The reimbursement landscape is evolving with a move towards reimbursements based less on fee-for-service and more on pay-for-performance. To produce better the clinical outcomes required to meet these performance targets, healthcare providers will need to optimize their RCM operations by adding technological capabilities to collect data and drive analytics. Payer scrutiny of compliance and charges by both government and commercial operators is becoming increasingly stringent. Meeting this challenge requires enhanced tracking and management capabilities in the RCM function, with interested parties embracing value-based reimbursement structures.
To achieve this RCM systems must be automated. However, healthcare providers also need to know how to incorporate the human touch, something that is especially important given the nature of the sector. It’s essential during the design, implementation and execution stages to include input from all stakeholders, especially, as the Northwell Health writers argue, patients. This involves a clear explanation to patients of issues such as the difference between estimates and final costs. RCM systems and other administration need also to ensure that patients are made aware of the risk of insurance denials and opportunities for accessing the Affordable Care Act provisions, as well as navigating Medicaid provisions and charitable support options.
In fact, healthcare providers frequently discover that many of the considerations are related less to the design of RCM architecture and are more related to its implementation on a day-to-day basis. Staff training is essential to deliver a high-quality patient experience, supported by RCM systems.
One particularly important issue here is the possible change in revenue management brought about by the introduction of remote physiologic monitoring, in the wake of COVID-19. Already expanding rapidly before the COVID-19, it has grown by a remarkable 38 times its pre-COVID-19 rate, according to McKinsey.
Meanwhile, many patients and healthcare workers still do not fully understand the new codes introduced by the American Medical Association (AMA). Healthcare providers need to ensure that their RCM systems are capable of managing them.
Practitioners need RCM that provides visual data representation and dashboards to make receiving meaningful information drawn from data easy to read and act on. Systems should also be ready to provide more information for patients directly, alleviating the need for them to speak to hospital and insurance representatives, improving transparency and giving them a greater sense of empowerment.
Healthcare providers should also ensure that their RCM systems are ready to incorporate and exploit technologies such as Artificial Intelligence (AI), Machine Learning and the use of bots. AI can be used to predict additional health treatments and cost for patients as well as the risk of denial by an insurer among other issues.
As it evolves and integrates these rapidly emerging technologies RCM has the potential to transform the management of hospital revenues. Trends such as aging populations and new, more complex treatments mean that existing health services infrastructure is facing new kind of challenges. The next-generation RCM, blended with traditional human care, presents healthcare providers with a means of not only meeting these challenges but of delivering the efficient administered, high-quality healthcare that patients are increasingly demanding.
Dr. Gauri Puri is Business Unit Head for Life Sciences and Healthcare Practice at WNS.