Kathy Schwartz, Product Manager, Craneware Inc.
Schwartz: All of the above. Revenue cycle man- agement is the complement of actions, process and technologies that manage revenue generation. T e revenue cycle management process begins as a patient schedules an appointment or arrives at a hospital, and it continues after they leave, the bill is paid, and earned revenue is defended against recovery auditors from government and commercial payors as needed. At any point in this process, if coordination is lacking among responsibilities, or if breakdowns occur in com-
munication, reporting or monitoring, then there will be inaccurate data capture and revenue leakage will occur. Traditional revenue cycle management is being turned on its ear
by the revenue integrity movement sweeping hospitals and health systems for the past few years. Revenue integrity encompasses goals of operational effi ciency, compliance risk reduction and optimal reimbursement. It is the alignment for clarity, of complex business and clinical operations.
England: Maintaining common procedure pric- ing across all facilities; billing, claims processing, patient charge capture and payment; and mini- mizing the impact of reimbursement cuts and payer mix migration.
Karen England, Revenue Cycle Consultant, Ingenious Med.
Lang: In the simplest terms, the goal of revenue cycle management (RCM) is to capture all net revenue contractually owed to the provider from all payment sources for the services performed. The RCM team manages claims processing, payment and revenue generation. RCM includes every aspect of revenue potential from focusing on patient eligibility, collecting co-pays, to properly coding claims using ICD-9 (soon to be ICD- 10) to avoid denied claims or missed revenue opportunities. Trends indicate hospitals are losing three to
Mary Beth Lang, ScD, Vice President, Healthcare Pharmacy and Supply Chain Management Commercial
Services, University of Pittsburgh Medical Center (UPMC)
fi ve percent of revenue from lack of eff ective RCM. Many providers are looking closely at hospital and physician billing processes through their clinical systems and EMR to improve rev- enue cycle management processes and procedures as they prepare for signifi cant changes in payment restructuring to risk-based reimbursements of expanded value-based payment requirements, shared savings plans and accountable care orga- nizations.
How will revenue cycle management have to improve under the Affordable Care Act, and what should IT’s contributions be to ensure those improvements happen?
Dragovits: It all has to do with collaboration and communication. Information must fl ow through the system from start to fi nish and there must be visibility at all points of care; not just in one solution,
Jim Riley, President and CEO, Capario
but in all of them. T is is the only way we will be able to link quality and payments. Most IT platforms in use today are not open enough to accommodate the information and process fl ow from start to fi nish because they are coded with old technology on old platforms. New payment models and processes require fl exibility and proac- tive monitoring, and the ability to change direction if necessary.
Riley: T e ACA ultimately encourages coopera- tion and interoperability between disparate legacy systems, and IT must fi nd revenue cycle solutions that will work seamlessly with them all, especially with PMS/EHR systems. It also sets the stage for value-based reimburse- ment models (risk-bearing models). Business intelligence tools will be necessary to identify the risk-to-reward ratio for your organization so that you can be prepared. In addition, the ACA will drive an increased
growth in the number of insured patients. Organizations must prepare now with IT solutions to be ready for the infl ux in patients and maintain and enhance profi tability.
Amy Amick, President, Revenue Cycle Management Segment,
Amick: Of course, a lot of revenue cycle man- agement discussion related to the Aff ordable Care Act centers on the fact that per-patient rate reimbursement levels are going to decrease, which is true. Making sure that the organization optimizes reimbursement due for services deliv- ered will be more critical than ever. What’s less talked about is the budget drain that’s going to occur from the tremendous competitive pressures placed on providers – particularly in building a diff erentiating business model, e.g., purchasing physician offi ces, mergers and acquisitions – all of this business activity requires lots of capital ex-
penditures. T ese unprecedented market drivers make establishing a best practice revenue cycle management (meaning doing the things we’ve done before, but doing them exceptionally well – execution, simplify workfl ow, improve automation) ever more critical to keep- ing your doors open while you carry out future strategy initiatives. Optimized cash fl ow for current state is going to become essential to the long-term viability of the organization. T e other IT piece is ensuring your revenue cycle management technology and data analysis capabilities enable assessing and making informed decisions on higher-risk reimbursement models like ACOs, bundled payments or patient-centered medical home – analytics to support looking at the underlying cost drivers before taking on reimbursement risk – which contracts, which service lines. Revenue cycle management will need to have technology and services in place to help the organization transition from fee for service and direct which is the right path among a number of diff erent ways to move – whether it’s a simple bundled payment or taking on population risk. Having the necessary IT budget and technical resources will be essential to enabling these new technologies and in the sharing of databases between billing, accounts payable, clinical EHR/EMR, revenue cycle and supply chain across the entire health system.
England: Revenue cycle management must have the ability to adapt to frequent and rapid changes in federal, local and payer require- ments. Additionally, the need to access real-time data regarding
HEALTH MANAGEMENT TECHNOLOGY June 2014 9
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