Looking to outsource your hospital's revenue cycle management? Explore the criteria to look for in a comprehensive RCM.
Revenue cycle management (RCM) is a complex process that can significantly impact the financial health and reputation of a healthcare provider.
Denials are common. The rise in out-of-pocket medical bills results in lower collection rates and higher bad debt. Adding to this challenging environment, errors in the revenue cycle often delay reimbursement from insurers and patients.
What if there was a way to help increase provider revenue and improve patient experience? An RCM vendor partner can help to create a more positive outlook for the future. But not all RCM vendors are created equal. Here are some key considerations to make before selecting an RCM vendor partner.
Before you start evaluating potential vendors, it’s important to identify your specific needs and priorities. Consider your organization’s current pain points and the features and capabilities you need in a new system.
Having a clear idea of your requirements will help you select a vendor provider that's the proper fit for your organization. After you understand your needs better, the next step is to ask specific questions to assess potential RCM vendors.
You’ll want to look for a vendor partner with a strong track record of success and a clear understanding of the complexities and nuances of healthcare billing.
When vetting potential vendors, inquire about their experience in areas such as claims management, denials management, collections, and payer contract negotiation. Also, check their understanding of the regulatory environment, as this can affect how effectively they can support your organization. A vendor with the right expertise and experience will be a valuable partner in helping you navigate the revenue cycle and achieve your financial goals.
You’ll want to find a partner with experience working with healthcare providers similar to yours in size, specialty, and complexity. This will ensure that they understand your unique needs and can tailor their services to meet your requirements.
In addition to comparing how different RCM vendors integrate with your existing systems, you should also ask about their onboarding and implementation process. How long will it take to get up and running with your organization? What kind of training and support will they provide for your team? How will they help you through the transition, and what kind of ongoing support can you expect?
Everyone who works in healthcare administration knows that change is a constant when it comes to regulations. The RCM vendor should have a comprehensive understanding of HIPAA, CMS, and other relevant regulations and be able to clearly explain how they ensure compliance. Ask about their training and education programs, compliance audits, and how they handle any potential violations.
You’ll want to understand the provider’s pricing structure and ensure it aligns with your budget and financial goals. Make sure to dig deeper into the fine print to uncover any additional fees or hidden costs. While cost is an important factor, prioritize value and the potential for revenue optimization over the lowest price. The right vendor will be an investment that provides an appropriate ROI.
It’s important to inquire and compare RCM vendors’ typical implementation timeline. Pay close attention to how they handle the data migration process, and what support they offer during and after this phase. It’s also a good idea to ask about their change management process and how they plan to help your staff get up to speed on the new system. With a clear understanding of the implementation process, you can plan accordingly and avoid any surprises.
An experienced RCM vendor partner should bring more than just industry knowledge and know-how to the table. They also bring valuable connections and relationships with key players in the industry, such as insurance companies and third-party payers. With these resources, they can then help you to stay compliant with the latest regulations and policies.
Check for industry certifications, which provide assurance that your provider is committed to upholding the highest standards of quality and ethics. This checklist of certifications will help you during the vetting process to properly filter through potential vendors:
Technologies like automation and AI are revolutionizing the healthcare revenue cycle by streamlining processes and increasing efficiency, all of which helps healthcare organizations optimize their revenue.
Robotic process automation (RPA) and cognitive automation are two key technologies that are transforming the way healthcare organizations manage revenue. RPA automates repetitive tasks, including patient scheduling, check-in, and bill pay, while cognitive automation uses machine learning (ML) and natural language processing to understand and respond to data inputs.
ML algorithms can take data analysis to the next level, detecting patterns in billing and coding data that humans might miss or not have the bandwidth to analyze. This can help to identify billing errors and optimize net revenue. In addition, by automating tedious tasks like verifying patient data or coding claims, AI and ML can free up healthcare professionals to focus on the human element of healthcare delivery, providing a better experience for patients and staff alike.
While automation is a key component of efficient revenue cycle management, it’s not the only technological factor to consider. Here are some additional considerations to check into when looking at capabilities and infrastructure:
All of these factors can have a direct impact on your organization’s bottom line as well as patient satisfaction, which makes technological functions and features an important area worth deeply exploring.
