Provides an overview of the current revenue cycle management and its processes and offers a point-of-view on today’s RCM trends and areas of transformation.

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CitiusTech Thought
Leadership
23rd April, 2018 | Author: Ramganesh Subramanian| Sr. Healthcare Consultant
Five Key Imperatives of Today’s RCM
CitiusTech Thought
Leadership

2. 2
Objective
 Provide a quick overview of the current Revenue Cycle Management and
its processes
 Offer a point-of-view on today’s RCM trends and areas of transformation
 Highlight how providers, payers and technology organizations can align
their technology initiatives to achieve five key imperatives which form the
essence of successful RCM

3. 3
Agenda
 What is RCM?
 RCM Process Flows
 Key Transformations in RCM
 5 Key Imperatives
 Integrating Various Healthcare Applications
 Transformative Partnerships for RCM
 Few Illustrative Use Cases using IoT, EDW & Analytics
 Key Takeaways

4. 4
What is RCM?
 Revenue Cycle Management (RCM) refers to the steps to receive payment for the services
rendered by healthcare organizations like hospitals, practices, SNFs, ACOs, HMOs, etc.
 RCM historically was viewed as a back-office function. However, RCM today touches every aspect
of the clinical practice, from appointment scheduling to collections.
 A holistic RCM comprises of 3 important functions.
Generate Revenue Capture Revenue Collect Revenue
 Proactive approach to
scheduling and capturing of
all necessary patient
information and copays – up
front
 When this function of
revenue cycle is optimized,
practices can increase their
revenue by minimizing the
number of no-shows
 Once a patient is called from the
waiting room, the clinical encounter
begins
 The clinical encounter ends when a
patient leaves the appointment
 The activities that occur during this
timeframe determine a practice’s
ability to capture revenue. These
activities must be accurately and
thoroughly recorded
 Accurate and complete
documentation of services rendered
and proper coding is required to
ensure effective payments
 In general terms, back
office billing functions
enable a practice to collect
revenue and complete the
RCM cycle
 Included in this category
are the steps associated
with billing, posting and
collection of payments
 These are the last steps in
the RCM process

5. 5
RCM Process Flow
The revenue cycle process starts when the patient calls the physician’s office for an appointment and
the cycle ends when the balance on the patient’s account is zero.
Key IT Systems
 Practice management systems
 Claims management
 Health information management
systems
 Contract management
 Automated call distribution (ACD)
reporting system
 Automated billing & collection system
Stakeholders
 Front desk office
 Financial counselor
 Physicians / Medical staff
 Medical coder
 Clearing house
 Billing team
 Cashiering team
 Payer
RCM
Processes
Appointment
Scheduling
Patient &
Eligibility
Verification
Medical
Coding
Authorization &
Precertification
Pricing
Estimation
Payment
Assessment
Payment
Processing
AR and
Denials
Management
Payment
Follow-up
Bad Debt,
Medicaid &
Charity
Assessment
Collections
& Appeals

6. 6
Key Transformations in RCM (1/3)
Challenges that drives RCM:
 Changes in laws & regulations – Obamacare, ICD10 etc.
 Adoption of cost-containment strategies
 Ensuring high quality of healthcare services
Contributors to shrinking revenues:
 Transition from fee-for-service to value-based payments
 Lower hospital admission rates
 PQRS penalties
 Escalating healthcare costs

7. 7
Key Transformations in RCM (2/3)
Current demands for RCM
 Efficiently running financial operations to ensure better clinical and operational efficiency
 A well-managed revenue cycle to minimize the time spent on administrative duties
 Ensure maximum revenue and unobstructed cash flow
 Lesser time spent on operational issues and time to focus on core functions, i.e., provision of
healthcare services
Three key elements of a successful transformation includes:
 Optimizing the RCM technology environment
 Improving the performance by adopting advanced analytics techniques
 Enhancing the patient experience
Organizations that successfully transform along these three core transformation areas will be well on
their way to achieving a leading RCM environment.

8. 8
Key Transformations in RCM (3/3)
Key Market Forces:
 Regulatory changes
 Increasing patient
demands
 Increasing patient
financial costs
 Standardization in
care
 Reimbursement cuts
 Volume based to
value-based care
Key RCM Imperatives
Time&Resources
Degree of transformation
 Size of the bubble in the Y axis indicates the time and resource required for the transformation
 Size of the bubble in the X axis indicates the degree of transformation required
1
2
3
 Enhancing patient experience
 Payer – Provider Collaborative RCM
 Integrating various healthcare
applications like EHRs, Labs,
Pharma, Payer Systems, etc.
 Process Automation
 Adoption to new payment
models
 Operationalizing analytics

