Healthcare Reform’s Impact on Revenue Cycle Integration
The Affordable Care Act has expanded access to more than 20 million Americans who were uninsured. MIPS will accelerate the shift from fee-for-service to value-based reimbursement. While only 30 percent of healthcare payments were value-based in 2015, that is expected to rise to 50 percent by 2018. This shift demands closer integration between clinical and financial operations. After years of working to qualify for Meaningful Use, PQRS and other reimbursement incentives, value-based programs including MACRA now require organizations to tackle even tougher clinical/financial integration issues, such as how to improve patient access and better manage care quality. Managing patient care, in terms of access, services, and costs, however, requires clinical and financial operations to coordinate their efforts and align their priorities. The integration of EHRs, clinical workflows, and care coordination are vital to the revenue cycle. A clinically-driven revenue cycle has created a paradigm shift in the traditional revenue cycle mindset.
Healthcare reform and the shift to value-based care has placed a greater emphasis on improving patient access. This includes access to the appropriate medical services in a timely fashion (patient satisfaction, patient “keepage,” and care management), patient-centric financial counseling and proactive self-pay strategies. A more defined focus on patient access in the front-end sets the foundation for a clinically-driven revenue cycle. With these thoughts in mind, there are three key areas of the revenue cycle where healthcare organizations must focus integration efforts:
1. Patient Access
A clinically-driven revenue cycle starts from the time a patient calls to schedule an appointment. The increase in patient payment responsibility places critical emphasis on front-end functions including eligibility verification, prior authorization, and financial counseling. These activities, as well as patient check-in, also represent an ideal opportunity to address outstanding patient responsibilities.
Financial transparency can also increase patient satisfaction and help reduce the current bad debt average of 25-30 percent, but this requires an adjustment of focus and resources to the front-end of the revenue cycle to improve overall performance measures. An increasingly common approach adopted by many organizations is to centralize patient access operations, standardize policies and procedures, and leverage PM technology in order to:
- Ensure the capture of clean demographic and insurance data.
- Validate insurance coverage.
- Educate patients on their estimated responsibility.
- Assess patient propensity to pay and offer financial counseling.
- Collect patient payments like co-pays when registering or at time of
A centralized access center provides the patient with a single point of contact to address all front-end related questions and allows staff to be proactive rather than reactive. These preemptive measures will enhance patient satisfaction, which greatly influences reimbursement. A satisfied patient is less likely to seek services outside of their system. From a reimbursement perspective, this enables more effective care management in a value-based environment.
2. Integration of Clinical and Financial Workflows
With patient access and front-end operations being a large influencer of reimbursement, another factor that affects the revenue cycle is how clinical documentation and coding workflows are implemented and executed. Clinical workflows and EHR design must support, not hinder, a clinician’s ability to document patient care. It is also essential for physicians and staff to be properly trained on those systems. If diagnoses, orders, procedures, etc., are not properly documented/coded, it will ultimately result in billing delays or potentially lost revenues. If something is not captured, it will not be billed for on the back-end, which results in a loss of revenue. Long-term, this also impacts the ability to effectively manage population health programs.
The various technologies available to healthcare organizations contributes to revenue cycle workflows. Workflows and processes must parallel the technology being utilized. Fully integrated clinical and financial systems do provide several benefits. Organizations should adapt IT systems to support the clinical workflow and resist the urge to alter their workflow to accommodate IT platforms.
3. Reimbursement Analysis
Value-based contracts require more complex reimbursement analysis than periodic, retrospective reviews to see whether insurance claims were paid according to contract terms. Going forward, both financial and clinical teams will need to work together to assess reimbursement. The quality department will need to continually monitor clinical metrics for accuracy, for example, while the financial department will need to ensure accurate payment based on those metrics. Tight clinical/financial system integration — or clinical and financial reporting from one system — can help practices better manage cost and quality data together.
Consolidating patient access, developing collections efficiencies, and bringing clinical and financial viewpoints to the reimbursement process can help practices thrive under value-based care. Keep in mind that these strategies all require integrated technologies, not technology-dictated workflows. With emerging value-based models, tremendous opportunity exists for organizations to create a clinically-driven revenue cycle that reduces costs and improves the patient experience — all the while achieving key tenets of healthcare reform.
Brad Boyd is president of Culbert Healthcare Solutions.