appointments that involve both physicians and nonphysician practitioners and take place in various institutional settings, such as hospitals and skilled nursing facilities (SNF). The changes to the Current Procedural Terminology (CPT) guidelines for CY 2025 will include the definition of a “substantive portion” of a split (or shared) visit. For Medicare billing purposes, a “substantive portion” refers to a significant portion of the medical substantive portion of a split (or shared) visit, or more than half of the total time the physician or non-physician practitioner spends performing the split (or shared) visit.

Additionally, CMS requires documentation to identify the two individuals who performed the service, and the billing professional must sign and date the record.

Split Shared in Layman Terms

In layman’s terms, CMS will determine the substantive portion based on the practitioner who spends more than 50% of the time or the practitioner who performs and approves the medical decision-making (MDM). When both practitioners spend time with the patient together, they can only count it once. Provider types include MD, DO, PA and NP when patients are seen in place of service 19 at an off-campus outpatient hospital or 22 at an on-campus outpatient hospital. Only billing-related incidents can occur in outpatient offices.

Consider the following examples: 

For instance, if the NPP initially spent 7 minutes with the patient and the physician then spent an additional 10 minutes, the sum of their individual time would equal a total of 17 minutes. We would bill the physician for this visit because they contributed more than half of the total time (10 of the 17 total minutes). In the same scenario, if the physician and NPP convened for an additional eight minutes (beyond the 17 minutes) to discuss the patient’s treatment plan, we could only count this overlapping time once to determine the total time and identify the individual responsible for the substantive portion of the visit. The total duration of the visit would be 25 minutes, and the physician would receive payment for it, as they accounted for more than half of this time (18 out of 25 total minutes).

In order to bill for a split or shared subsequent hospital service, the billing practitioner should report CPT code 99231, provided that the coding is based on time. In the calendar year 2025, when not considering time, bill CPT codes 99231-99233 as they satisfy the essential level of key components on which the coding is founded. The billing practitioner is required to carry out and record medical decision-making.

Streamline your practice with Velan’s Medical Billing & Coding Services!

Conclusion

It is evident that all parties involved in submitting claims, such as providers, coders, and EMR vendors, must receive thorough training regarding the E/M modifications for the first seven sections of E/M Services in 2025.

The main objective of these E/M changes is to simplify the process of documenting. The objective is to diminish the administrative workload and enhance the duration that physicians can allocate to patient care. It is important to remember that medical coding should accurately represent the events of the medical encounter and provide evidence for the medical necessity. Providers should maintain the connection between ICD-10-CM diagnosis codes and identify any social health determinants that could impact the patient’s treatment. Always endeavor to record diagnosis codes with the utmost precision and specificity.

Do you require aid in managing your medical billing and coding? Velan is more than pleased to assist your practice with medical billing services, medical credentialing solutions, and much more.

Positive Patient Interactions: Revenue Cycle Management (RCM) also features prominently when it comes to providing excellent patient service and ensuring that people get the best possible care, while managing timely billing with insurance claims settled quickly.

It’s not just a matter of whether a patient will seek care, but also where they will receive it and the duration of their relationship with that healthcare provider. Learning about patient financial needs is a major first step in facilitating person-centered care, and that need informs their ability to manage care costs. Revenue cycle management (RCM) is an essential element in creating a positive patient experience, with a transparent billing system ensuring accurate claims to insurance companies and articulating clear communication on all financial responsibilities.

This kind of automation has a very direct impact for healthcare organizations, as they receive their payments quickly and revenue flow increases with fewer disputes while at the same time satisfying customers. It’s a win-win situation!

Learn the Patient Financial Journey

First Touchpoint—Registration: This is the point at which a patient shares their insurance information and personal details, essential for accurate billing and the smooth processing of an insurance claim. Understanding the patient’s expectations and providing assistance with insurance coverage can significantly enhance the financial aspect of their experience.

Following that, they get a cost estimate for their healthcare services and, if desired, will establish terms of payment. Easy-to-understand cost estimates will remove any confusion on the part of patients, allowing them to make better-informed decisions.

Patients may also have other financial hurdles throughout their treatment, along with copayments and deductibles. They want to know their financial obligations and be able to choose from a variety of payment methods.

Healthcare initiates the billing or claim process as soon as services are provided. Timely and accurate billing, clear explanations about charges, and a supportive healthcare staff can facilitate patients’ experiences with the financial aspects of their care. Many patients struggle with the complexities of insurance, confusing bills, including statements and co-pays (money you must pay before getting a service at each visit), additional out-of-pocket expenses, and a lack of pricing transparency. To address these issues, healthcare organizations must provide financial advice to their patients and implement price transparency initiatives so that invoices are equally accurate for ease of understanding.

Transparent Pricing and Quotes

Utilizing modern analytics and pricing software can enable healthcare providers to effectively calculate expected care costs. Knowing about healthcare costs in advance enables patients to make informed decisions and plan their expenses.

This allows patients to understand what financial responsibility and out-of-pocket expenses they can expect, helping them plan their budget more accurately. They can then examine payment plans or provide financial support services.

Price transparency enables trust between patients and healthcare providers. Patients who understand the scope of their treatment are less vulnerable to unexpected bills and financial surprises. This transparency breeds confidence in the healthcare system and a better patient experience.

Transparency is another driver of competition, allowing healthcare providers to compete with each other based on price and quality.

Customized Financial Counseling and Support

Customized financial counseling is a large part of the capabilities within Revenue Cycle Management (RCM). During the RCM process, this is a service that healthcare organizations should offer to patients so they can readily understand where their place within national health care stood in certain financial terms.

Healthcare organizations can assist patients through the typically complex and confusing billing process by utilizing trained financial counselors. The counselors offer personalized help with patient problems, questions and payment alternatives. This type of personalized guidance empowers patients to understand what their financial options are and choose how they would like to move forward, which in turn takes the stress out of medical billing.

In addition to one-on-one assistance, financial counseling can include providing tools or educational materials on personal finance. These resources help patients better navigate their out-of-pocket costs by explaining insurance terminology, billing and payments.

Payment Methods: Easier and more flexible to use

This is why providing flexible and easily accessible payment options that meet patients where they are can really help to improve patient financial experiences in healthcare.

However, you can also massively benefit by introducing online gateways and mobile apps to facilitate the process of payment for your patients. Allowing them to establish payment plans, schedule payments automatically and receive their billing statements electronically. They should cater to various tastes and suggest payment schemes such as credit cards, electronic Transfer or even installment plans.

The Role of Technology in Patient Engagement

Advanced technology for better patient engagement in Revenue Cycle Management (RCM). Starting with the obvious, using technology to improve your RCM is a no brainer! Integrating self-service and patient portals that can provide billing information promptly is beneficial. These systems allow patients to review and manage their financial obligations.

AI-led RCM solutions can also enhance financial counseling through automated data entry, claims processing and payment verification, leading to error reduction and faster turnaround time. As a result, financial counselors often offer more precise and tailored guidance on managing healthcare costs while also strengthening their bottom lines in the process.

These RCM solutions use advanced algorithms to analyze data, recognize patterns and detect errors or inconsistencies. The goal is to reduce the dependence on manual intervention and prevent fraud, as Barton stressed, while bankruptcy automatically leads to not correct or timely claim processing. Increased transparency allows healthcare organizations to remain compliant, optimize revenue capture, and build trust with patients.

An effective method is to use communication channels—email and text notifications, for example—that can reach out to patients throughout the whole process so they are not left in the dark about what their financial responsibilities will be. Additionally, since chatbots and AI-powered virtual assistants help with the most common patient billing and payment questions.

These advanced solutions in RCM can provide accurate and quick responses, enhance communication processes and enable patients to be actively involved in their financial journey.

Successful Implementation and Key Performance Indicators

When shopping for RCM software that enhances the financial experience of patients, there are many features to be mindful of:

It must accurately extract and process information from various documents (e.g., insurance forms, medical invoices) to assure the appropriate data collection of financial related data while removing errors.

Automation: For example, a document processing software that can automate data extraction and verification saves time and improves efficiency so employees can work more on value-added tasks while patients receive faster returns.

Integration: The system should be able to cooperate with EHR and billing systems for seamless data access, which leads to higher precision as well as lower manual effort.

Tailoring: The software must be tailored to the specific needs and processes of a healthcare organization so that custom document management and financial practices can be taken into account.

Security: In order to ensure that patient financial data is kept secure, the program must have a myriad of security benefits in place, including things like encryption and access limits.

Analytics and Reporting: The software should allow you to use analytics and reporting to gain visibility into the efficiency of the revenue cycle, identify bottlenecks, and make data-driven decisions to improve the patient’s financial experience.

Honesty: A transparent financial procedure and billing system ensures that all stakeholders, including health care systems, payers, and patients, can make informed decisions. It also makes it possible to effectively monitor and audit AI algorithms in order to ensure that they are fair, accountable, and legally compliant. Additionally, this allows for the always-on enhancement of such AI-enabled RCM solutions by spotting opportunities for improvements and removing any bias or inaccuracies.