9. 9
Enhance patient
experience
Improve outcomes
Boost provider’s
financial performance
Bring down revenue
cycle cost
Modernize
technology environment
1
2
3
4
5
 Customer centricity
 Patient feedback
 Care management
 Quality improvement
 Value based care
 Pop Health Mgmt.
 Payment reforms
 Maximize incentives
 Advanced models
 Denials and claims leaks
 A/R arbitrage, bad debts
 Cost containment
 Robust technology
 Scalable architecture
 Streaming analytics
Key focus areas
 Consumer
engagement
 Performance
improvement
 Operationalizing
analytics
 Revenue and cost
analytics
 Application portfolio
optimization
Needofthehour
Revenue Cycle Management: 5 Key Imperatives

10. 10
Improving Patient Experience
Seamless patient access
 Providers that integrate scheduling and
registration through a call center or
patient portal will set up one seamless
patient-friendly process
Patient financing program
 Patient financing is a necessary payment
option that will make a patient’s burden
more manageable as well as decrease
bad debt for providers
Financial assistance and counsel
 In many situations, providers need to provide
financial counseling services to explain:
• The increasingly complex nature of
healthcare reimbursements
• Benefit plans
• Financial responsibility to patients
Transparent pricing for single / combined
services and patient-estimates
 Stronger connectivity with payers to establish
effective and transparent bill estimation
 Combined or integrated estimates provided to
patients prior to care to increase transparency
and improve estimate accuracy
Health plans and provider services that are being developed and envisioned for transforming the
healthcare consumerism is reaping better benefits than the traditional behavior focused services.
1
Traditional consumer behavior has a low impact on cost management potential whereas the
new personalized healthcare has a great potential for effective cost management. Key
benefits include:

11. 11
Performance Improvement 2
In order to improve the quality and performance of the revenue cycle management there is
a need to implement initiatives that maintain the steady revenue stream for the hospitals.
Following are the few important performance improvement solutions:
Benchmarking Healthcare Data
Benchmarking in RCM can be
done using:
 HFMA (Healthcare
Financial Management
Association)
 MAP (Measure, Apply,
Perform) initiative, or with
AHIMA benchmarks for
revenue cycle
management excellence
 EDW for trending
healthcare data
 Consolidated data analysis
Monitoring Payer Contracts
 With new regulations and
tighter, margins, monitoring
payer contracts and
communicating clearly and
frequently with payers is
imperative
 It is important to ensure
reimbursement and denials
are optimized
 Use of analytics helps in
monitoring the payer
contracts and improving
performance by ensuring
that the providers are not
under-reimbursed
Value-Based Reimbursements /
Payments
 Improving the reach of care
to higher number of patients
 Aging population with
multiple chronic conditions
 Highly engaged patient
population that is responsible
for its own care
 Patients in turn want more
insight into their
care and value for their dollar
 Increasing market share when
patients have more choice in
where they want to be
treated

12. 12
Operationalizing Analytics
Operationalizing analytics implies an expectation that some absolute truth will be revealed by
applying statistical models that can be a panacea for the unending problems of RCM such as high
rates or readmissions in a hospital, etc. Four important components in the technology world for
operationalizing analytics in which RCM environment would become more effective are:
Data Integration Analytical Models Platform/Infrastructure Visualization
Usage of an EDW to
extract and integrate
data from multiple
sources
Predictive model
development to
quantify the likelihood
of revenue outcomes
Technology platforms to
handle with large volumes
of structured and
unstructured data
IoT usage to create visually
appealing format to access
and consume actionable
items, anytime and anywhere
Common Problems How can Operationalizing Analytics Help?
 Monitoring and improve performance of RCM
cash flows
 Benchmarking denials with industry standards
 Predicting possible future denials
 Cost Containment in RCM
 Optimizing appropriate payment models based on the
size of provider organizations
 Budgeting cash flow and working capital
 Optimizing processes and reducing overall cost
 Derive financial performance indicators for different
departments or service lines
 Providing actionable insights and optimizing Denials
Management processes
 Predicting and helping in retaining funds for future
capitalization, modernization and expansion
 Operationalize and provide insights on cash
embezzlement, wastage, fraud and leakages
3

13. 13
Revenue & Cost Analytics
 Advance analytics are imperative, not only to conduct analysis on historical information
but also to leverage the information for predictive intelligence
 Few key initiatives that RCM companies should focus on using advanced analytics for
revenue and cost analytics are as follows:
4
Revenue&CostAnalyticsScenarios
Creation of new tools to reduce bad debts and A/R days outstanding
(DRO) :
Ability to adjudicate a claim instantly and provide a bill to the patient at
the POS, would significantly reduce the potential for bad debt. This
feature also helps providers reduce DRO.
Proactive denials management :
A collaborative technology platform to be used by both payers and providers
would improve the accuracy and timely notification of denials, improving the
providers ability to resubmit/appeal the claims without any errors.
Use of predictive analytics and BI:
Data Mining using robust tools and techniques, using predictive analytics and risk
modeling for revenue programs which enables providers to enhance revenues,
negotiate pricing, optimize payer contracts and improve patient treatment outcomes.

