I will start with one polling question before I talk. So what do you think is the leading cause of claims denial? Is it insurance eligibility, clinical documentation required, authorization or medical necessity? As I expected, it's just all over the place. I would have answered it wrong as well, probably a couple of years back if I had not looked at the data as well. But that's exactly what I'm gonna lay down, the data available about the revenue cycle and we're gonna talk about that. Revenue cycle management. We're going to talk briefly about what a revenue cycle management is. What are the key drivers and elements of a revenue cycle? How improved revenue cycle impacts a practice and its profitability. And in the end, we will go over the effects of COVID on revenue cycle and the future trends that are going to be drivers in revenue cycle management. So first of all, what is a revenue cycle management? It includes all the administrative and clinical functions that contribute to the capture, management and collection of patient service revenue. It essentially encompasses everything that is involved for a patient service. It starts when the patient calls in to make an appointment to the last dollar that was collected for the services provided. This is a graphical representation of the revenue cycle as I explained in my previous slide. And it includes everything that a patient goes through or the finances for that service that was provided to the patient in the practice. And it's called a cycle because once you go through the whole thing, you go back to the starting point where the next patient appointment is scheduled. Very first thing in a revenue cycle is the insurance eligibility and cost estimation. This is the process of checking a patient's insurance coverage and benefits prior to the date of service to ensure the payment for services. It is one of the most important factors in a revenue cycle management. This picture has been taken from an article from 2020 from the data collected earlier about the denials for patient related claims. And you can see the highest number of denials are due to the registration or eligibility problems, which are front end and the very first thing when the patient is scheduled. So this is one of the most important factors in a revenue cycle management. Where if you can create a difference, you can make a difference for the practice and how the revenue is captured. As I mentioned earlier, it is one of the most important factors in the revenue cycle. So you have to check, is the insurance enforced today? And it is done every time and it should be done every time a patient comes in for check-in, for their appointment. Are their premiums paid? Are their premiums paid? And are they up to date on their premiums? Is the service that is being provided covered under their insurance or not? Also, in some cases, you have to make sure it is medically necessary and the insurance will cover the service as medically necessary or not. So when do you check for the insurance eligibility? When the patient makes an appointment, of course. You have to check their insurance. You have to check and make sure that their insurance is valid. They know what their cost estimation is. And you check it again when they come in for the service. When they are coming in for their appointment, you check it again. And when they come in for follow-up, you check it again. So the crux of this slide is that you check the insurance eligibility every time patient comes in to the front desk. You cannot and you should not assume that the insurance is there. Although it has been checked previously, there are always changes. So you have to make sure that the insurance eligibility is still in force. So whose responsibility is to check the insurance eligibility? Of course, the front office. That is why it is important to train your front office that they go through all the necessary steps and make sure that the service which is being provided will be appropriately compensated. So it would be done. It should be done when the appointment is made. It should be done when the patient comes in for their visit. There are numerous tools available online. Most of the electronic medical record systems have these front office systems, have these tools embedded in them where you can check their eligibility online. All carriers have their website and access for providers to check it. So that should be done right away in the front office. If you wait for that information to reach when you're billing for that service, it is too late. The service has already been provided. If the eligibility is not there, you won't be paid for that service. And also make sure that you have the system in place that a copy of the insurance card is scanned and retained in your records. You should have the address available where to submit the claims as well. So you have the system to check the insurance eligibility in your front desk. There are certain things that should be included in that process. The things to check, there should be eligibility, whether the eligibility is in force or not on the day of service. Who is the subscriber? Whether there is any deductible for the type of service you are going to provide or not. Then there are certain policy limitations about the preventive services or contracted services or whether there is any pre-authorization required for the service you are going to provide. Again, the patient responsibility. So all these factors should be included in the initial insurance eligibility and cost estimation. So nothing is a surprise for the patient or for your billing team. Because once, as I said, once the service is provided, it is too late to know that the eligibility is not there. Cost sharing has become an important factor for the insurance coverage. And patient responsibility could be the deductible, the copayment or the coinsurance. But you need to make sure that the staff on the front desk knows how to look up for these patient responsibility part of the insurance as well. They should know how to see the fee schedule and also able to tell the patient in dollar amount what they will owe for the service that is being provided. This helps the patient not to have a surprise charge for the service and also avoid the