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  • Writer's pictureEffy Healthcare

Healthcare Business Assurance: The Next Step of RCM Evolution

Updated: Oct 2, 2020

Healthcare RCM technology has been evolving for decades. Some organizations have begun looking outside of healthcare to find the capabilities they need to continue their drive toward operational efficiency and new reimbursement model management. The answers they are looking for may come from an unlikely industry – telecommunications.

What does a mobile phone company and a hospital have in common? If your first thought is, “not much,” you’re not alone!

On the surface, the telecommunications (telecom) and healthcare industries don’t have much in common. Telecom is in the business of communication, and healthcare is in the business of medicine and healing. If you look under the surface of what they do and take a closer look at how they do it, the commonalities become easier to see.


The growth of telecom and healthcare have more in common than many realize. The first telephones relied on physical materials to transfer sound (information). A wire was the first conductor of sound, but the technology soon evolved to use electricity. As the new technology caught on, phones became more commonplace and people with different brands of telephones wanted to talk to one another but couldn’t because the brands didn’t work together – so, the telephone switchboard was born.

In its infancy, modern healthcare also relied on physical materials to transfer information, paper and pen. Many of us remember the vast rooms that housed handwritten medical files in offices and hospitals. The adoption of electronic medical records began about 25 years ago as a more efficient way to record and store health data. Over time, providers and payers wanted to exchange information electronically. However, much like early telephones, different brands of EMRs didn’t work together – so the claim clearinghouse came into being.

To evolve into the industry we know today, telecom had to solve the problem of interoperability between brands of technology.

To survive and thrive in the future, healthcare will have to do the same.

By the 1990s, mobile phones were commonplace. Today's smartphones even replace computers in some parts of the world -- technology has come a long way from wires and tin! Telecom companies now deal with millions of data points – from individual phone users to service plans, to companies that supply infrastructure. Healthcare data management is evolving in a similar way. There are millions of patients, each with different reimbursement plans, accessing healthcare through multiple channels that use various brands of electronic management. That’s why healthcare data management is fast approaching the volume of telecom companies. Like telecom, healthcare will soon need a better way to recognize inefficiencies and streamline operations among all its disparate systems or risk losing revenue.


As telecom companies experienced rapid growth, they recognized that the lack of interoperable technologies was affecting revenue. Often, it was difficult to pinpoint the heart of an issue because separate systems siloed information, and there was no way to audit so many different systems at once comprehensively. They needed a technology that could take data from different platforms and reconcile it back to business rules that would tell them what is happening versus what should be happening – the solution to the problem was Business Assurance technology.

The nature of Business Assurance technology is adaptable. New departments such as Revenue Assurance and Fraud Management quickly developed because the programs overlay existing transactional and operational systems to perform real-time auditing, and reporting, on any quantifiable metric. When deviations from customizable rules are detected, business leaders can take immediate action. Today, Business Assurance tools are used in virtually every telecom company for functions ranging from preventing revenue leakage, to fraud mitigation, to marketing. Any digitally stored information is a candidate for Business Assurance analysis.


Business Assurance tools can empower hospitals, healthcare systems and integrated delivery networks to retrieve, review and compare massive amounts of operational, clinical and financial data across their total enterprise – no matter the size, data incompatibility or platform complexity. Customizable, exception-based triggers identify deviations from norms, allowing organizations to reduce claim errors,  decrease and mitigate denials, improve efficiency and productivity, meet compliance requirements and ensure financial viability.

Healthcare organizations that use multiple technologies and platforms have the most to gain from creating a Business Assurance program.


Today, most large healthcare organizations have settled into their EMR and practice management systems; many have augmented those capabilities with specialized software and applications to maximize clinical and financial performance. They are taking advantage of the best healthcare technology available. However, the pressure of changing payment models based on performance and outcomes drives some facilities to find the 'next' solution, and they need to look outward to find proven systems that can deliver the results they need. The evolution of technology used for telecom Business Assurance, with a proven track record spanning over the course of decades, makes it a natural fit for healthcare.


Effy Healthcare is the case-in-point. Effy's leadership realized that traditional approaches to data analytics and business intelligence weren’t suited to healthcare. Organizations that developed solutions internally often were restricted by limited resources and needed to rely heavily on manual workflows. External solutions, such as EMR-bundled analytics and business intelligence (BI) tools, were often either too limited in scope or overly generic. Plus, these tools relied on after-the-fact reporting to create retrospective analysis, which could not deliver real-time actionable data to prevent business rule outliers.

To create the system healthcare needs, one that provides real-time insight into healthcare revenue cycle and clinical performance while at the same time delivering predictive analysis and instantaneous data alerts, EFFY turned to RAID. RAID’s software platform is the established leader of Business Assurance technology for international telecommunications and is used by the most prominent telecom companies worldwide to improve performance; cellular and cable companies across five continents have depended on RAID software for many years. Since it is not an operational or transactional solution, RAID can be layered on top of any existing system. Effy enhanced RAID’s proven capabilities in telecom to launch RAID Healthcare, a platform unique to the health industry. RAID Healthcare audits and continually examines behaviors to detect exceptions that impact the financial, operational, and clinical performance of healthcare organizations. The result of this collaboration is reporting, dashboarding, analytics, workflow management and variation alerts delivered through a single, real-time solution that streamlines decision-making, protects revenue and measures performance against KPIs.


One example of Effy’s impact on RCM began in 2017, when an extensive health system located in the southeastern United States asked Effy to address challenges specifically related to denial management, appeals and Medicare LCDs. The health system had recently implemented one of the leading EMR brands in the country and yet they were facing the same usual problems with high claims denial rates. Infusion treatments were targeted, and RAID Healthcare tools began monitoring charges. RAID-generated alarms soon alerted leadership to problems with the authorization process. Real-time alerts enabled the health system to rectify authorization issues before treatment, ensuring reimbursement and avoiding denials. Inadequate and missing documentation proving medical necessity was also identified and corrected through the system. Cost savings continue to accrue, while improved systems and streamlined workflows have protected millions of dollars in revenue. Even more good news for the health system was that it saw a return on its investment within months.


If your healthcare organization is ready to move beyond the standard tools available for RCM insights, it may be time to explore what Effy can do for you. Contact us today and request a demo.


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