Revenue Cycle Expertise Gaps

Revenue Cycle Expertise Gaps Might Require Looking Externally

Revenue cycle management has grown to an unmatched level of complexity in recent years. For most organizations, this has meant increased needs for training and improved hiring processes – but is it possible there’s a limit to the effectiveness of these tactics?

If you take a close look at the requirements of many revenue cycle roles, you’ll likely find something interesting. A select few are so complex, that they require looking outside the organization for expertise to access a higher level of performance in revenue cycle management services. These are typically positions that have one or more of the following characteristics: 

  • Inherent hyper-complexity and regular, significant disruption 
  • Nuances that reflect influences from all phases of the revenue cycle
  • Requiring in-depth foresight and proactive responses

This includes roles like denials management, prior authorization, and medical coding, especially risk adjustment coding. These roles require extensive subject matter expertise and while these can be developed and maintained in-house, it’s worth considering a different approach. 

For example, look at the positions in your revenue cycle that require the most subject matter expertise and reframe them – automatically classifying them as having higher potential for success through leveraging outsourced revenue cycle management services. By taking this perspective, you’ll start from a position that allows you to focus your resources on simpler, easier-to-maintain roles, and pass off hiring and training responsibilities to a revenue cycle management company

This is an especially pressing issue as confusion emerges as a result of payers changing processes and requirements. In the ambulatory space in particular, providers are experiencing increases in A/R days, denials, appeal processing time, and effort getting payer guidance on coverage. A recent KLAS report has revealed that providers are facing increased pressure to manage claim cycles in the midst of staffing shortages on both the payer and provider sides. Two out of three respondents to the survey indicated this dynamic has influenced their decision to outsource revenue cycle services [1]. 

As we close out 2023, and challenges around staffing, remote work, and training and education continue to increase, I encourage all revenue cycle leaders to take the time to identify expertise-intensive roles. Now is a time to start short listing partners to avoid the knowledge and competence deficits that can crop up when you default to taking on the most investment-intensive revenue cycle roles on in house. 

You might find that the specific roles that are the most challenging are particular to your organization, but regardless, you can see a new level of success by approaching this from an “outsource first” perspective that you might not have considered in the past. 

References
[1] V. Bailey, “Providers Are Outsourcing Revenue Cycle Services Amid Workforce Shortages,” TechTarget, Inc., 19 July 2023. Available: https://revcycleintelligence.com/news/providers-are-outsourcing-revenue-cycle-services-amid-workforce-shortages.

 

Hemant Apte, Chief Executive Officer in

Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.

Medical Coding Audit Prevention for 2024

Medical Coding Audit Prevention for 2024

With Q4 of 2023 coming around the corner, it’s time to start looking at plans for 2024. It might not seem like it should make your short list of priorities, but medical coding audits should be on the mind of your leadership team today – specifically looking for ways to get in front of them. 

Healthcare providers will be in a much better position next year if they take the remainder of 2023 to step back, look for current issues, and devise ways to prevent and respond. You might feel prepared since you recently reviewed your strategy around medical coding and medical coding audit processes – but I want to stress the fact that the healthcare landscape is much more volatile than it has been in the past. Issues around COVID and labor shortages mean that taking another, updated look will likely be highly beneficial to your long-term organizational health. I see this broadly playing out from three potential angles:

Early Action
If an organization starts early in identifying issues like upcoding (billing for services that weren’t provided) and employee supervision issues, they’ll be able to make smart adjustments to revenue cycle processes and outsourcing strategies. These should be aligned with current and coming challenges – and these coming challenges aren’t just hypothetical. CMS is sending multiple signals that providers should expect an increase in medical coding audits.  

Program Design
We can look to CMS’ 7 core compliance requirements for some guidance on taking action. Element VI is Suggest an Effective System for Routine Monitoring, Auditing, and Identification of Compliance Risks. The agency highlights the importance of internal monitoring and audits, including external audits to keep up with compliance with CMS requirements and general compliance program effectiveness. 

Billing and Outsourcing Strategy
To prepare for 2024, most providers will also need to turn their medical coding teams and departments into “centers of excellence” – investing in staff training, smart KPI creation and monitoring, process improvement, and in many cases, tapping into the type of outsourcing relationships that fit their unique needs. 

Remember, revenue cycle management has changed. We’re now functioning in a volatile environment where ongoing adjustments are necessary. Thankfully, providers have never had so many tools and options at their disposal

Hemant Apte, Chief Executive Officer in

Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.

The Future of Medical Coding Isn’t AI – It’s Collaboration

The Future of Medical Coding Isn’t AI – It’s Collaboration

One of my greatest concerns around AI isn’t that it’s going to one day go rogue and cause massive issues for some unfortunate provider. I believe the chances of that are slim to none.

My deepest concern is potential missed opportunities. This is because AI promises so much to the healthcare revenue cycle – increase in quality and accuracy, efficient medical coding workflows, and, in the end, a profitable organization. And while that might be possible down the line, for the vast majority of healthcare providers, their path to revenue cycle success starts with something that’s much more accessible – collaboration.

The key though, is collaboration from a multi-dimensional perspective. Revenue cycle leaders should be looking to build a culture of collaboration – one that pulls in clinical, billing, coding and external stakeholders like outsourcing companies and other vendors to support a holistic approach to revenue cycle management that helps your organization meet its goals. I’ve talked before about answering three critical questions to get started.

  • How are we assessing costs and resources like staff time and processing costs?
  • How are we handling PHI and what does our cybersecurity risk look like?
  • What does our collaboration map look like so that we know what we’re aiming for?

But there is a fourth question, and that involves asking whether you’re missing out on low-hanging fruit because of the shiny promises of advancements in AI. It’s very possible that overly energetic perspectives on AI are obscuring issues like the fact that payers are dealing with archaic systems, an issue that’s been acknowledged as an impediment to implementation. But even internally, many providers’ approaches to data is far from being ready for even simple AI solutions.

Ultimately, healthcare revenue cycle leaders should take a step back to make sure they’re looking at the potential of AI realistically. I’m concerned that in the coming months and years, any are going to pay an opportunity cost that’s entirely too high simply because the hype around the technology has been so intense. For most, avoiding that cost will mean examining solutions that are a lot closer to home.

 

Hemant Apte, Chief Executive Officer in

Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.

Get In Touch!
close slider

    Get In Touch!