bad debt which the practice might have to incur if the patient does not pay their part for the service they are being provided. Discussing the money part in healthcare situation is of course difficult, especially when someone is not feeling well, they are having healthcare issues. It is difficult to discuss the financial part. So it is imperative that the staff is trained to discuss these issues with the patients. It is important that the patients do understand their insurance coverage. And many times they do not because these terms are complicated and the terms of their insurances change. So the staff should be able to explain to the patients their own insurance coverage. They should be able to explain to them what these deductibles or coinsurance mean and why they owe money in addition to their coverage. The patient, the staff should be trained to answer all these questions. They should have access to the fee schedule. They should have tools to calculate what patient's responsibilities will be. And they should call the patients in advance, especially at the time of making an appointment and advise them of their financial responsibility. This takes care of that surprise factor that many a time is cause of dissatisfaction among the patient, because if they are showing up for a procedure and at that day they are told about their responsibility and they are not able to pay. Instead, if they are told beforehand, it is much easier to manage these type of financial responsibilities. Now we are going to go over some of the important financial key performance indicators. This is a set of KPIs that can help to improve the revenue cycle. First of all, is the account receivable over 120 days? Of course, this is an indication of how much revenue you are capturing for the services you are providing. And improving this KPI helps to improve the overall financial health. Reimbursement rates, that's an interesting KPI, especially for internal benchmarking to see and compare the paymixes, paymix and its effect on your revenue cycle. Gross collection rates, then the revenue realization rate, average reimbursement per encounter, and the first pass denial rate and resolution rate. First pass denial rate is the number of denials you are getting when you submit your claims for the very first time. And that can indicate and actually help you to identify the problems in the revenue cycle where you can make some improvements. I'm gonna go over one of the financial KPIs for revenue cycle to see how you can compare and contrast and then formulate a way to fix the problem. So account receivable in 120 days or more, the table above is from MGMA data and you can see the surgical single speciality with better performance at only 14% of account receivable at that time, while the others had up to 37%. So if you find yourself way above the benchmark for these account receivable, you need to formulate a way to fix this problem. There are various ways of looking at it. You can calculate by pair how many denials are coming and if there is a one pair or two pairs that are causing most of the denials, you can look at how the bidding claims are being submitted and where the issue is. Similarly, you can see if there is increased first pass resolution rate, you have to look at the front end and where all these issues that are causing the denials. You can look at per provider, if there is a lag in submitting the charges, that might be one thing to fix so that the account receivable can go down. Similarly, you have to make sure that patient part of the charges are being collected at the time of the service and they are being given the estimation earlier and their eligibility is verified as mentioned earlier. Similarly, consumer or patient-based solutions is an important part that has become more important recently as people expect to have more flexibility in the way they can pay their charges through the mobile phone apps or through the website. So these solutions need to be provided as well. Next few slides, we are going to go over the claim denial management and some of the tips or suggestions that can help to improve that. I showed this graph earlier because it is an interesting analysis of why there are denials. And again, it's the registration or the eligibility of the insurance is one of the biggest factor in denial. And the second most common is missing data. Again, it is more of what information you have collected and put in your system when the patient appointment was made. Similarly, pre-authorization is the third most common that again falls into the eligibility criteria or eligibility of insurance. So it is important to look at these common causes of denials to see if you can correct it on the front end rather than waiting for the denial and then fixing it. Coming to the same point of things that cause the major denials and that are easily fixable by training your staff. So demographic data, as we saw in the previous graph, is one of the common factors of denials. Either the date of birth does not match and the subscriber ID or group ID is missing or invalid. There was a pre-authorization required and was not checked prior to the service provided or the authorization timed out. No, it is after the date for the authorization. Similarly, non-covered services was not checked whether this service was covered by the insurance or not. Medical necessity is another common reason. You have to make sure that the diagnosis is appropriate and the service is covered under the benefits. Missing or invalid codes and then timely filling of the claim is an important part of this. For the denial management, there are certain KPIs that can be measured and help to identify the cause of these denials so that an appropriate strategy can be carved out. This includes the denial codes because of course that can identify exactly where in the revenue cycle the problem is. Identifying the trends, because this could be peer-specific and can be remedied by looking at that peer, that where the issue is, and specifically for those claims, you can make those changes. You have to review the UDI claim edits and rejections because majority of the time, these are data entry issues and need further changes in that regard. So how that can be mitigated? Re-educating