Conclusion

With patient-centric initiatives at the core of business excellence, healthcare organizations can digitize their revenue cycle management (RCM) process while ensuring that patients are satisfied throughout while staying abreast of the latest financial wellbeing. People can comfortably navigate the financial aspects of healthcare if they understand their insurance, know what to expect in terms of cost, and receive clear communication. [email protected] for more details.

When you enter a hospital or clinic, we are pretty confident that you immediately head into the reception, confirm your appointment, see your doctor and nurse, submit your insurance claims, head straight to the pharmacy, and exit the healthcare center. Not many people know this, but in addition to the doctors, medical assistants, and staff, there is another individual who works just as hard as them to keep the healthcare facility operating efficiently. We are discussing the medical billing department.

Medical billing is a laborious and challenging operation to run. These individuals are responsible for the billing process. Their job is to submit claims and ensure that insurance providers reimburse the patient for the services used. If you do not send the appropriate bills to your patients, your account receivables team is likely to suffer huge distress, followed by a decline in your collection rates. Small medical practices often face numerous challenges due to their limited staffing numbers. This is a primary reason for physicians and healthcare teams to outsource their medical billing services to a reputable medical billing company, such as Velan.

What are the advantages of outsourcing your medical billing services?

Before considering outsourcing your medical billing services, ensure that you have valid justifications. Outsourcing your medical billing services is not mandatory.

Taking that chance will cause your company to do the same.

Have an advantageous position.

Implement an efficient and environmentally friendly strategy for managing your finance department.

The true benefit of outsourcing medical billing lies in its enduring sustainability. The doctors, patient volume, staffing levels, and other hospital requirements will continuously fluctuate. Unlike the internal team, which may face difficulties due to an overwhelming amount of work, a medical billing company can consistently achieve results.

In fact, the benefits of outsourcing medical billing are plentiful, and they extend to all areas of your medical practice.

15 key benefits of outsourcing medical billing services

Be sure of your patient’s insurance eligibility.

Your patient’s insurance, it must be current, valid, and eligible for claims in order for their insurance service providers to process it. Employing resources to validate insurance eligibility can be extremely exhausting. If your team undertakes this validation, it will add significant time to their already overwhelming workload.

However, if you enlist the services of a medical billing company, you can rest assured that they will credit the payment to your healthcare account. Your medical billing service will be

Be aware of your patient’s details.

their deductible or the covered expenses,

Which expenses need pre-consent, etc.?

Faster and more secure insurance payments

Your staff is prone to making medical billing and coding errors. We are not blaming your staff for their mistakes, but rather the limited time they have to accomplish a significant amount of work. Correcting these billing errors will ensure quick and secure payments and reimbursements. By collaborating with a proficient medical billing company, you can reap the advantages of a streamlined workflow, enhanced revenue, and improved returns for your medical practice. This will ultimately result in reduced expenses and more efficient payment processing.

The reason is obvious: a medical billing service company is proficient at dealing with codes, and their staff will have an advantage over your staff.

Expert consulting

Insurance billing and its processes are complex. There are constant changes in the process that your patients may not be aware of until they encounter a specific situation. To deal with such a crisis and attend to all the basic questions they may have, you need to have dedicated staff who can take the blow.

Outsourcing is the best option. Expert consultants, capable of handling even the most trivial questions, will redirect your customers. It will also curtail your administrative requirements, like hiring dedicated customer support staff, computers, desks, internet connections, phones, etc.

Improve your productivity.

Medical billing is a full-time profession. To handle the large volume of transactions, one must remain at the top of the field. Healthcare facilities will greatly benefit from outsourcing medical billing, freeing up their staff for other suitable tasks. It will save a lot of your time and boost your productivity at work. Additionally, standard tools equipped by a typical medical billing company will enable them to complete the work efficiently and quickly.

Protect your patient’s data

A third-party, expert medical billing company will protect your patient’s data. They’ll have tech-savvy professionals who can protect your patient’s sensitive data from cyberattacks. From performing regular checks to updating the security patches, the team will ensure they are on top of the security of your healthcare data.

Minimal costs to ensure normal billing activity

The procedures your medical practice employs to print out and mail bills, as well as monitor payments and non-payments, are laborious and time-consuming. Outsourcing this work to a medical billing company will reduce costs. By minimizing expenses on payment supervision, including service time management, reminder setting, and reimbursement processing, you can allocate your staff to more important tasks.

Stay compliant with evolving regulations.

As previously mentioned, the healthcare industry’s government protocols are constantly evolving, making medical billing a complex process to navigate. There are always new protocols and updates in the medical industry.

The process requires an expert to keep track of the changes, what they mean, what services they will cover, etc. A dedicated medical billing professional, whose job it is to be cognizant of this information, will know the upper-hand details and make it easy for your patients. It will help them make sure that they are submitting clear and updated claims.

Control and transparency

The notion that outsourcing medical billing implies relinquishing control over the business, specifically medical billing, is a fallacy. We call it a complete nuisance. Once you sign a contract with an outsourcing vendor, they become obliged to help you with details whenever you need them and to meet all the defined metrics. They must provide you with data from time to time, provide answers for the outcomes, ensure transparency in the overall process, and work towards meeting the purpose defined in the contract.

Velan, a reputable medical billing company, has been serving healthcare providers for more than a decade, and we understand what it takes to be a highly trustworthy vendor to our clients. We provide detailed performance reports in a timely manner, keep you informed about what is happening with your business, give you prompt updates about your patients’ claim statuses, and inform you of delays and payment issues, if any. This means our clients will have complete control over their revenue cycle management, eliminating the need to micromanage or control any billing staff.

Easy integration with your EHR

Before that what is EHR?

EHR is an acronym for electronic health records. It is a digital format of a patient’s health chart. From the patient’s medical history to current health problems and diagnosis, an EHR is a complete warehouse of information about a patient.

If you are handling your medical billing in-house, you will understand that managing various EHR systems is really strenuous and takes a lot of time. Medical practices are hesitant to outsource, fearing that their vendors might not be able to easily integrate with their EHS and would ask them to replace it with their recommended software.

Scale your business’s growth.

Healthcare businesses have a huge opportunity to scale their businesses when they are free from the burden of medical billing complexities and can focus on their everyday tasks. By outsourcing medical billing and coding, you are eliminating distractions, noise, interruptions, and complications that would otherwise hamper your routine at work.

Keep your customers happy.

Customer satisfaction is the key that makes or breaks any business, and medical practice is no exception. Every medical office aims to deliver outstanding customer care and better service. Juggling multiple tasks could put your customer satisfaction on hold, potentially leading to catastrophic consequences later.

By outsourcing medical billing services, you are liberating your staff to do what they are best at: running scheduled tasks, executing patient check-in and check-out processes, maintaining the books, and handling clinical concerns.

Improved Access to Insurance and Billing Information

When you outsource your medical billing, you’ll have more convenient access to billing and insurance information. The medical billing services staff will handle all claims and paperwork for you. This can significantly reduce the time required to access this information.

Decreased Probability of Fraudulent Activity

Outsourced invoicing services can mitigate the likelihood of fraudulent activity. This is because the outsourced billing team comprises professionals who have a thorough understanding of the medical billing process. This outsourced medical billing and coding team will manage the claims and documentation on your behalf. They will be capable of identifying any suspicious activity or red flags.

Keep up-to-date regularly.

Changes in coding are one of the numerous factors that can influence reimbursement. By outsourcing medical billing services, you can be confident that the medical billing company’s team of experts will remain informed about the most recent coding changes. This ensures the accurate processing of your claims.

Increased Income as a Result of Effective Follow-Up

Proper follow-up with insurance companies accounts for 40% of your income. It is essential to receive the correct payments in order to accurately calculate your income and expenses. You can guarantee that you will receive the correct amount.

Conclusion

Healthcare is an industry that is constantly evolving with escalating demands. Medical billing and coding companies can help you achieve success by advocating for your patients’ interests.

There are numerous beneficial reasons to outsource your medical invoicing. Outsourced medical invoicing can allow you to concentrate on patient care, saving you both time and money.

In order to provide a tailored solution, it is important to locate the appropriate medical billing company that will comprehend the unique requirements of your organization. So that you can concentrate on what’s important patient care our team of billing experts can help you outsource your medical billing and coding. We urge you to contact us today if you are contemplating the use of medical billing services. We would appreciate the opportunity to engage in a conversation regarding how we can assist you in reducing your expenses, increasing your income, and saving time.

Health care, already grappling with struggles that range from staff shortages and clinician burnout to declining margins and worsening health outcomes – particularly in underserved areas — faces a maze of complex challenges. Therefore, it has become important to make the best use of new technologies and at the same time maintain healthcare quality. As generative AI models in healthcare can solve these pain points, democratizing knowledge, and boosting interoperability and discovery to new levels of speed and accuracy while enabling real personalization.

Generative AI in healthcare was recently reported to have the power to save billions of dollars from waste, where over $1 trillion is wasted every year on ineffective treatment and care. Generative AI in healthcare presents a valuable opportunity to enhance healthcare outcomes and provide a personalized approach to patient care, given the significant cost containment.

