By Matt Skoufalos
For as much thought as goes into providing optimal patient experiences in health care from the perspectives of health outcomes and quality of care, management of revenue streams seldom seems to enter the conversation. Yet for its importance not only to the bottom line of any clinical operation, but also for its impact on patient satisfaction and total quality of experience, revenue cycle management (RCM) is a vital element of practice management and an often-overlooked component of it.
In understanding the revenue cycle from a comprehensive perspective, Mario Pistilli, administrative director of imaging services at Children’s Hospital Los Angeles, said it’s important to recognize the breadth of patient and administrative experiences that RCM touches. It begins before a patient is ever seen, with the collection of demographic information, and concludes after services have been rendered, through final payment and disposition of the bill. However, before that bill is discharged, there are always opportunities for things to go sideways, and without clear understanding of how bills are being generated, and visibility into that process, any other efforts to improve RCM operations won’t take root.
In radiology departments, billing information might be an internalized component of a radiology information system (RIS), or it might originate from a separate process that’s managed independently. Such information will include identifying details about the patient, the procedures they’ve undergone – including the universal Current Procedural Terminology (CPT) code describing that service – and the time, place and provider related to it. When the process doesn’t go smoothly, then it’s a question of troubleshooting points of failure in the system, from missing documentation to mistyped data to incorrectly coded procedures. Any one of those issues can delay billing (and reimbursement), leading to the work of unpacking the process to see where it failed (or was failed by error). Sometimes those issues are on the coding side, sometimes they’re on the billing side, and sometimes they surface at another point along the way. But without knowing there’s a problem, issues can linger and persist until they’re impossible to ignore.
The way to address such concerns involves reporting processes that identify issues within the system – denials, missing documentation, coding errors – and what’s needed to resolve them regardless of the reason they emerge, Pistilli said. Implementing tracking metrics and a way to visualize and manage those data allows institutions to get a handle on RCM issues and how to resolve them. While automation and AI-powered processes can support some of that detective work, at some point, process improvement is reliant upon individual expertise to correct.
“I prefer to eliminate errors before I make them rather than spending this work, time, money, effort, to fix stuff after,” Pistilli said. “Let’s get clean information in and a clean bill out the door in the first place. How do we stop that so we have less accounts to work on the back end? There’s process issues that the radiology director can control to really impact the revenue cycle, and it could be worth a lot of money,” he said.
Pistilli has dedicated one full-time employee exclusively to revenue cycle work, the better to identify any data trends before they hit reporting, as well as unpacking what might be behind them.
“I want to know why these things are in there, and not just fix the same problems month after month,” he said.
In some practice environments, intelligent revenue cycle automation and billing applications driven by artificial intelligence (AI) software offer an alternative to dedicating staff or management resources to investigating RCM issues. Amy Raymond, vice president of revenue cycle operations at healthcare AI developer AKASA of San Francisco, California, said that AI-powered RCM tools are no longer “nice-to-have technology” but have instead become “a mission-critical tool.”
“Many health systems and hospitals have already implemented automation and AI for their operations, or are looking to do so,” Raymond said.
According to an AKASA survey of nearly 400 CFOs and revenue cycle leaders at hospitals and health systems across the United States, some 78 percent of those polled “are currently using or are in the process of implementing automation in the revenue cycle,” she said.
Raymond reported that revenue cycle AI and automation processes are being sought to deal with “the most time-consuming, manual workflows,” including prior authorizations, claims denials, and to make up for staffing shortfalls. However, in order to successfully automate these processes, systems must be trained in which questions to ask and how to answer them.
“Just as a self-driving car can accelerate, brake, and turn based on what it encounters, revenue cycle automation solutions need to be capable of navigating complex workflows rife with edge cases and the unknown,” Raymond said. “This is why we believe in the power of automation combined with human experts in the loop as the way forward. When the system runs into a new challenge, it can flag down an RCM expert to complete the task in question, all while the automation watches and learns over time. This is a great way for revenue cycle departments to overcome the above-mentioned challenges and avoid common (human) errors that occur within the medical billing process.”
Some automated processes have been employed for a number of years, Raymond pointed out. These include robotic process automation (RPA), whereby a vendor-built bot (i.e., program) can be used to automate each step of a specific revenue cycle process; however, once those bots are constructed, they are often static, and can’t adapt to changes in things like payer portals or electronic healthcare records. AKASA seeks to distinguish itself from those fixed processes by leveraging AI and machine learning technologies supported by human revenue cycle experts to confront those shortfalls in the automation approach.
“If the system runs into outliers – for example, a payer changes requirements needed for a certain procedure without any heads up – rather than breaking or stopping work, our AI flags it to our revenue cycle experts, who resolve it in real-time while teaching the machines how to handle it correctly the next time it occurs,” Raymond said. “These more intelligent AI and machine learning solutions that leverage humans-in-the-loop, and can adapt to changes in real time with little to no maintenance, will be the future of revenue cycle automation.”
