Choosing the right revenue cycle management (RCM) system can make or break a hospital or physician practice. The moment a patient makes a doctor's appointment or enters the hospital, the RCM system kicks in. What happens after that depends a lot on whether there is an effective and transparent marriage between claims data, clinical data and IT.
According to the 2012 Black Book IT Yearbook for accountable healthcare organizations (ACOs), 95% of hospital and healthcare system executives polled said they were accelerating their acquisitions of health information exchange (HIE), electronic health record (EHR), clinical decision support, care coordination, business intelligence, and complex revenue cycle management systems to prepare for ACO and other care delivery models pegged to new reimbursement methods.
So what should a hospital, traditional practice, or ACO look for in a RCM program?
According to Jane Sarasohn-Kahn, health economist, management consultant and Health Populi blogger, today's health providers need to focus on revenue cycle workflow because they will be caring for patients over the long term, not episodically. "That means looking horizontally at the value-chain of care, from pre-encounters through to the post-encounter administrative tasks," she said. "At the front end, the provider must capture and clarify the insurance and payment provisions for the patient.
"Throughout this chain, RCM systems can help health providers pinpoint areas for cost improvement in real time," said Sarasohn-Kahnsays. "The systems should also be able to integrate clinical and care management information along with the financial information along the patient's journey."
Sarasohn-Kahn pointed out that predictive modeling is emerging out of big data sets to help providers spot, say, the top 5% of patient "high utilizers" in order to identify opportunities for better care management -- for example, prescribing a remote home health monitoring device for patients with a pattern of hospital readmissions for congestive heart failure.
For Sharon Hawthorne, business manager at Dr. Rochelle G. Catus' Ob/Gyn practice in St. Louis, Missouri, there are two sides to revenue cycling. There is "revenue cycle from the business side and revenue cycle from the clinical side," she said. "And from a business side, scheduling is one of the important features, and complex scheduling is a feature that is necessary because it starts from the appointment."
It's imperative to accurately capture patient demographics and insurance, and know that you are working with a patient with whom you are contracted, said Hawthorne. "To schedule a patient who you do not have a contract with might not be in the best business interests for that practice," she said. Catus' practice uses ADP's AdvancedMD RCM product.
A good revenue management system effectively deals with different insurance carriers, Hawthorne added. "You need to know all the different nuances and rules that carriers have when you're processing claims, and a good revenue management system has the ability to have those rules so that you don't have to have your employees memorize them." she said.
Hawthorne also pointed out that mobile applications are playing a greater role in revenue cycle management. Her practice, for example, is currently using tablet computers. "As a manager, the ability to look at my company from anywhere I am is important because sometimes I'm not in my office; I'm assisting in another office," she said.
Dan Johnson, president of RCM vendor Experian Healthcare, told InformationWeek Healthcare that he frequently hears from hospitals and practices that they are looking for tools that have been used by financial services companies and modified to be used in health care. "I've heard that more in the last year; there's a recognition that they lack those tools," said Johnson.
Johnson said he's also noticed there's a new focus on revenue cycle tools that work in both the hospital and the physician practice, and that integrate data. "[M]any hospitals [are] buying physician practices and so many of these organizations [are] forming hospital physician partnerships," Johnson said.
Another emerging issue, according to Johnson, is the need for a higher degree of electronic authentication for access into medical records systems, an issue that has been driven by Meaningful Use Stage 2 standards. "That is requiring a higher level of authentication for access to medical records systems, and this has started with CMS deploying ID proofing for Medicare recipients to access the CMS website where medical data exists," he said.
Revenue cycle management can be complicated, but it's a necessary part of running a successful healthcare organization, especially with changing federal requirements. This overview of six RCM systems will help you make an informed decision.