The Healthcare Market Landscape is Changing

The healthcare system is currently faced with a critical situation as a result of the interconnectedness of operational, talent, financial, and value crises in the modern world. We operate in an intricate place wherein the healthcare system confronts a combination of operational, talent, financial and value crises that are all interrelated, forming a critical predicament. Although healthcare providers have been trying to tackle these issues step by step, they still haven’t delivered truly equitable, high-quality care. There are few challenges that need to be quickly fixed in healthcare:

Labor Shortage

Every sector of the healthcare industry is short on employees. Workforce challenges are currently the number one concern for healthcare providers, according to a recent survey. Assistance is required by even the most elite healthcare systems to address the growing demand for healthcare services. Numerous organizations depend on contract labour due to a shortage of 1.1 million nurses.

Burnout among clinicians

81% of clinicians report experiencing high or moderate levels of burnout as a result of the increasing administrative burdens and obligations they encounter. A significant amount of manual labor is necessary for administrative duties, including patient scheduling, electronic health record management, and follow-up with patients. Clinicians are advocating for the implementation of technology and automation to enable them to concentrate on patient care. Nevertheless, only 45% of frontline clinicians have confidence in their leadership’s ability to prioritize patient care.

The absence of patient care

Healthcare professionals typically engage in administrative tasks such as data entry, documentation, and paperwork. They waste precious time and focus directed towards patient care. Administration is getting in the way of provider-patient relationships and increasing burnout.

Lower AI Adoption

In many cases, the healthcare sector is considered later adopters of AI technology compared to other sectors due in part to technical challenges and difficulty interpreting outputs from machines but also because most data are text rather than numbers. These included previous NLP techniques, which were limited in their ability to understand the context of the medical text. The stakes of healthcare, combined with dangers like hyperparameters obscenely high on the sensitivity in AI implementation.

The emergence of generative AI in the healthcare sector

Healthcare is currently the world’s largest data repository, accounting for 30% of annual production and 80% of healthcare data in unstructured formats. This implies that it is not meticulously organized in spreadsheets or databases. The profundity of healthcare data and the ongoing advancements suggest that generative AI has a promising future. In healthcare, generative AI has the potential to provide immediate benefits in terms of efficacy, efficiency, and personalization.

Healthcare Applications of Generative Artificial Intelligence

Generative AI is well-suited to the functional requirements of healthcare that may be disregarded by conventional AI and ML models. Generative AI in healthcare billing has the potential to replace tasks and roles related to data entry, classification, and generation in specific areas, while also augmenting functions that require empathy, innovation, and complex decision-making. The following are a few potential applications of generative AI in the healthcare sector:

EHR Management

The primary focus of conventional AI models in electronic health record management is data entry and classification. Although presentations like these have automated some record-keeping procedures, the type of information healthcare providers need to capture and maintain has become increasingly complex. Through its capacity to comprehend and produce human text, generative AI can summarize patient notes by extracting relevant data, etc., thereby enabling a holistic healthcare record management system.

Medical Scribe

Due to the manual process of traditional transcription methods, it can be error- and time consuming. Other challenges for providers Few healthcare providers would say they love to document patient encounters, assist physicians with administrative tasks, and maintain accurate medical records. If you combined the two technologies, generative AI could be seamlessly integrated into a patient’s healthcare system to generate real-time, accurate medical notes (Capgemini Research Institute).

Generative AI steps in to help process and document the conversation, so that medical scribes can spend more time focusing on patient care.

Patient Scheduling

Direct the scheduling of a patient (i.e., who they see and when). This involves how appointments can be coordinated and cancellations managed to minimize clinics falling behind their set times. Generative AI adds a layer of adaptability and personalization, while traditional AI models can assist with appointment reminders and scheduling algorithms. Generative AI can analyse patient preferences, historical data, and clinic resources to recommend optimal appointment times, predict no-shows, and alter real-time schedules.

Personalized Patient Experience

Patients frequently endure extended interactions with Interactive Voice Response (IVR) systems and other automated systems in order to address their concerns. Numerous agents are required to effectively manage the high volume of inquiries. Generative AI provides a solution by customizing responses to the preferences and requirements of consumers.

It even assists in conducting live agent recap inquiries or at times, as with Hubspot, applying real-time personalized guidance to those queries. Faster resolution time means happier customers, better agent productivity and lower operational costs achieved thanks to generative AI.

Claims Denial Management

Healthcare providers face increased costs due to denied claims on an annual basis. Around 60% of the denied claims are recoverable, yet only 2% were appealed. It rapidly indexes and retrieves relevant content from vast policy databases to provide context for claim appeals, thereby offering a solution in the form of generative AI within healthcare. It can also pull relevant patient information from the EHR and generate case-specific appeal letters. These capabilities provide dramatic value to healthcare systems, enabling them to recoup billions of dollars in appeals and reduce the time-consuming nature of filing claims.

Pros of Generative AI in Healthcare

Healthcare implications: This means the generative AI in healthcare can touch everything from patient care to healthcare’s multiple domain functions. Some of its benefits are:

By using unstructured data for healthcare insurance claims and revenue cycle management, generative AI can automate back-office tasks. In fact, combining Generative AI with chatbots can also allow enterprises to handle daily IT queries like password resets and HR inquiries while heightening the employee experience and reducing administrative costs.

For the workflow side of healthcare operations, it can be discharges, care coordination notes, and checklists — in real-time.

The natural language understanding skills of generative AI could help improve Electronic Health Records (EHRs) in a variety of ways, such as automatically populating visit summaries, prompting for documentation updates, and displaying decision support research.

Conclusion

Generative AI offers newer capabilities in healthcare that were not possible earlier, and which could revolutionise the sector completely with its advanced functionality. The evolution of Generative AI could enhance various emerging technologies such as virtual and augmented reality, among other types of AI, to reform healthcare delivery.

Although these concepts appear in the future, they illustrate practical potential as Generative AI continues to evolve. Nevertheless, the use of this technology by healthcare providers must be made in a responsible and ethical manner.

Through Velan’s collaboration, Generative AI has been integrated smoothly into its solutions for expanding processes like patient scheduling, voice notes, healthcare insurance claims management and data analytics. Furthermore, Velan HCS offers healthcare providers a revolutionary chatbot with built-in gyro AI that really helps you understand patient questions and answer immediately from the institutional knowledge base. This integration is meant to improve the experiences of patients interacting with clinic or hospital support systems.

In a rapidly changing healthcare landscape, value-based care revenue cycle management (VBC RCM) is an increasingly critical concept for many organizations. This focuses on the arrangements and payable activities of the patient life cycle, providing high-quality service within a low-cost system. The results of VBC RCM prove it decreases administrative burden, enhances efficiency, and boosts reimbursements while delivering better patient outcomes.

Healthcare organizations can drive cost savings through VBC RCM, which also increases transparency into the various cost structures within the system, facilitating the streamlining of processes related to the services provided. In this article, we will explore how VBC RCM affects healthcare organizations with respect to finances, operations culture, staff morale and customer satisfaction.

Value-Based Care Overview Revenue Cycle Management

In value-based care, patient outcomes take precedence over the volume of services delivered. It differs from the traditional fee-for-service healthcare model, where healthcare professionals are compensated for the number of services they provide.

Clinical and financial aspects of patient care are the same across most settings; for instance, in an ambulatory/outpatient setting, Revenue Cycle Management (RCM) manages every aspect from first contact with a patient to receiving payment of services rendered or debts incurred. RCM consists of everything from scheduling appointments to insurance verification and billing and collections.

What are the advantages of value-based care RCM management?

Both value-based care (VBC) and healthcare revenue cycle management (RCM) have incredible benefits for patients.

Patient’s favorable outcomes 

Hence, VBC RCM is more about getting better patient outcomes and, in return, creating excellent experiences for them so that the patients are happy. By putting a greater focus on preventive care and streamlining the way in which that care is delivered, VBC RCM can raise standards of patient treatment, leading to enhanced health outcomes.

Reduce Administrative Workload 

You can reduce the administrative burden that VBC RCM imposes on patient care. It can also save money and time for healthcare organizations, providing reimbursement on time by fixing processes.

Spend Less

A VBC RCM offers an incentive for healthcare providers to perform more preventive care and reduce the frequency of costly medical procedures and hospital stays. This has the potential to reduce costs for both patients and healthcare providers.

Better Performance on the Financial Front

4018514 It can improve financial performance by boosting cash flow and cutting down on administrative expenses. VBC RCM also ensures timely and accurate payments, maximizing healthcare organizations’ incentives for their revenue potential.

Enhanced Revenue

RCM allows healthcare providers to receive full payment for the services they provide. Effective use of revenue cycle management enables healthcare providers to decrease denied claims and boost overall revenues.

Enhanced Productivity

The VBC RCM necessitates meticulous coordination and management of care delivery. It can improve efficiency by eliminating duplicate or superfluous processes, reducing administrative overhead, and ensuring that patients receive the right care at the right time.