Raymond believes the future of automation in RCM will involve ever-tighter interrelationships between those AI-powered processes and human staffers with situational judgment and the expertise to appraise the circumstances of any issue in the cycle. As much as that evolution follows along with the cycle of technological development and process improvement, that relationship has also been driven increasingly by labor concerns brought on by the novel coronavirus (COVID-19) pandemic and the “Great Resignation” social trend that has followed it.
“The back office of health care is essential to keeping the doors of hospitals open by ensuring the bills are paid,” Raymond said “Yet, these revenue cycle teams were facing labor shortages like never before. COVID-19 has stretched hospitals and health care systems beyond the breaking point. And for all the new problems the pandemic has introduced, it has also shed a light on decades-old issues, where health care operations teams have historically been understaffed.”
The result of these circumstances has been that those staffers who have stuck with their roles have faced extra work and the burnout that come with it. On the management side, staffing issues have resulted in higher costs for overtime pay, retention bonuses, and hiring incentives, and not every health care institution is in a competitive position to meet those financial challenges.
“Several factors, including volatile patient volumes, ballooning labor costs, and the ending of pandemic relief funding have squeezed hospitals,” Raymond said. “Days of cash on hand at not-for-profit hospital systems are trending downward as the sector recalibrates after last year’s higher-than-normal balances. For some, it requires tough choices to be made.”
“The prime directive from this landscape is leaders have to unearth every nook and cranny where there’s potential to lower operating expenses, and find any sources of revenue we can to get back on solid financial footing, while also looking for tools to alleviate the burden on staff,” she said.
“The hard truth of the revenue cycle is that no one ever touches everything,” Raymond said. “There isn’t enough time or staffing resources. What happens? Queues get deprioritized, denials aren’t appealed, accounts receivable gets increasingly aged, payments are delayed, and write-offs go up.”
Software automation offers the potential to address RCM issues while also freeing up staffers to address those projects for which their discretion, expertise and understanding is most required. In those instances where onsite staff (or budgets) aren’t available to manage some of those functions, health systems may consider outsourcing those roles to staff outside of the company. Sometimes, that strategy can lower costs or plug holes in the short term, but Raymond believes that after a while, RCM outsourcing can complicate in-house processes by being either more expensive or less responsive to change.
“Getting it right matters when you fully outsource revenue cycle operations,” Raymond said. “There’s a lot of expertise, context and operational knowledge that gets lost. This creates inefficiencies, so ultimately, the exercise can cause more pain than it solves. If you keep things in-house, and layer on automation, all the savings trickle back to you.”
Getting to the root of RCM issues isn’t only meaningful for the financial health of a practice environment, but it can also affect whether its clients return to the same provider in the future. Sara Nofziger-Drew, client relations director for HealthPro Medical Billing of Lima, Ohio, said that when patients are confronted by surprise medical bills, or don’t understand for what they’re being billed, not only are they frustrated, but their confusion can make more work for the call center or billing environment, which can also impede the revenue cycle. At worst, it can turn a patient away from considering a given provider, hospital or practice group entirely.
“Whether the billing is sourced internally to the organization or outsourced, that process is vital to patient care, because that is often what people connect with at the end of their experience,” Nofziger-Drew said. “Patients are looking to see where they can be serviced the best. They are checking reviews, they are seeing what’s out there, and when a patient doesn’t have a positive ending experience, they’re going to look elsewhere.”
To alleviate those risks, Nofziger-Drew said providers should work to understand how much of an impact they can have on patient experience at the end of the appointment. Then, it becomes incumbent upon that billing department to ensure that patient has a positive experience through proper workflow, which can be compromised by a lack of oversight, potentially setting the patient up for a fight with their insurance provider, or the clinical office, or the billing department, or someone else.
“RCM is often the last interaction the patient has with anyone relating to their care,” Nofziger-Drew said. “If the patient has a great experience with their provider, but then billing doesn’t perform their duties well, it leaves a poor taste with the patient, and many times a patient will not come back to the same provider. Often patients and even providers don’t understand all of the steps involved to ensuring a service is billed appropriately and timely to the insurance company and subsequently to the patient if there is a balance owing.
“Failing to provide that generates frustration for the patient and extra calls to the call center,” she said. “When a patient has questions, the call center has to be knowledgeable about the process so they can help them resolve the problem.”
Even Nofziger-Drew, who has decades of experience in medical billing, confesses to having been frustrated when asked to help out friends and families with their challenging medical billing issues.
“Society in any area doesn’t do a good job of educating patients about every type of bill because of the way the health care system works,” she said. “Hospitals are dealing with challenges as well, so it’s hard to advocate and staff a person or people to educate patients. I have to sometimes jump through hoops to get my own bills paid, and that’s with my understanding of the system. How can we bring everything together symbiotically to provide the best care a patient can have?”