14. 14
Application Portfolio Optimization in RCM
 Best-in-class performance in the revenue cycle management applications are driven by advanced
analytics for organic growth in the organizations, may it be Core RCM Operators, or Provider
Organizations, or RCM Product vendors
 Advanced Analytics would drive the below initiatives in the RCM application portfolio
RCM Areas for
Optimization
 Insurance
verification
 Revenue cycle
optimization
 Charge capture
 Financial
reporting (A/R,
Net rates, etc.
 Technology
 Claims
management
5
Build executive
dashboards to
monitor end to
end revenue
cycle system
performances
Build right
EDW to drive
desired
insights that
leads into
actionable
analytics
Drive Insights
to understand
top performing
and low
performing
specialties and
benchmark
them
Perform root
cause analysis
of productivity
gap, purpose,
end-product
activity
analysis, etc.
Revenue
stream
systems
optimization
Optimize
integrated
systems data
Optimize
systems under
target micro
services (i.e.
Specialties)
Optimize
system
resource
productivity
RCMInitiativesKeyActionPoints

15. 15
Integrating Various Healthcare Applications
Through integration of various healthcare applications, many providers will need to forge innovative
partnerships to drive revenue cycle modernization. Partnering with key stakeholders from technology
companies to EHR/RCM vendors will offer providers a modernized, technology-enabled revenue cycle
Technology
Organizations
 Providers can establish an opportunity for sophisticated analytics platforms that
improve operational efficiency as well as improve patient outcomes and enhance the
patient experience through partnership with technology companies
Payers
 Payers should find right collaboration strategy to gain with their providers and
partners
 Payers can benefit from access to clinical and administration data from providers,
while the increased transparency of information and communication helps to
streamline processes and reduce costs
Financial
Institutions
 Integration of data and financial applications between RCM companies and providers
set the stage for new and diversified revenue opportunities, including outsourcing
fees, payment guarantee fees, and patient financing
EHR / RCM
Vendors
 Vendors benefit from co-development with customers to create solutions better
tailored to healthcare needs
 To create RCM operations for value-based reimbursement or transformation, the
provider organizations form partnerships with revenue cycle outsourcing
organizations and strategic alliances with industry participants (e.g., payers) or
nontraditional players (e.g., financial institutions)

16. 16
Transformative Partnerships for RCM
 Integrated EHR /RCM
solutions
 Improved coding solutions
 Coding automation
Technology
Organizations
 Platforms optimized for new
payment models
 Effective claims management
 Real time adjudications
 Seamless patient access
 Patient financing programs
 Effective high deductibles
plan management
RCM Companies
Financial institutions
 Cost containment initiatives
 Effective denials
Management
 Predictive analytics & BI
Payers
Technology enabled Revenue
Cycle Management and
Modernization
 Modernization and
optimization of RCM
technology environment
 Patient experience
 Payer connectivity
 BI & Advanced analytics
Key RCM Functionalities Provider Partners RCM Market Needs

17. 17
Few Illustrative Use Cases using IoT, EDW & Analytics
Patient
Consumerism
 Patient liability estimation for providers
 Patient facing estimation for patients seeking healthcare services
 Home health monitoring of patients remotely
 Physicians gaining insights through wearable technologies
 Automated reminders
 Self-Pay services and customer services experience
 Monitoring patient interaction
Denial
Management
 Integrated, just in time, exception-based claims management and
follow-up
 Real-time and strategic denial analysis
 Quick drill down to root cause of issues using prescriptive analytics
 Predictive analytics to flag potential denials and address them
before claims are submitted
 Registering data quality control

18. 18
Key Takeaways
 Understanding RCM and its three key important functions, various RCM processes,
Key RCM IT systems and stakeholders in an RCM setup
 Knowledge of the RCM world which is evolving and transforming to cater to the needs
of new technology, consumer and hospital needs
 The five key imperatives transforming the RCM world, i.e. Patient Consumerism,
Applications Performance Improvement, Operationalizing Analytics, Revenue and Cost
Analytics and Application Portfolio Optimization
 Understanding the working of the transformative partnerships and their RCM market
needs
 And at last, few Illustrative use cases pertaining to the current scenario in RCM

19. 19
Keywords
 Revenue Cycle Management
 RCM
 Patient Experience
 Denial Management
 Revenue and Cost Analytics
 RCM Process

20. 20
Thank You
Authors:
Ramganesh Subramanian
Sr. Healthcare Consultant
thoughtleaders@citiustech.com
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