The Power of Data-Driven Decisions

Therefore, VBC RCM relies on data collection and analysis to pinpoint every area for care improvement. Through data analytics, the healthcare service provider can make insightful decisions regarding patient care and revenue cycle management.

What does VBC Revenue Cycle Management include?

Some key elements of value-based care models and revenue cycle management (RCM) are as follows:

Patient Identification and Eligibility Determination

VBC RCM is a license for healthcare organizations to improve patient outcomes, reduce costs and earn more. To make the RCM process go as smoothly and effectively as possible, it must begin at the point of care with providers identifying patients eligible for value-based programs and verifying their eligibility through insurance checking. We can rely on it to make better decisions without jeopardizing the quality of care or overstretching assistance, while simultaneously alleviating administrative responsibilities such as patient scheduling, billing, and patient payment issues through data analytics.

Care Coordination

Making sure the patients receive their care on time and at their place of residence requires a tremendous deal of collaboration between multiple healthcare providers, as mandated by VBC RCM. Care coordinators can also facilitate communication between providers, help with appointment scheduling, and offer patient support during more challenging stages of their journey.

Quality Measures

VBC programs frequently use quality measures to monitor patient outcomes and ensure that healthcare workers render high-quality care. To successfully participate in programs, providers must collect and report on these measures. It can also be used to identify areas for improvement and streamline care delivery.

Claims Processing and Reimbursements

Healthcare providers must process claims in VBC RCM efficiently and accurately to receive prompt reimbursements. Healthcare providers must validate claims, send them to insurers, and chase denials or rejections. Automated systems may speed up the claim processing process and reduce administrative costs.

Care Management

Successful VBC RCM requires effective management of care delivery. Such measures include using only evidence-based, quality treatments and following performance data to outline priorities for improvement. Healthcare organizations can work with care managers to create plans for efficient care coordination while maximizing program reimbursement.

Financial Management

For healthcare providers to have effective cost management, VBC RCM requires financial accountability. It encompasses revenue and expenditure tracking, performance analysis, and adequate compensation for services rendered. Providers can use data analytics to find areas in which financial management is lacking.

Analysis and Reporting

VBC RCM uses data analytics to identify areas for improvement and boost the quality of care. Health care providers must capture, analyse and report data relating to patient outcomes, quality measures, and financial performance.

Issues with Implementing Revenue Cycle Management for Value-Based Care

Healthcare providers often face many hurdles when switching to VBC RCM. It requires a complete rewrite of business processes and a shift in perspective from the administration management aspects to the patient perspective. The following are some of the main challenges to VBC RCM adoption:

Able to Resist Change

The primary obstacle to the adoption of value-based care (VBC) and revenue cycle management (RCM) is the resistance to change. There are also providers who may be reluctant to break free from conventional fee-for-service models, thus not willing to spend on the infrastructure needed for value-based care revenue cycle management (VBC RCM).

Complicated Regulations

A lot of the VBC programs come with rules and requirements that are extremely convoluted, which makes it difficult for healthcare providers to wrap their heads around. It is time- and resource-intensive for providers to comply with different quality measures, reporting rules and payment models. This puts extra pressure on already overloaded healthcare organizations.

The Use of Technology

In order to be effective, VBC RCM leverages multiple technologies, such as electronic health records, revenue cycle management software, and data analytics tools. This poses challenges to integrating these technologies, particularly for smaller healthcare providers with limited resources. Implementing this technology can be costly and can delay the transition to VBC RCM.

Managing Data

VBC RCM relies on healthcare providers to collect and analyze data about patient outcomes, as well as the quality of care delivery and financial performance. It necessitates a complex data management flow, which is difficult to follow in real life. Moreover, the various systems seldom jive together, which makes it impossible to manage and share data effectively.

Involvement of Patients

Physicians and other healthcare providers must involve patients in their own treatment. This can include providing educational and informational tools, as well as ensuring patients have access to the resources they need. Personalized care can lead to better outcomes and lower costs.

Exposure to Financial Risk

 Because providers receive payment based on the quality and outcome of the program rather than the number of services rendered, VBC programs are often a dangerous financial gamble. Such a change can be difficult for providers practicing fee-for-service, and they may not want to take on the new financial risk.

Tips to Improve Revenue with VBC Models

To boost outsourcing revenue cycle management in value-based care (VBC) models, healthcare providers should focus on the following strategies:

Identify High-risk Patients

Identifying the highest-risk patients is a major strategy for maximizing revenue in value-based care (VBC) models. Finding the right patients has significant implications, as treating these high-cost groups can lead to better outcomes and fewer expensive medical interventions.

Care Delivery Optimization

Successful VBC models focus on patient preventive care and continuum of care delivery coordination. Providers should analyze data to identify areas for enhancing care while also accommodating patient voice in determining quality improvement practices, which can lead to decreased costs and improved outcomes.

Favor Quality Care

We need to reward these organizations for quality, not for the number of services per unit of care. This might mean paying providers in part for achieving specified performance goals or providing bonuses to individual employees who hit specific targets. This can ensure that healthcare providers are more efficient in delivering cost-effective yet high-quality healthcare services.

Make Technology Investments

The widespread use of technology enables providers to manage data, track outcomes, and coordinate care management for value-based payment models. Invest in technology that supports VBC models: Healthcare providers should invest in technologies and IT solutions to support these types of value-based care delivery businesses, including software for revenue cycle management (RCM), electronic health records systems, data analytics tools, etc. This means healthcare will be paperless, and providers can maximize revenue under VBC models.

Handling Quality Measures

Healthcare providers are required to report on several quality measures, which many VBC models rely on. Therefore, providers must regularly monitor these measures to identify areas for improvement and optimize performance under value-based care (VBC) programs. It can also help ensure other providers you use are meeting quality metrics and driving more revenue.

Consolidate Revenue Cycle Management

Revenue cycle management healthcare that works well is an essential part of revenues under VBC models. Therefore, healthcare providers must simplify the revenue cycle management processes to reduce administrative workload and prevent claim denials or rejections. A system like this will guarantee prompt payment to providers and maximize their revenue through VBC models.

Patient Follow-Up

 Healthcare providers must follow up with patients on a regular basis, monitor their progress, and provide all necessary care. This can help providers identify and resolve potential issues upfront, leading to better patient outcomes at a lower cost.

Explore More with Velan!

With decades of experience in accelerating payers and providers alike, Velan focuses on empowering our nation’s healthcare providers to fully utilize the power of VBC models to maximize reimbursement potential. Using our efficient healthcare RCM services and data analytics tools, healthcare organizations can optimize their processes for better throughput under VBC programs. Contact us today to learn how VBC models can help your organization maximize revenue.

With the recent controversy over generative AI in Hollywood (likeness theft), academia (cheating), and business (chatbots), you may be concerned about how using this technology to generate information will affect the healthcare revenue cycle. However, even though generative AIs present a novel use for our industry, 

ChatGPT is used by Epic this way with some health record processing tasks.

On Google Cloud, AI-augmented prior authorization processing is now available.

Telemedicine platform Doximity is rolling out a ChatGPT application that can generate preauthorization and appeal letters.

Currently, there are barely any live examples of generative AI at work in a healthcare organization. A New Orleans-based healthcare system is using ChatGPT to assist clinicians in responding to emails with its email-based system. Chapel Hill’s UNC Health has also launched an internal chatbot that is generative AI-type and powered by the Microsoft Azure OpenAI Service to answer queries, provide instant recommendations for solutions, and instruct visitors on destinations.

This is a controversial update to the traditional AI model and now boasts allegedly generative properties in the healthcare revenue cycle. Have no fear; there is more than enough time to look at what these exciting and a bit frightening new technologies may offer.

Understanding AI’s Role in Revenue Cycle Management

To find the right answer for your revenue cycle, you need to understand at a deeper level what AI is and does, interpreting both its possibilities and perils. What follows is a head-to-head look at the improvements that each can bring to your revenue cycle if implemented correctly.

AI in RCM: Traditional vs. Generative AI

Before using generative AI—immediately garnering significant attention—a revenue cycle manager must realize that current “AI-driven” revenue cycle solutions used by most health systems are powered by traditional, not generative, AI.

Old-school AI, or as it’s more concretely referred to these days, “machine learning,” powers those eligibility checks, patient estimates, and prior auth headaches you’ve got; it also runs your account recovery pieces. It’s an example of what we can call problem-solving AI, which uses large data sets to find patterns and do very specific tasks. It can make predictions or take actions that are learned to be done without being programmed explicitly, but the algorithm in its criteria is based on human-defined rules. Sometimes veiled patterns cannot even be caught by experts, but traditional AI allows for catching them.

Traditional AI Applications in RCM

Check Patient Eligibility: AI algorithms can enable systems to quickly check patients’ eligibility, benefits, and coverage, leading to reduced servicing costs for ineligible patients. This ensures proper compensation for services and helps improve revenue cycle efficiency by reducing claim denials or delays related to eligibility issues.