the staff. You have to file the claims in timely manner, especially you have to involve the patient for the services you are providing and educate them about their insurance. And you have to, of course, use the appeal process. We are going to go over some of the effects of COVID-19 pandemic on the revenue cycle management. There are three, four issues here. There are challenges, then there are opportunities, and of course the changes that have come in due to this. Challenges have been the decreased revenue because of the reduced volume of the patients and the services that are being provided. Then there has been a major issue with the workforce that it is difficult to retain the staff and hire new staff. There has been changes in the regulations, new codes and new reimbursement rates. And all of this has caused major challenges since the COVID-19. But there have been some opportunities in this regard as well. Because of all these issues, there are opportunities to make your revenue cycle more refined, to review it more often and have more KPIs introduced there so that you can monitor the changes more closely. Automation has also been an opportunity here that a lot of these processes can be automated. Those processes that required human input or manual submission or data entry, they can be automated, especially with the improvement in the information technology. So the changes that are coming in are the use of the clinical decision-making support because it helps to avoid a lot of the denials and the services that are being provided. Similarly, for the data entry related things, there have been an increased use of the robotic process automation. And these bots, that software bots that are being used, they are helping to expedite and accelerate the process of the revenue cycle management. And it actually also mitigates a lot of the data entry errors that are being previously made by the staff. Now we are going to go over some of the future trends that we are seeing in the revenue cycle management. On the front desk, with the advent of all the technology and consumer-driven solutions, there is more need and requirement of the same in the healthcare and the practice as well. People like to make appointments on the websites, on the smartphone-based apps. So there is more demand of similar things to be available for the practice as well. Similarly, price transparency is an important factor and with the increasing awareness among the patients, they want to know how much a service would cost. Not only their own part, but overall what the charges would be. So this has resulted in demand for automated patient responsibility calculation, so that if a patient is coming and entering their own data, their insurance information and their demographics on the website platform, they should be able to get their own responsibility or the financial responsibility automatically by checking their benefits. Similarly, insurance coverage confirmation has to be automated as well. And a lot of the softwares for the front desk are coming in with these type of applications. Last but not the least, the consumer-based solutions include the online payments. That makes it easy for the patients to pay their part of the service. For clinical encounter part of the revenue cycle, technology and automation again is the key in the future as well. Documentation at the point of care improves the timeliness of the claim submission. Similarly, care gap analysis helps to avoid unnecessary services and make sure that the service provided meets the standard of the care. In the claim submission part of a revenue cycle, there has been again the same trend with the increasing automation. There has to be a pre-submission scrub to avoid first-pass denial. And then you do a peer trend analysis. And based on those analysis, those changes are already made prior to the submission, anticipating the same denial reasons. And similarly, all of this claim submission is being automated. That's where the robotic process automation is being used that not only increases the number of claims per day that are submitted, but also avoids all the errors in data entry that has been one of the big causes of denials as well. Humans or human input is only needed for the flag claims where the software thinks that something amiss or something needs to be looked at by a human. Otherwise, most of these processes that were previously done or currently are done by humans are usually will be done by these softwares. Similarly, for the denial management, it's the automation that is the key, which is the future for the revenue cycle as well. Artificial intelligence or machine learning-based softwares can analyze these denial codes. They can resubmit the claims after correcting those claims. And if needed, we can flag them for human review. This will not only decrease the cost of review, cost of resubmission, but also decrease the time that is needed to correct these issues. These are some of the most common reasons practices lose money or revenue. And by mitigating these issues, the revenue cycle can be improved as well. Failure to have in-house policies and oversight of the staff to implement those policies. When patient co-pays or deductibles are not collected or the denials of the claims are not managed appropriately. Failure to verify the insurance and benefits every time patient comes in for a service. Also, failure to cater to patient's consumerism or consumer-based policies can help in loss of revenue as well. And failure to measure the KPIs, as mentioned earlier, not only causes loss of revenue, but also it makes it almost impossible to improve anything in your revenue cycle. Because if you are not going to measure, you cannot see what exactly you need to fix. In the end, few points. Policies need to be in place for financial decisions. Collections, write-offs, bad debt, all of these have to have written policies. You have to train your staff to effectively communicate with the patient about their financial obligations. You need to educate your patients about their own insurance and responsibilities and also choose your financial KPIs appropriately. Thank you.

revenue cycle management

healthcare industry

claims denial

automation

patient satisfaction

financial KPIs