Given the sensitive nature of patient information and the complex regulatory environment, RCM companies must maintain the highest data privacy, security, and compliance standards. Because the stakes are so high for health systems when it comes to patient data and privacy, it’s crucial to make sure your RCM vendor covers all of the bases in terms of compliance and security. Each of the following safeguards and requirements should be met by your chosen vendor:
HIPAAThe Health Insurance Portability and Accountability Act (HIPAA) establishes national standards for the privacy and security of health information, including electronic protected health information (ePHI). HIPAA mandates that healthcare providers and their business associates take appropriate measures to safeguard the confidentiality of ePHI.
HITECH ActThe Health Information Technology for Economic and Clinical Health (HITECH) Act strengthens privacy and security protections for electronic health information. It requires prompt notification of any breach of unsecured PHI, and provides financial incentives for healthcare providers who adopt electronic health records and meet meaningful use requirements.
Affordable Care ActThe Affordable Care Act (ACA) includes provisions related to improving the quality of healthcare, reducing healthcare costs, and detecting and preventing healthcare fraud and abuse.
State-Specific RegulationsRCM vendors may be subject to state-specific regulations like the California Consumer Privacy Act (CCPA), so it’s best to determine which criteria need to be met within your state(s) and ensure the vendor you select can meet these guidelines.
PCI Compliance PCI compliance ensures that any time a healthcare provider processes, stores, or transmits credit card information, it’s done so in a secure environment. This is crucial to protect patients from potential data breaches and unauthorized transactions as well as to safeguard the reputation and financial integrity of individual healthcare organizations.
Stakeholders should also evaluate the provider’s security infrastructure, policies and practices. This may include reviewing documentation such as security risk assessments, incident response plans, disaster recovery plans and security audits.
Several different pricing models exist for revenue cycle management services and it’s best to compare each to find the one that suits the size and needs of your healthcare organization. Here is an explanation of several of the most common pricing structures.
A bundled pricing model packages several services together for a single price. In addition to the considerations noted above for fee-for-service and flat-fee pricing, here's what to look for when evaluating a bundled pricing contract:
When evaluating any RCM pricing model or contract structure, review each component carefully to ensure that it aligns with your organization's unique needs and provides the level of support required for successful revenue cycle management.
Having the right components and safeguards are only one part of the process of adopting an RCM system with a new vendor. The next stage, of implementing and training staff to efficiently utilize it, is just as important. While this journey can vary depending on your vendor partners, it universally progresses through these key six stages:
Each vendor has a different approach to this onboarding process. For instance, GetixHealth differentiates itself by delivering innovative and result-driven implementation solutions to our client partners. Our Director, Christian Wilkin, explains why this is one of our key guiding principles:
A crucial part of GetixHealth’s commitment to healthcare providers is our comprehensive and tailored RCM implementation process. Wilkin notes the diligence with which our teams approach each project, adding,
When selecting a RCM vendor, you’ll want to ensure that each phase of the implementation process is meticulously designed to ensure the seamless setup of the revenue cycle management software, guaranteeing that all data is accurately imported and that all users are fully equipped to make full use of the system.
Let's unpack these steps in more detail.
Revenue cycle management companies can ensure patient satisfaction by implementing strategies that improve the patient experience. Here are some ways that revenue cycle management companies can achieve this:
Outsourcing revenue cycle management services can help healthcare organizations realize numerous benefits, both in the short and long-term.
Out of the healthcare providers that participated in the survey, a whopping 95% reported an increase in revenue, with two-thirds saying the improvement was substantial. These findings suggest that outsourcing RCM can be a real game-changer, helping to boost a provider’s bottom line and improve their financial health.
The benefits of outsourcing RCM go beyond just improving financial performance. According to the Medical Group Management Association (MGMA), facilities that outsource their RCM can also enjoy other benefits, like reduced staff turnover and improved patient satisfaction.
Outsourcing their RCM allows staff to focus on providing high-quality patient care rather than getting bogged down in administrative tasks. How could the following benefits change the landscape of your health system?
Use this list as a guide while evaluating potential RCM vendor partners and if you have any questions during your search, reach out to GetixHealth for more information. Our expert team has guided many healthcare providers through the process, so we understand the concerns and questions healthcare leaders have during the selection process.