Enhancing Prior Authorization: Accelerate the precision of prior authorizations via AI algorithms that evaluate candidate patient introductions with predefined guidelines and clinical standards. This leads to better decisions with less information, streamlining procedural control automation.

Schedule Filling: AI-driven scheduling systems intelligently assess patient demand, physician availability, and resource utilization data to optimize appointment schedules, minimizing no-show rates and optimizing resource utilization.

Optimizing Billing and Coding Accuracy: Automating coding and billing procedures improves accuracy and speeds up reimbursement cycles, reducing errors and denials in claims.

Enhance Claim Processing and Detect Errors: Advanced algorithms automate claim processing and help lower personnel costs by reducing the need for additional RCM staff.

Minimized Denials: AI recognizes trends in claim rejections by investigating historical claims data management, limiting revenue loss due to denials while enforcing remediation steps for charge capture and documentation optimization.

Investigate the Revenue Cycle: AI algorithms combined with automation scrutinize vast amounts of healthcare data to detect trends regarding insurance claims, reimbursement rates, patient profiles, and physician performance, informing financial decisions.

How Traditional RCM AI Lowers Transaction Costs

Healthcare executives are turning to standard AI for financial and operational reprieve, facing staffing shortages and rising clinician burnout. Currently, many healthcare organizations are operating at a deficit. The average hospital profit margin is now 3 percent, compared to 7 percent in 2019, as reported by Moody’s. According to Fitch Ratings, 50% of hospitals are either unprofitable or failing to produce any revenue.

Cost reduction is essential for sustainable operation. By combining traditional AI with automation, labor costs, prior authorization, and claim denials can significantly decrease. McKinsey & Co. estimates that the U.S. healthcare sector could save between $200 to $360 billion annually through intelligent automation and traditional AI on administrative tasks. Research from the Institute for Robotic Process Automation and Artificial Intelligence supports this, indicating that healthcare costs could be slashed by 25–50% when combining traditional AI with automation.

Improving Working Conditions with AI

Beyond cost savings, traditional AI is also enhancing working conditions within the revenue cycle. The Association of American Medical Colleges predicts a physician deficit of up to 124,000 by 2034, citing increasing complexity in documentation and job dissatisfaction among doctors.

AI and automation can alleviate the burdens placed on revenue cycle staff, whose workloads often include extensive tasks like prior authorizations and eligibility verifications. Many RCM workers might consider more manageable jobs outside their field, as indicated by a survey where 49% of respondents were contemplating leaving for other healthcare positions.

Utilizing AI and automation-enabled software can improve job satisfaction and productivity among staff. A survey conducted by Salesforce found that 89% of automation users reported increased job satisfaction, and 84% noted improvements across the company. Ultimately, enhanced job satisfaction can reduce turnover rates, benefiting overall operational costs.

Generative AI Approaches in Healthcare RCM

While we are still in the developmental phase for generative AI in revenue cycles, it is crucial to anticipate future trends to position your organization for cost-effective technology adoption. Technology shifts can drastically alter industries, as seen with Blockbuster and Kodak’s failures to adapt.

Promising Uses for Generative AI

Here are some of the most effective uses of generative AI emerging in the healthcare sector:

Creating automated clinical documentation.

Developing real-time patient interaction bots for FAQs and appointment scheduling.

Generating patient discharge instructions tailored to individual needs.

Assisting with data collection and analysis for clinical decision support.

Advancements in Medical Records Management

Development of Software for Note-Reading and Voice-Recognition Dictation: Using deep learning powered by generative AI, the software is now able to read physician notes faster and with greater accuracy. However, the implementation of this technology has proven challenging for many physicians, with few health systems achieving moderate success in automating physician notes using OCR and natural language processing (NNLP).

Challenges with Traditional OCR: While traditional AI has provided OCR solutions, these systems often struggle with errors, especially with documents featuring complex layouts or messy handwriting. Generative AI significantly enhances OCR capabilities, allowing for better contextual understanding and improved accuracy in processing partially visible or poorly written text.

Enhanced Note-Taking and Transcription: Generative AI software aids in more precise note-taking and transcription during patient interactions, automatically using that information to support administrative billing events. This alleviates the burden of note-taking from physicians, reducing “pajama time” spent on documentation.

Improving Patient Accessibility

Recent advancements involve the use of generative AI to identify redundant patient records early in their interaction with the system. This extends beyond eligibility assessments to automate and align them more closely with specific payer policies and agreements.

Currently, traditional AI-powered solutions can assist with some prior authorization tasks, but generative AI enhances accuracy in reviewing patient data, medical histories, and insurance information. This allows for quicker determination of whether treatment criteria are satisfied and helps mitigate operational staff burdens by addressing time-consuming exceptions.

Transforming Receivables with AI

Developers are exploring how AI-generated material can streamline accounts receivable in healthcare organizations. By utilizing historical performance metrics and payer policy information, generative AI could automate the creation of unique appeal letters for health insurers. This system acts similarly to ChatGPT for appeals, automating all outreach efforts.

Debating Generative AI in Healthcare Billing Role

Generative AI is emerging as a significant player in the healthcare sector, and organizations must consider whether they will adapt quickly or take a more cautious approach. A survey by Bain & Company revealed that 75% of healthcare executives believe generative AI is set to reshape the industry, yet only 6% have established a strategy to implement it.

Understanding the Risks of Generative AI

Despite its promise, early adopters highlight important concerns surrounding generative AI:

Accuracy and Robustness: There are apprehensions about generative AI’s ability to produce accurate outputs, as errors could jeopardize the revenue cycle and lead to suboptimal patient outcomes.

Ethical and Legal Challenges: AI systems often mirror the biases present in healthcare billing practices, raising significant ethical and legal concerns that need to be addressed.

Patient Data Security: The reliance on patient data for accurate insights makes AI systems vulnerable to hacking, thereby compromising patient privacy and data security.

Contextual Understanding Limitations: Generative AI lacks the contextual understanding that experienced healthcare professionals possess, which can lead to missed insights vital for nuanced clinical decisions.

Integration Challenges: Implementing generative AI requires considerable time, effort, and financial investment, along with potential resistance from staff.

Strategies for Successful AI in Healthcare Billing Implementation

Bain & Company suggests several best practices for healthcare systems looking to harness the potential of AI:

Ensure a strong commitment to technology initiatives guided by a clear end-state vision through comprehensive planning.

Design robust processes for redesigning operational procedures for maximum value capture.

Develop a detailed technology investment strategy, ensuring funding for projects and maintaining quality assurance throughout implementation.

Establish effective feedback loops and holistic outcome-based success metrics to gauge performance and success effectively.

The Future of AI in Revenue Cycle Management

As interest in AI quickens, revenue cycle professionals are excited by headlines touting AI’s transformative potential in healthcare. However, it’s critical for healthcare vendors to distinguish between traditional machine learning applications and the advancements brought forth by generative AI.

Currently, while generative AI is a promising technology, its implementation in clinical settings may still lag behind the hype. Healthcare revenue cycles are inherently complex and require a nuanced understanding beyond what a generative AI in healthcare billing can provide. Nevertheless, both traditional AI and generative AI offer opportunities for improving performance within healthcare systems.

Regardless of whether you lean toward traditional AI solutions or the emerging capabilities of generative AI, understanding your organization’s financial landscape is vital to identifying underpayment areas and driving revenue improvements.

For further insights into utilizing AI for enhancing revenue cycle management, be sure to visit Velan Healthcare Services. To learn more about the evolving landscape of AI in healthcare, see the latest updates from Bain & Company.

Introduction

Claim denials represent a major obstacle for providers when it comes to ensuring their cash flow in the nuanced universe of healthcare revenue cycle management (RCM). Successfully working with these denials will help organizations get paid for the services they are rendering.

The bottom lines of healthcare organizations are continually under immense pressure due to wage inflation, rising costs, lagging patient and service volume, and pandemic-driven uncertainty. This situation is further exacerbated by unresolved claim denials, which represent an average annual loss of $5 million for hospitals and up to 5 percent of net patient revenue.

Denial rates for hospitals have increased by over 20% in the past five years, with an average denial rate of 10% or higher. In 2021, survey respondents reported an average increase in denials of 17 percent on the practice side, according to a Medical Group Management Association (MGMA) stat poll. As many as 60% of returned claims are never resubmitted, and nearly 20% of all claims are denied, according to industry averages. The cost of reworking or appealing denials, which averages $25 per claim for practices and a staggering $181 per claim for hospitals, further exacerbates the impact on the bottom line.

The good news is that claims are not inevitably relegated to the write-off bin as a result of denial. In reality, up to two-thirds of rejected claims are recoverable. Finally, we look at the state-of-the-art in denial management and how our technical capabilities are constantly evolving to automate this all-important process. By taking the proper steps, healthcare organizations can take some of the sting out of denials protect their revenue and streamline processes. Continue reading to learn more about it and discover some useful tips that will assist you in streamlining your revenue cycle via RCM denial management.

Procedures for the RCM Denial Management Process

Providers should adhere to four important measures in the RCM denial management process. First, determine the reason for the denial of a claim. Secondly, deal with the issue in order to manage the claim. Third, keep an eye on other claims regarding the matter. Lastly, develop a strategy to prevent future denials.

