Not your father's RCM anymore
In the days of strictly Fee-for-Service (FFS) reimbursement, the revenue cycle management process for physician groups was more straightforward. Deliver a service and receive a payment. Today's revenue cycle management (RCM) is changing to meet the challenges of today’s value-based healthcare environment, including new tools and practices that increase revenue collection performance. Providers have always regarded high quality care as imperative, but now must embrace additional competencies required to thrive in complex payor arrangements, especially those associated with accountable care programs.
Key factors affecting today's RCM process
Until the onset of healthcare insurance, payment for services was a matter simply between patient and provider. The entry of insurers meant the introduction of a third party and the use of claims with their even greater need to convey accuracy of patient data and coding. Managed care requirements introduced yet another level of complexity in the claims process. Databases that once featured a relatively simple set of data now include a vast amount of information, ranging from patient coverage and ICD-9 coding, to payor requirements and performance measurements.
Today at least four factors have made RCM a significant challenge:
The increasing complexity of medical care itself (witness the impending introduction of ICD-10 coding)
Each payor’s development of its own set of payment rules and standards, calling for each clinical practice to acquire large, multi-layered and highly complex data sets for any number of payors
Growing patient self-payment or high deductible obligations, a significant change in reimbursement patterns
Revenues based increasingly on performance measures, again varying by payor
As a result of all these factors, physician practices now face a highly complex revenue cycle. Consider the enormous variety of reimbursement models alone: fee-for-service, capitation, bundled payments, pay-for-performance and shared savings, and add to that the challenge of different rules and guidelines for each of a long list of payors, including many different payment models, reimbursement and incentive.
Where does billing begin?
Consequently, billing begins not at submission of the claim, but far earlier at the point of patient contact with the provider, sometimes even before patient registration. What is the patient’s insurer? What is the patient’s eligibility, correct billing address, previous denials? Once the patient has been seen, what is the correct coding? What treatment was actually delivered? Is this a patient with a chronic condition that qualifies the provider for non-face-to-face reimbursement associated with new CPT-9 code 99490 (effective Jan., 2015)? How much has the patient paid to date? What are the particular requirements and standards of the patient’s insurer?
A next generation RCM platform contains complete data about each payor’s requirements and also applies complex algorithms that access every piece of that data. Technology can perform many of the tasks, such as checking whether a claim has been paid, further freeing up staff from tedious manual work.
Next generation RCM platforms must address:
Tracking Claim Status
Tracking Patient Eligibility
Two new challenges to futher complicate the process
Revenue cycle management is undergoing two additional changes that will continue into the foreseeable future: patients are responsible for a growing percentage of payment for services, and value-based reimbursement calls for a degree of reporting with its own complexities.
Read more about these areas, as well as challenges facing hospital-owned practices in our FREE whitepaper: Next Generation Revenue Cycle Management for Value-Based Healthcare.