Driving Value: Taking the Healthcare Revenue Cycle to the Next Level

As hospitals and healthcare systems evolve to meet the needs of a growing and aging population, they find themselves struggling to remain financially healthy. An effective healthcare revenue cycle ensures patients receive treatment and hospitals can be reimbursed quickly.

The current healthcare revenue cycle evolved from a fee-for-service model to a value-based care model. While this accelerated a significantly more engaging and efficient patient care process, it also made managing and monitoring administrative and clinical functions financially critical tasks.

It is crucial to understand revenue cycle management, its value, and its challenges in healthcare.

Understanding the Healthcare Revenue Cycle

A thriving healthcare revenue cycle reduces and prevents errors. Several factors contribute to errors, but an agile revenue cycle management framework can eliminate these challenges before they occur. To do this, hospitals must enhance specific RCM components and enablers, which include:

• Documentation: Clinical Documentation (CD) refers to digital or analog records that maintain the details of medical treatment, clinical test, or a medical trial. Accurate documentation is imperative to ensure proper reimbursements.
• Claims submission: The process of submitting details about the care provided to determine the reimbursement amount
• Remittance processing: An explanation of the payment toward one or more claims submitted by a provider
• A/R management: The handling of Accounts Receivable (AR) or the amount owed to providers or medical billing companies for the care provided to patients.
• Analytics: Healthcare analytics refers to analyzing current and past healthcare data to manage ailments better, improve outreach and predict trends to generate actionable insights for providers.

Optimizing these factors allow healthcare centers to build solid and efficient and reap tangible benefits, such as:

• Increased revenue and practice collections
• Increased paid claims after the first submission
• Enhanced focus on quality care
• Better patient experience
• Lowered administrative burden

RCM Challenges in 2021

Maintaining a healthy revenue cycle is daunting, especially in an increasingly over-burdened healthcare sector and during a pandemic. Hurdles that can often cause the most damage to the revenue management cycle include:

• Communication issues
• Inadequate data flow
• Human error
• Technical failure
• Other exacerbating issues
• Errors in the coding/billing and documentation process

The introduction of the ICD-10 guidelines presented a fresh layer of complexity to an already onerous coding process. For hospitals, failure to comply with the guidelines could result in incorrect coding and billing, lost revenue, and harsh penalties for any mishaps. Additionally, not maintaining specialty-specific A/R benchmarks poses additional challenges.

Secondly, documentation errors can further strain the management process. A recent review by a medical liability insurance provider reveals documentation errors make up 72% of all EHR risks. Documentation errors significantly impact the quality of patient care and provider reimbursements, and they affect all other processes on the outpatient chain.

Technology as the Solution – The AGS Initiative

Leveraging cutting-edge technology offerings to simplify processes and streamline revenue is necessary in an increasingly digital world. And this is where AGS Health’s advanced solutions can offer substantial benefits across multiple aspects of the revenue management cycle.

Our Computer-Assisted Coding (CAC) tool uses Artificial Intelligence and Natural Language Processing  to maintain coding guidelines and suggest correct codes. This automation reduces coder workloads significantly and mitigates human errors in coding. At the same time, our Clinical Documentation Improvement (CDI) solution automates query suggestions to maintain coding accuracy and improve document quality.

Additionally, AGS Health’s analytics engine provides visibility over the entire coding function and granular insights aid in the continuous improvement of processes and people. With real-time tracking of clinical, CDI, and audit performances, the engine helps providers proactively identify issues and implement fixes.

AGS Health strives to surpass outpatient coding quality and accuracy benchmarks with rapid and consistent CAC and CDI. The objective: help healthcare centers provide the best possible value and receive the best returns on investment in the current value-based healthcare landscape.

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