The AI Difference in Revenue Cycle Management

AI difference in Healthcare

Effective Revenue Cycle Management (RCM) is non-negotiable for all health care practices, but despite this, clinics across the board are reporting increasing levels of dissatisfaction with their current RCM tools.

According to a 2019 KLAS report, more than one-third of the 140 respondents to their RCM survey said they wouldn’t purchase their vendor’s services again, and even more respondents reported complete dissatisfaction with their vendor’s full RCM outsourcing software.

RCM includes everything surrounding claims processing, and the revenue cycle is the most important administrative function for health care practices. Without it, clinics and hospitals can’t financially support themselves in order to treat their patients. Effective RCM isn’t something clinics should take lightly—their revenue cycles need to be optimized at every stage to ensure cash flow.

Using advanced, user-friendly artificial intelligence (AI) solutions can save clinics $7 billion each year, according to data from Accenture Analytics. RCM tasks such as coding, billing, collections, denials, and more can now be easily automated with AI.

To get a complete picture of what’s holding effective RCM back, it’s critical to have a basic understanding of the industry’s pain points and to understand how technology can address the mounting issues surrounding the revenue cycle. RCM is constantly changing, but it’s time that it finally changed for the better.

Claim Denials

One of the primary reasons for RCM dissatisfaction is the growth in denied health care claims. The American Academy of Family Physicians reported that practices experience a rejection rate between 5-10%, and each denial costs the clinic an additional $25 to re-process.

Not only does this process frustrate clinical staff, it also causes panic for the patients. Patient out-of-pocket costs have increased four times over the last 12 years, and the average inpatient bill totals nearly $5,000, according to research from TransUnion Healthcare. Although patient insurance plays a factor in high out-of-pocket costs, insurance is just one of five key contributing factors to claim denials.

The other top reasons are:

  • Incomplete or incorrect or repeated information
  • Missing deadlines
  • Missing certifications
  • Incorrect billing codes

While an uninsured medical service might be unavoidable at times, these additional reasons uncover issues with the clinic’s RCM. If an RCM solution is unable to correctly file claims on time, that’s a strong indicator that it could be time to look for a new one. Clinics should never forget that RCMs are supposed to work with them, not against them.

Poor Scalability

Scalability is a common pain point for clinics and hospitals with multiple locations, but especially for clinics looking to expand. Having one or two people at the front desk to handle the revenue cycle might work for small clinics with low patient volume, but this strategy becomes increasingly ineffective the more the clinic grows.

The key to scaling RCM is automation, and not having robust automation is costing billions. According to the CAQH index, the lack of automation for claims processing costs the health care industry more than $11 billion each year. By having an automatic operational flow, clinics with high patient volumes and multiple locations can effectively speed up their revenue cycles. Instead of employing dozens, or even hundreds of administrative employees, clinics can leverage RCM solutions with artificial intelligence to properly code thousands of claims without risking human error.

Lack of Interoperability

Interoperability is one of the most important reasons why clinics struggle to manage their revenue cycle. While some clinics operate with no RCM tools, it’s even more common for clinics to have three or more separate RCMs. These RCMs usually can’t communicate with one another, leaving room for patient billing information to get filed incorrectly or lost completely. This causes operational issues and introduces the problem of data silos, and having too many RCM providers spread out across an entire organization is arguably as inefficient as having no RCM at all.

It’s important for clinics and hospitals alike to choose one RCM that can be integrated with its existing technology and with the technology at other clinics. Black Book Research discovered that 86 percent of hospital networks with one EHR and RCM vendor stated they were confidently prepared to provide value-based care. And with health care budgets that are tighter than ever before, clinics need an interoperable solution that can address everything, from changing regulations, all the way to data size management.

How RCM Needs to Evolve

One of the best ways RCM can improve is by prioritizing patient pre-registration. By having as much information as possible about patient insurance eligibility, scheduling, and past payment information before the patient walks in the door, clinics can get a better understanding of the patient’s ability to pay. This can be done easily by using a patient portal. The portal makes it simple for patients to conveniently pay their bills online, and it makes it possible for the clinic to send reminders and notifications to help keep the revenue cycle on track.

It’s equally as important for clinics to automate the revenue cycle strategically. When systems are both automated and interoperable, it allows the revenue process to operate seamlessly with little room for error. Otherwise, providers that don’t take a strategic and detailed look at their RCM’s automation capabilities could just be adding an extra layer of complexity to the process. And as mentioned, the more that can be automated on the front-end of the patient lifecycle, the better. By having a strong front-end, staff members who handle the back-end have more accurate information to work with.

No matter where a patient’s claim is in the revenue cycle, clinics should have an RCM that’s able to process all claims quickly, correctly and seamlessly. By prioritizing the technology that powers the revenue cycle, clinics should see a boost in their bottom lines.

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