What are some of the best strategies to maintain cost efficiency?
It’s about achieving accurate and timely payments to a provider. When we work with an organization, we often realize that their biggest issue is difficulty keeping up with software updates, government regulations and accuracy of government claims payment information. Our focus is making sure they understand where those inefficiencies are and whether they’re technical or business related. You’ve got to have a model that allows for efficient software and technology updates where necessary.
For instance, a lot of healthcare organizations say they have high automation, but then have to redo the processes because the end result was inaccurate for some of the time.
We seek to solve that problem. Not having the right work flow or the right technologies to achieve that goal is very detrimental to cost efficiency in the industry.
What are primary claims reimbursement challenges and how can they be best resolved?
As an industry, we look to Centers for Medicare and Medicaid Services (CMS) to set the standard of how we should act when it comes to reimbursement.
The challenge then is to operationalize the changing mandates. The government will put more rules in effect over the next few years concerning a switch from fee for service to more value-based care. The provider can no longer just perform services and expect to be reimbursed. They have to switch their mindset to be more focused on outcomes and less reliant on performing a volume of services to get paid. This creates huge reimbursement challenges. How do you successfully administer a program like that?
At this point, no one knows exactly how to in a way that perfectly marries all the different clinical, financial and quality data sets to achieve optimal results. There also isn’t enough statistical evidence to prove that value-based care is the best way to achieve cost efficiency and outcomes for people who are sick. All we can do is analyze the data and apply realistic measures and software processes to see if shared payment arrangements for episodic and chronic care are going to work. A sensible path will be for the industry to phase-in new reimbursement models, ensure providers take on some risk but can remain financially stable, and then begin to measure medical and financial improvements.
Therefore, provider organizations have to be partnered with the right software firms and with respective payer organizations to achieve quality of care improvements and appropriate reimbursement in a more realistic way. Legacy or traditional “out of the box” processes are not going to work here. It’s going to achieve the same sort of waste we have, just in a new way.
How does enhanced claims accuracy strengthen revenue cycle management?
The accuracy of the data you submit enables revenue to come in much more efficiently and at the levels you expect. From the payment side, everyone lives in the fee-for-service world where if I submit my claim with checks and balances, I’ll be reimbursed based on the services I provide. Now it’s becoming more complex. It’s not just the services you provide, but did you adhere to all of the quality standards that we agreed upon? Were some of these services really necessary given the arrangements and norms for treating the patient? It’s a lot more important to have defensible data and make sure you’re accurate internally through all phases of the revenue cycle from bringing the patient in, to performing the treatment, to coding it correctly and getting the claim or encounter submitted correctly. That’s always been important, but now more data is being assessed, and the provider is more accountable for the results after the patient is discharged home or to another care setting.
The good thing is the technology is there to reconcile all of it. It’s what the government is asking us to do, so if you’re not doing it correctly, the revenue is going to be held up or you could be penalized based on not meeting certain quality measures. From a revenue cycle perspective, a lot of provider organizations have had to change how they’re managing that and implement reporting processes for the organizations that are paying them. Otherwise they’re leaving dollars on the table or not getting back what they thought because they’re being penalized.
If you don’t have the right technology and the right workflow, even if you have the best intentions and you’re doing what you’re supposed to be doing, your revenue cycle may not be cost efficient.
What should healthcare providers be focused on next regarding upcoming reimbursement opportunities?
If you can have an efficient lump sum arrangement of payment with high quality care and service your population well, you stand to have a positive outcome from a reimbursement perspective. I recommend that providers take on the financial risk of having more bundled payments and commit to being more efficient rather than continuing with the traditional Fee-For-Service model.
The risk involves managing the outcomes of your population more from an administrative standpoint. That’s a huge reimbursement opportunity that I’ve seen a lot of the more forward-thinking provider organizations take on. They are actually acting as a payer to their own providers and figuring out how to accomplish that. Who better than the organization administrating the services to figure that out?
With technology, the healthcare industry has always been behind other industries, so we really need to be more forward-thinking. We are making great progress. For instance, many healthcare organizations now utilize cloud-based technology providers to achieve IT cost savings and enable a quicker response to industry changes like Medicare payment methodology updates. Leveraging technology takes some of that burden off organizations to have their own massive data centers and processes internally, when all of that can be managed better by those organizations with that core competency. We have to go further, however, and we have to be comfortable with it. We are all regulated. We are all under some sort of scrutiny.
One of the things we’re doing well as an industry is mandating that everyone be efficient, which will ultimately ensure better financial outcomes. Look to the partners who are trying to be efficient from a technology perspective and open those doors for sharing data. Otherwise, it’s just going to be more difficult. That’s one of the key talking points in the industry right now.