It’s no secret that the healthcare market is continuing to shift due to a variety of catalysts, including continued wide-spread staffing shortages, a consumer driven market driving preferred sites of care into the ambulatory and at-home space, expanding virtual care options, and the emergence of artificial intelligence (AI). As health systems move to modernize their care delivery and address the changing landscape, it’s imperative to identify areas of opportunities in existing operating models where changes can be made so that the organization can provide more care and services with fewer staff and tighter margins. To accomplish this, health systems are focusing in six areas: strengthening post-acute care networks, creating care at home programs, expanding virtual care and digital front doors; standing up virtual nursing programs, embracing patient-driven consumerism, and leveraging new technologies for bi-directional data exchange with payers.
As health systems continue to focus in all six of these strategic areas, it’s opening the door to new ways that health organizations can collaborate with their payer partners and this has a direct impact on organizations leveraging a revenue cycle outsourcer. For example, a health system in the process of scaling a hospital at home program while in parallel rolling out new integration that enables a bidirectional data feed between a health system and payer (e.g., Epic’s Payer Platform), can positively impact the utilization management, billing, claims, and other third party workflows that a revenue cycle outsourcer provides as part of a service contract.
As the adoption of the electronic exchange of information between a health system and its payer partners increases and matures, so do the opportunities for innovation, cross care team collaboration and patient services. Mature integration can mean a significant decrease of manual chart pulls, attestations and clinical documentation requests that are typically handled via phone calls, faxes and portal input by a revenue cycle team. In a health system where the revenue cycle is managed internally, there are immediate efficiency gains and cost savings opportunities. However, revenue cycle outsourcers are often hesitant to take advantage of these new capabilities and are locked into legacy ways of doing business. Their reluctance to adopt new systems means longer delays and more costs for the health system.
Revenue cycle outsourcing deals are typically multi-year agreements with teams being rebadged and staffed based on the revenue cycle outsourcer establishing standardized workflows. These workflows are pre-defined and not flexible. In addition, many revenue cycle outsourcers also leverage specialized niche third parties to supplement many of the manual workflows (e.g., manual chart pulls). Transitioning to a digital bi-directional exchange between a health system and payer means that a revenue cycle outsourcer must adapt to change and streamline their claims adjudication processes, support automating authorization requests and reduce or eliminate manual requests for information with the goal of accelerating payments for the health systems they serve. This is no easy task as revenue cycle outsourcing contracts are often predicated on the legacy workflows, which are directly tied to how the revenue cycle outsourcer earns their service fees.
Revenue cycle outsourcers need to change their staff models and workflows to take advantage of the efficiencies gained from the electronic exchange of information between health systems and payers and focus on establishing new workflows to support the expansion of virtual care, care at home and virtual nursing programs, ensuring health systems are maximizing reimbursement.
The benefits of health systems and payers leveraging a bi-directional data exchange is clear – it drives HEDIS and Stars quality measures, enables more accurate risk adjustment and easier access to records for utilization management, decreases manual chart pulls, attestations and clinical documentation requests. Health systems leveraging a revenue cycle outsourcer should position themselves to take advantage of this by re-examining their service contract and pushing for the modernization of their revenue cycle workflows to ensure they meet the needs of the organization and modernized care delivery services.