According to Curlett, insurance companies are motivated to compensate only legitimate claims. They cannot anticipate that the provider will enforce their policies. They will discover any discrepancies in your claim and deny it accordingly.

Therefore, it is imperative to respond appropriately.

In order to ensure that denial is converted into revenue, we consistently adhere to a set of essential steps whenever we receive one. We identify the underlying cause of the claim denial, implement immediate corrective measures, and subsequently integrate this valuable information into our prevention program with the objective of minimizing the number of incoming claims.

The following are the primary steps in the RCM denial management process.

Identifying the problem

The initial stage involves the identification of the claim problem.

A claim adjustment reason code (CARC) is appended to an explanation of benefit (EOB) form by payers when they reject your claim. The payer’s rationale for rejecting the claim is delineated in the code.

There are a variety of reasons why a claim may be denied by the payer when we submit it. Common causes include technical constraints on the provision of the service, non-coverage of the service, and a lack of prior authorization. Denials can result from even the smallest of errors, such as an incorrect insurance policy number or a misspelled last name.

To understand the rationale behind the denial, the denial management team is primarily responsible for interpreting the CARC code. The CARC code can be challenging to comprehend; however, our primary goal is to figure out the cause for the payer’s rejection of the claim. 

Frequently, the denial management team must communicate with the payer in order to comprehend the problem. 

Handle

Now that you are aware of the reason the payer denied your claim, you can take the necessary measures to resolve the issue and receive payment. You formulate a strategy to rectify the error and resubmit the claim. This is also known as appeal management.

Typically, the payer permits the correction and resubmission of the claim within a specified timeframe; it is crucial to comprehend and comply with this timeline. Your right to payment is forfeited if you fail to resubmit within the designated time frame.

Numerous claims are simultaneously processed by the majority of healthcare providers and clinics. Therefore, they prioritize claims and adhere to a protocol to guarantee that they address denials promptly and do not forfeit funds.

Observe

This stage involves the monitoring of denials to ascertain their categories and volumes. Subsequently, you organize the denials according to their nature, date of receipt, date of appeal, and result.

You also organize the insurance payers and the reasons for denials. With this intelligence, they can engage in discussions with the insurer regarding more effective strategies for decreasing claim denials.

Prevent occurrence

You execute an exhaustive prevention strategy in the final phase.

A significant number of claims can be avoided through the process of prevention, which involves ensuring that our pre-billing procedure is robust. This process begins with the enhancement of front-end processes.

Prior to the provision of services, pre-billing involves the verification of card copies, the verification of multiple checks and balances, the confirmation of members’ eligibility and benefits, and the completion of all necessary preparations.

The labor persists even after appointments have been scheduled.

Whether or not the codes are chargeable to the particular payer is something that we check. We perform all of these validations prior to submitting claims, underscoring our dedication to proactive measures from the outset.

It is inevitable that individuals will make errors; however, this does not necessitate the accumulation of more significant issues.

A successful organization with robust denial management practices will extract common system weaknesses from past data, as a good denial management team will learn from their errors. For instance, the pre-billing team becomes exceedingly vigilant in its examination of this issue in the event that numerous claims are rejected as a result of prior authorization issues.

Denial Types in RCM

Two categories of denials are discussed by certain professionals: hard and soft. It is challenging to appeal hard denials, which typically pertain to clinical matters. Minor technical errors that are readily rectifiable are the subject of soft denials. Additionally, you may encounter terms such as administrative, technical, and clinical denials.

Nevertheless, Waldorf asserts that those designations are not frequently encountered in the context of denial management.

In practice, we do not formally classify denials as ‘soft’ or ‘hard’; rather, we endeavor to appeal to all potential denials. Nevertheless, we do occasionally employ the terms when communicating with external stakeholders, such as healthcare organizations, due to the fact that distinct denials necessitate diverse workflows. It facilitates the elucidation of our approach to managing the various denials they may encounter.

The following is a more comprehensive examination of denial terminology

Hard refusals:

In technical terms, a strong denial is a resolute refusal to pay the claim. The provider must initiate a formal appeal procedure in order to contest these types of claims. The provider may abandon the claim due to the complexity of this procedure, which results in lost revenue.

Typically, hard denials are the consequence of the provider failing to adhere to pre-authorization procedures, the recipient determining that the service is not covered, or the provider filing the claim too late. Preventable and clinical denials are the two subcategories of severe denials.

A preventable denial is a denial of an insurance claim that could have been avoided or mitigated by implementing the appropriate measures. Accurate patient information, correct classification, comprehensive documentation, timely claim submission, and adherence to insurance policies are frequently the focus of these measures. Healthcare providers can optimize their revenue collection processes and decrease the probability of preventable denials by proactively addressing these factors.

Clinical denials are harsh denials that occur when a payer refuses to reimburse due to their disagreement with the clinical justifications that the provider used to justify treatment. For instance, clinical denials may result from incorrect coding, uncovered services, or a lack of medical necessity.

Soft denials

Soft denials are denials of insurance claims by a payer, citing reasons for coder education that are typically administrative or procedural. Soft denials, in contrast to hard denials, are more of a definitive action that necessitates a formal appeal. They are generally viewed as temporary, which means they may be either corrected or resubmitted with additional information or explanations. 

Scenarios of RCM Denial

Common RCM denial scenarios involve errors such as lacking information or coding errors. Additionally, denials will be based on patient eligibility and prior authorizations. The clearinghouse electronically transmits the information when an insurance claim is filed with the payer by the healthcare provider. It is returned to the provider for correction and is rejected if an issue arises. If no faults are found, the claim is sent to the payer. 

At this time, the payer will enter the adjudication stage, at which time they will thoroughly review and determine whether to accept or deny the claim based on medical necessity and policy terms. When a claim that had previously been approved by the clearinghouse is denied by the payer, it is generally indicative that the provider did not follow the correct submission process.

The following is a concise overview of the primary reasons why creditors reject claims

Invalid and incomplete information, as well as missing modifiers

A vacant field, such as the social security number box or the demographic information field, maybe a problem. A technological problem may also be present, such as the absence of a modifier. A modifier is a two-character code that indicates a service change without a corresponding code change.

Another prevalent issue is the absence or misspelling of a last name, as well as the absence of a date for the commencement of a medical emergency or condition.

Denial and the necessity of claim adjustments will result from inaccurate information regarding the patient’s date of birth, gender, and other pertinent details. Additionally, ensure that claim numbers, insurance payer details, group numbers, diagnosis codes, and other pertinent information are included.

Qualifications

Eligibility concerns typically arise when your team is unaware of the patient’s extent of coverage. Typically, this occurs when the provider fails to verify the patient’s insurance information. Occasionally, the payer may be prompted to locate a different patient due to a misspelled last or first name.

Prerequisites for medical necessity

The payer disputes the physician’s assessment of the necessary services to address the patient’s condition, and the policy does not provide coverage for medically superfluous healthcare services.

Modifier and coding errors

Medical coding professionals convert the specifics of a patient’s appointment into claim codes.

Medical coding encompasses each interaction between the patient and the provider, including admission, treatment, and discharge. The diagnosis code may not correspond with the procedure that was conducted by certain coders. The insurance company will likely reject the claim if the scribe fails to rectify the error, as the treatment does not correspond to the health condition.

Unrecognized services

In this instance, the payer determines that the medical service is not included in the approved list of covered procedures and services.

Failure to obtain prior authorization

In the event that healthcare providers fail to adhere to prior authorization guidelines, payers deny claims. These guidelines may prove to be perplexing. The American Medical Association (AMA) reports that 64% of physicians are unaware of which procedures or tests necessitate prior authorization.

Failure to timely submit or file the claim

You are required to submit your claim within the time frame specified by the payer. Even if your claim is not deficient, the payer will reject it if you submit it after the deadline. This rule also applies to any claim modifications that you make when appealing a denial.

The Effects of Denials on RCM

Healthcare providers encounter obstacles when an insurance company rejects a claim. For instance, the denial causes a delay in their payment and disrupts their cash flow. Additionally, it elevates the provider’s administrative expenses. Nevertheless, it is possible to address these issues through the implementation of denial management strategies.

A denial rate of one percent is not a concern, as it indicates that we have successfully processed 99% of claims. However, the organization is significantly affected when this rate exceeds approximately 5%.

Financial instability may result from denial.

It impedes our capacity to manage office costs, maintain our revenue cycle, and cover day-to-day expenses. Our financial capacity to maintain operations, pay employee salaries, and provide care is limited.

In further, it is impossible to circumvent all denials.  However, it is imperative that you maintain it at a level that does not have a substantial impact on your organization. Otherwise, your revenue will be either lost or remain stuck.

Financial Consequences of Denials

The financial well-being of a healthcare organization can be substantially impacted by claim denials. When denial rates surpass 5%, they restrict cash flow and the availability of resources for patient care and employee salaries. Ultimately, the organization’s revenue is diminished by denials.

