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  • Writer's pictureby José Xavier

The strategic importance of having continuous auditing and improvement solution for your RCM

Updated: Oct 13, 2020

by José Xavier, Founder and CEO at Effy Healthcare

Amidst all the COVID related events of the past few weeks, many, if not most, health systems are facing increased complexities to the health system’s RCM processes throughout the enterprise. Furthermore, the difficult in keeping track of government policies daily changes, plus the fact that different payers are taking different approaches, results in massive sets of disparate data to be reconciled and reviewed.

Now, more than ever, it’s important to select a continuous auditing solution for your Revenue Cycle that will ensure clinical and operational excellence while supporting the financial viability of the organization. 

Addressing real issues 

Specific issues regarding treatment authorizations can be particularly confounding, impacting an organization’s ability to mitigate claim denials for treatments provided. This can occur when there is a deviation in the plan of care, burdening clinical and operational teams to secure authorizations for treatment necessitated by a change in the patient’s health status. As a result, the claims might be denied, even though the care was rendered and the expense incurred, which causes a hospital system to bear the burden and file a write off. Even if the screens on a health system’s existing operating system register that the charges for treatment would be dropping on the claim, those systems can also fail to confirm re-authorization and there goes another missed billing opportunity. 

Another area of deep concern is documenting medical necessity in order to ensure reimbursement. Here again, the current system may be burdened with claim denials resulting from documentation failure.

The complexity of finding the right solution

Hospital leaders responsible for revenue cycle are now tasked with having to evaluate numerous competing vendor solutions with all promising to deliver big results. Since many health systems have already invested significant funds in their overall operating system, and perhaps some analytic tools, the idea of discarding and replacing their current system with a different and equally expensive transaction-based model just isn’t feasible. 

So, it’s imperative to choose an actionable RCM solution that overlays existing systems to help compare massive amounts of data across the total healthcare organization, detect exceptions and problems, and guide the ‘fixes’ you will need to make, actions and interventions to improve efficiency, without the need of changing the already existing systems.

Having this in mind, when seeking a solution, hospitals can eliminate the need for large up-front acquisition costs and make a financial transaction that falls within budget and gives a robust return on investment even.

A real example of ROI

One large hospital system’s outpatient infusion center, when carefully looking for a RCM solution, chose EFFY powered by RAID Healthcare to help them deliver some of the objectives mentioned above. Here’s what they’ve achieved so far.

  • They initially identified seven rules that governed authorizations for infusion treatments and then tasked the RCM solution to begin monitoring CPT changes. The solution generated alarms so critical to diagnosing problems with the authorization process, and provided immediate opportunities to initiate corrective action, that hospital leaders quickly expanded the rule set to 10. 

  • Savings related to denials and write-offs continue to accrue and achieved a 7 digit savings mark in the first 12 months of operation in this clinical area. 

  • Back-end processes have been streamlined, relieving stress and time constraints imposed on the clinical staff. 

  • Inadequate or missing documentation of medical necessity have been addressed, allowing the hospital to transition charges to patient self-pay or to initiating a change in the course of treatment. 

The main conclusion is than an effective RCM audit solution should help hospitals increase net revenue by 3% to 4% just by adding a real-time actionable analytics platform.

This will allow hospital managers to quickly gain control of aggregated data from any operational system, set up sophisticated validations to detect and resolve issues that impact revenue integrity and clinical and operational performance, and prevent inefficiencies and other causes of revenue leakage even before they occur, in the most cost-effective way. 

In summary, current times are challenging times - keeping up with all the former business as usual plus the new “business as unusual” - in which it is critical to keep financial health of healthcare organizations in a minimum good shape. The health systems networks need to at least be able to return back to some normal soon, without permanent damages to the organization sustainability. This is where continuous and automated tools can help. And time is of the essence.


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