The healthcare RCM process becomes more complex each day — and that complexity is compounded by external pressures.
“In today’s market, so many factors affect efficiency in the healthcare RCM process,” says Christine Fontaine, Waystar Solution Strategist. “Staffing issues can lead to longer time-to-payment. Ever-changing payer rules and insufficient edits can lead to staff frustration. Poor work queue routing can cause users to have to manage claims that don’t need to be reviewed.
“All of that leads to poor utilization of limited staff and a frustrating result: You keep trying to dig yourself out of a hole only to end up digging a deeper one.”
So, how do you improve your healthcare RCM process?
You start by pinpointing places where your staff is losing time and efficiency. Whether it’s taking manual touches out of claim statusing or leveraging automated prior authorization, you have to find and address your problem areas.
“I’ve worked with many organizations that, after investigating their processes, found that they’re losing productivity because staff is managing work that could easily be automated,” says Christine. “I call these unproductive touches, and I see a few over and over again.”
5 unproductive touches in healthcare RCM
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1. Insurance verification
Manual verifying eligibility adds cost and time to each transaction, which contributes to staff inefficiency. In fact, manually checking benefits can add up to $10.57 per verification.
“Despite the availability of 270 transactions, there are more than 1.5 billion calls made each year to verify eligibility and benefits,” says Christine. “Some organizations report their staff spends more than two hours per day simply following up with payers! On the whole, the industry could save more than $4 billion a year simply by automating eligibility.”
Look for automated insurance eligibility technology that:
- Identifies missing coverage
- Uses AI + RPA to augment missing data from X12
- Accesses vast amounts of payer data to curate accurate benefit information
- Offers robust alerts so teams can work by exception
- Triages eligibility issues so staff can prioritize tasks properly
- Seamlessly integrates with your EHR
Explore Eligibility Verification
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2. Prior authorization
How often are staff efforts wasted on prior auths? According to CAQH, manually obtaining prior authorization adds an average of 21 minutes per transaction. That’s an enormous amount of time — especially when you consider prior auths are only getting more complex.
“Almost 80% of practices say payer requirements for prior auths increased in the past 12 months, and that’s likely to continue,” says Christine. “Payers will keep putting in requirements to ensure care is medically necessary. And the only way for providers to stay on top of volume and reduce write-offs without adding staff is to use automated prior authorization.”
Look for automated prior authorization technology that:
- Verifies, initiates, statuses, and retrieves comprehensive details
- Initiates authorizations significantly faster than your manual processes
- Integrates directly with your HIS and PM systems
- Includes authorization submissions for unscheduled admissions
- Auto-generates Advance Beneficiary Notices or Notice of Non-Coverage forms
- Adapts to shifting payer rules and requirements
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3. Claim statusing
One revealing question for every RCM leader is: How much time does it take for your team to resubmit a claim or create an appeal? According to Becker’s, manually statusing a claim takes 19 minutes and costs providers $9.37 on average.
“Retrieving actionable information from payers about claim status is very time consuming,” says Christine, “and it often results in needlessly touching claims that are already being processed properly. That takes staff away from higher value tasks, such as working problem claims.”
To address that, providers are leveraging RPA to save time and money, in addition to improving staff satisfaction.
“Automation leads to less human error, wasted efforts, re-work, and staff friction,” says Christine. “A Forbes survey found that 92% of companies saw an improvement in employee satisfaction after implementing AI and RPA. That’s because employees are more engaged and satisfied when they can focus on meaningful, useful tasks.”
Look for automated claim statusing that:
- Predicts the right time to status a claim and intelligently drives follow-up
- Facilitates rapid intervention using flexible payer connections
- Curates the most enriched status response
- Controls status checks with a scheduling capability
- Proactively monitors payer portals
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4. Denial + appeal management
Nearly 12% of claims are denied, with the cost to recover coming in at roughly $120 per claim. Those costs are so high because manually gathering information and creating and submitting appeals can take anywhere from 20 minutes to more than an hour.
“RPA is a highly effective way to reduce denials and underpayments, especially when combined with analytics that give your staff actionable information,” says Christine. “For example, solutions using intelligent automation and machine learning can actually help staff identify accounts with the highest likelihood of payment so they know which appeals to work first.”
Look for an automated denials + appeals solution that:
- Triages denials based on probability of payment
- Automatically routes denials to appropriate teams or work queues
- Provide real-time, one-click eligibility verification
- Offers pre-populated payer-specific forms to auto-generate appeals content for you
- Automatically submits paperless appeals packages directly to payers
Explore Denial + Appeal Management
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5. Posting + reconciliation of payments
“Manual processes around payment reconciliation are very staff intensive, not to mention error prone,” says Christine. “Manual research, follow up, and reconciliation of payments double the time associated with posting. That makes posting and reconciliation an process to automate.”
Look for a payment posting + reconciliation solution that:
- Automates matching of claims to remits
- Posts payer and patient payments
- Splits remits and identifies missing payments plus reconciliation
“There’s no doubt it’s a challenging time to be in revenue cycle management,” says Christine. “But it’s also an exciting time because there are so many opportunities to use automation to increase efficiency and help your staff engage while increasing their satisfaction.”