Numerous healthcare organizations are ensnared in a denial wave, which results in a sense of distress and exacerbates their problems, according to experts. Eventually, they experience a financial deficit as a result of their inability to keep up with the claims.

Operational Consequences of Denials

Cash flow is delayed and the daily operations of a healthcare organization are impacted by denials. Staff members are additionally burdened by the management of denials. They are obligated to concentrate on denials rather than other responsibilities.

Operations can be substantially affected by the administrative challenge of handling denials. Your team is responsible for decoding the EOB (explanation of benefits) that a payer sends in order to comprehend the situation. Occasionally, clinicians are involved in this, which diverts their attention from their primary objective of providing patient treatment. The objective is to optimize the efficiency of your team’s work in order to minimize operational disruptions and guarantee the seamless processing of claims, particularly for clinicians.

The Current State of Denial Management in 2023

Denial management is perceived as the most significant challenge by the majority of healthcare professionals in 2023. The finances and daily operations of the majority of healthcare organizations are substantially impacted by denies. Fortunately, the implementation of new technologies is beginning to automate the process of denial management.

Healthcare organizations from a number of states, such as Georgia, Illinois, New York, California, Texas, Florida, and others, participated in the survey in 2023. It focused on organizations with yearly revenues between $25 million and $5 billion and RCM teams consisting of 50 or more members.

The primary conclusions of the survey were that numerous healthcare organizations encounter difficulties in managing denials. Fortunately, there is a promising technology on the horizon that has the potential to automate a significant portion of this process and, presumably, decrease the average denial rate.

Index of Management Challenges

One of the most significant obstacles in RCM is denial management.

The majority of providers surveyed (59%) identified insurance denials as the most significant obstacle to their RCM. Additionally, 42% of healthcare providers reported that their RCM claim denial management process was consistently backlogged.

Providers are incurring losses.

The effect is so substantial that 22% of healthcare organizations reported a revenue loss of $500,000 to $1 million annually as a result of denied claims.

Technology is not being utilized by providers to automate and enhance denial management.

Although 43% of healthcare providers have identified claim denial management in rcm as their primary RCM priority for the upcoming year, only 15% of respondents intend to enhance the RCM process through the use of robot process automation (RPA) and 10% intend to employ artificial intelligence (AI).

Conclusion

We are confident that you are currently capable of effectively managing a variety of healthcare claims denial management issues. Consequently, our beneficial advice will enable you to conserve 6 to 8 percent of your revenue from these issues. Aim to motivate your team and reduce the number of denials by incentivizing and training your staff.

Additionally, you may establish a robust and adaptable procedure to effectively address these concerns. Therefore, refrain from being the team that neglects to resubmit claims. Guide a team that is both proactive and well-informed in order to preserve your revenue.

Managing an in-house team for medical invoicing denial management in rcm can be a time-consuming and complex process in numerous instances. The process can be simplified by entrusting it to an external provider. Velan is a distinguished provider of denial management services that provides healthcare organizations with customized solutions. We are experts in the optimization of revenue cycles, the reduction of denials, and the resolution of intricate invoicing challenges. Please reach out to us today to discover how we can assist in decreasing the number of claim denials.

Frequently Asked Questions:

What is the procedure of denial management in medical billing?

The objective of the denial management service in medical invoicing is to effectively resolve claim denials through a systematic approach. It commences with the identification of denied claims through a comprehensive analysis and categorization of the reasons for denial, including insufficient documentation, eligibility issues, or coding errors. Upon identification, the subsequent step is to investigate the underlying causes of denials in order to prevent their recurrence. claim denial management this is followed by corrective actions, such as the collecting of additional information, the correction of errors, or the appeal of the denial if it is justified.

What exactly is RCM, and what is denial management?

Revenue Cycle Management (RCM) is the financial process of managing claims, payments, and revenue generation in the healthcare business. Denied claims are efficiently managed through denial management, which is a critical element of RCM.

It encompasses the following: the identification of the reasons for denials, the correction of errors, the prompt submission of claims, and the appeal of unjustified denials when necessary.

What is the definition of prior authorization?

It is a utilization management strategy employed by health insurance companies that necessitates the evaluation of specific operations, tests, and medications ordered by healthcare practitioners for their medical necessity and cost-of-care implications prior to their authorization.

The decision of a health insurance payer to approve or reject a prescribed course of treatment based on the results of a prior authorization review will determine whether a provider or pharmacy is reimbursed for a claim and, if so, whether such reimbursement is for the full or partial amount.

Is prior authorization becoming more common?

Certainly, there has been a significant increase in the number of medical procedures and prescribed medications that require prior authorization. The primary driver of this trend is the pursuit of strategies by insurance companies to control the rapidly increasing costs of healthcare, particularly those associated with the development of new technologies or cutting-edge specialty medications. Despite the fact that certain treatments or services can obviously enhance patient outcomes, they are often associated with exorbitant fees and are still relatively new to have a reputation.

Prior Authorization and Medical Necessity: How Do They Relate?

A legal principle known as medical necessity governs clinical conditions and provides a framework for evaluating the treatment provided to a patient by a physician or other provider. It is implemented in accordance with generally accepted medical standards to assess specific diagnostic and therapeutic recommendations. Insurance companies will not reimburse for prescribed care that does not meet the criteria for being medically necessary.

In order to obtain payer approval for care that necessitates prior authorization, it is typically necessary to demonstrate medical necessity.

Prior authorization has what drawbacks?

The delay in patient access to care that results from prior authorization is the most significant adverse consequence. It impedes the patient’s journey, and certain patients may opt not to receive treatment.

In reality, 75% of physicians who participated in an AMA survey reported that patients frequently forgo the prescribed course of therapy due to issues with the prior authorization process. In the same survey, 28% of physicians reported that preauthorization had resulted in a significant adverse event for a patient under their care. Prior authorization’s administrative burden impedes physicians from delivering patient care and contributes to the increasing prevalence of “physician burnout.”

What methods can be employed to alleviate the administrative burden and physician abrasions?

The prospect of defending a recommended treatment to insurance companies is often met with reluctance by healthcare professionals. This in and of itself generates disputes between payers and providers.

The “paper chase” that ensues subsequent to the submittal of a prior authorization request only serves to exacerbate this conflict, increase the administrative burden on the revenue cycle team, and exacerbate the animosity between providers and payers. Nevertheless, there are methods to modify this situation.

One of the most effective methods for preventing the issue is to automate or outsource the prior authorization process, which will eliminate the administrative burden of faxes, phone tags, and emails. The procedure is less likely to overwhelm physicians.

Approximately 90% of physicians believe that the authorization process delays patient access to care, and they spend 16 hours per week on the task, according to the American Medical Association (AMA). Returning those hours to physicians for patient care could potentially improve relations with payers, reduce administrative burdens, and improve outcomes.

Why do long-term care pharmacies and diagnostic and imaging centers face a disproportionate burden from prior authorization?

Typically, patients are not directly engaged in alternative care settings, such as long-term care pharmacies and diagnostic laboratories. Instead, they must depend on an originating provider, such as a hospital or doctor’s office, to refer them to clients and engage with patients on their behalf. The prior authorization process is further complicated by the fact that the lab/long-term care pharmacy is one step removed from the patient in this business connection.

The diagnostic or imaging center is compelled to utilize the referring provider as an intermediary and depend on them to address any issues with the insurance company in the event that there is even a single error in the prior authorization procedure. Rendering providers recognize that they can only apply a certain amount of pressure to the referring hospitals and physicians before they risk losing future business, as they depend on referrals from the originating providers.

The prior authorization process can be significantly time-consuming, despite the potential benefit of verifying that a patient’s insurance will cover procedures. Many medical professionals and support workers are discovering that pre-authorization is a time-consuming process, which is causing a decrease in their output and delays in the provision of care.

Issues that are frequently encountered include

Delayed access to vital services or remedies for the patient.

Practices incur elevated administrative expenses, particularly when they are required to recruit personnel to fulfill preauthorization obligations.

Unpaid time devoted by physicians or other employees of the practice.

Workflow inefficiencies and interruptions in practice.

According to the American Medical Association, pre-authorization consumes approximately 1 hour of doctor time, 13.1 hours of nurse time, and 6.3 hours of administrative time per week. This is equivalent to $82,975 in labor costs for each full-time physician or 853 hours of staff time annually.

Outsourcing the Prior Authorization Process

One method to avoid all the hassles is to outsource the pre-authorization process.

A third party, such as insurance companies or Medicaid, facilitates pre-authorizations between your clinic and the payer through an outsourced service.

The third-party organization collects patient information from your practice in order to obtain prior authorization for inpatient and outpatient operations and pre-certifications for hospital admissions.

A benefit of outsourced pre-authorization services is the establishment of a centralized and streamlined procedure that tends to reduce any inaccuracies in patient data. Unlike physicians and nurses, who are attempting to balance this with the rest of their work, they specialize in this type of work and are highly knowledgeable about the procedure and what needs to be done.

Tasks such as the following will be managed by an outsourcing company

The entire pre-authorization process

All necessary follow-ups, including the doctor’s requirement to furnish additional information for the pre-authorization

We entertain appeals against rejections where applicable.

For more insights on optimizing your revenue cycle and improving patient care, visit Velan Healthcare Services.

Behavioral Health Revenue Cycle Management (RCM) RCM consists of the entire process a patient goes through, from scheduling an appointment to making the final payment. RCM is essential for financial viability, operational efficiency and patient care delivery in behavioral health organizations. However the staffing issue is one of the biggest challenges in behavioral health RCM.

The results undoubtedly drive organizational performance on both a financial and business level, so staffing challenges can have wider-reaching consequences. According to a recent study, 80% of participants reported that their organization’s turnover of revenue cycle management staff is between eleven and forty percent. Such instability may expose practices to reduced throughput, higher billing and coding mistakes, as well as long accounts receivable.

In this article, we discuss five strategies that can help organizations confront some of the employee staffing challenges they may face in behavioral health RCM, establishing a competent workforce with respect to its size and stability.

Create detailed training programs

High turnover rates and skill gaps in behavioral health RCM departments are often best addressed with training programs. Such training programs should not only focus on the technical wording of billing and coding but also educate how behavioral health-specific RCM challenges significantly overlap with underlying psychiatric concerns.

An effective training program should include the following elements: 

Orientation training for new staff members: This establishes a prerequisite foundation before team members start, introducing the organization’s RCM processes and expectations.

Technical skill training: e.g., billing software, coding systems, etc. specific to behavioral health RCM (Spectrum Knowledge Gap).

Training specific to behavioral health: Look for training that focuses on the unique challenges and billing requirements in this sector.

Ongoing Compliance Training: Train employees and keep them up to date on all the new regulations.

Soft skills training: Improve the team’s communication and customer service abilities, which are especially important in dealing with patients as well as payers.

Leadership development opportunities: A variety of ways to advance within the business.

Continuous education and training can help organizations develop a confident, competent RCM workforce that commits fewer errors and, overall, forcibly performs better.

Cross-Training Initiative 

Cross-training programs can help develop a more flexible workforce so that organizations can better handle shifts in demand when it comes to workload peaks, absences or illness. In addition to developing skills, this approach also adds career development layers for employees, which could help fan the flames and improve job satisfaction and retention.

Here’s how to successfully put cross-training into place:

Identify the most crucial areas for cross-training. Seek out departments or roles where extra help could make a big difference in productivity.

Utilize mentorship: Create training pairs of some experienced staff members with those who are learning new skills; this can help foster a sense of connection amongst colleagues and enable knowledge transfer.

Rotate responsibilities—let them practice their new skills. Provide staff, the opportunity to apply what they have learned.

Spotlight and reward staff who are able to grow their skills: This helps build a culture of continuous learning.

Revise job descriptions based on the expanded skill set: This will formalize these new capabilities and be a great way to ensure that it propels more satisfaction at work.

 In this way, organizations can build their ability to address gaps in staffing and fluctuating workload by fostering a more multifaceted workforce—as well as the greater consistency of behavioral health RCM performance that follows.

Fashion a pool of staff and stencil contingency plans.

And staffing contingency planning—building an RCM pipeline—is step #1 to long-term sustainability. This includes building rapport with potential future employees and creating a clear track for where they might fit… in the organization.

Strategies for building a talent pipeline include the following:

Engaging with nearby colleges or trade schools: Develop internship opportunities to train students in behavioral health RCM processes and their potential role as future full-time employees.

Establishing an internal mentorship program: Train juniors for upper ranks by laying the path from lower to top within your organization.

Providing professional development opportunities: Assist the staff in obtaining certifications or higher degrees, which not only enhance their skills and knowledge but also foster a greater sense of commitment to the field.

Defining clear career progression helps to highlight the opportunity for growth within the organization and persuade employees towards long-term commitment.

This means not only a local training program but also the development of highly skilled RCM talent ready to graduate with a crystal-clear career. Grow opportunities within healthcare organizations, reducing turnover and ensuring a steady supply.

Managing Staff Vacations and Absences

Organizations face challenges in filling staffing gaps appropriately and maintaining smooth and effective behavioral health RCM operations when vacations and absences occur. This strategy emphasizes developing systems and processes that keep things moving when key personnel are out of the office.

Ways to cover it well:

Scheduling Time Off: Implement a system in place to schedule vacation and other planned absences at times when your company can adequately manage coverage.

Building a part-time or on-call workforce: We will use these flexible workers during peak times to cover staff absence and sickness, ensuring RCM remains operational every day of the year!

Being flexible with remote work: Allowing staff to work remotely where it makes sense will be more convenient for you and your team, while also reducing the likelihood of unplanned absences.

Build in strong documentation processes: Make sure that key information and processes are well documented so others can jump into the job if necessary.

By anticipating staffing gaps, organizations can ensure steady RCM performance and minimize onslaughts to the remaining workforce in times of absence.

Use outsourcing whenever feasible.

For some organizations, outsourcing specific revenue cycle management functions to a specialized provider may offer a solution. Facilitating the adjustment of workload, access to expertise and eliminating development overheads (cost). However, be sure to seek potential partners that truly understand the nuances of behavioral health RCM/billing.

Benefits of Outsourcing Behavioral Health RCM

Specialized Expertise: RCM outsourcing partners such as Velan have years of dedicated experience in behavioral health billing and coding maximizing performance.

Cost-Effectiveness: Outsourcing is commonly cheaper than internal teams, especially as costs add up for training, software and continued education.

Scalability: Outsourcing allows your RCM operations to scale up and down as per the organization’s requirements.

Optimized Cash Flow: A reliable outsourcing company from x, such as a claims denied solution, will have a proven record in reducing claim denials and decreasing your time to be reimbursed; hence, you can take an edge on cash flow.

Concentration on Core Competencies: Outsourcing RCM means that your staff will be free to devote their attention primarily towards areas such as patient care and other fundamental functions of the organization.

When considering outsourcing

Evaluate current billing and collections performance—specifically identifying areas where specialized expertise may be able to drive meaningful improvement (for example, contractors at the Revenue Cycle Management company reducing days in A/R or denial rates).

Ideal partners have deep expertise in behavioral health billing. Make sure they are qualified to meet the unique needs of your field, including complex billing requirements and frequent regulatory changes.

Assess both the direct costs and potential increased efficiencies as savings: By outsourcing behavioral health RCM services, what will it cost compared to in-house going forward [long-term] evaluation? In many cases, over time you can save costs from improved efficiency, fewer errors and increased collections.

Check that potential partners offer full service. Ensure they are not just billing but also addressing your revenue cycle, including trends affecting payment collection and upstream solutions to revenue cycle challenges.

Consider ease of integration: Select a partner that is able to integrate its services within your office structure with little disruption.

For the smaller organizations or those that are already tumbling under high staffing difficulty, outsourcing may provide valuable support and expertise.

Meeting behavioral health RCM staffing challenges is essential for financial viability and operational efficiency. Through these five principles—training programs, cross-training initiatives, staffing pipeline and fills plan, and understanding outsourcing options—behavioral health organizations can build a strong RCM team that is skilled in multiple areas.

More than just specific strategies, developing a positive work environment is integral to overcoming staffing gaps. This may involve instituting recognition and reward programs, implementing flexible scheduling options if possible, encouraging open communication in an effort to directly confront the issue rather than ignore it, as well as organizing weekend out-goings (not clownish but all-in-good-clean-fun outings), especially for teams/projects that are struggling.

Keep in mind that combating staffing challenges is a fluid experience: you must continually evolve with the changing needs of your organization and the field at large. To that end, by concentrating on these areas and looking at an outsourced arrangement as a viable option, behavioral health organizations can markedly boost their RCM performance, providing better financial outcomes and translating into more patient care.

How Can Velan Help?

Velan provides billing and collections outsourcing, which can help meet staffing shortages in behavioral health RCM services. Here’s how Velan can help your organization:

Scalable Model: With flexible and on-demand delivery options, you can expand your skilled workforce as needed.

Turnkey Effectiveness: Our billing experts are extensions of your organization, versed in the competencies to get claims processed effectively within a contemporary fluid model that is undergoing continual regulatory changes.

Regulatory Compliance: Velan provides skilled and trained billers who know the ins and outs of all present regulatory practices, making your behavioral health RCM services operations compliant.

Simple Integration: Velan enables seamless, non-disruptive integration into your existing workplace environment.

Transparency and Reporting: Velan adds another layer of transparency by providing you with concise reports that allow you to see through the very window where we can see operational issues causing billing delays and, consequently, delaying payment.

Performance Tracking: At Velan, we help you track key performance metrics and identify your behavioral health RCM services processes that provide opportunities for automation.

Staff Training Insights: Velan can also pinpoint the key areas for improvement where more assets would be useful in training your team to improve their skills and efficiency.

Engaging with Velan HCS gives you access to more specialized behavioral health RCM services expertise and support, resolving the insufficient staffing issue while optimizing billing and collections for your organization.