Healthcare Revenue Cycle Management: Improving Efficiency and Profitability for Healthcare Providers Worldwide

Do you believe that healthcare providers enjoy hefty profits in the advanced nations?

To the naked eye, it would appear so. In reality, most of them face razor-thin margins – around 2% of their revenues.

Based on data from more than 5600 hospitals in the Definitive Healthcare HospitalView product, the median operating margin for U.S. hospitals in 2022 was a loss of 3.8%. Meanwhile, the average operating margin for hospitals was a loss of 13.5%.

This is an alarming statistic, and it goes against our perception of the healthcare industry.

Given this situation, revenue cycle management (RCM) plays a crucial role in ensuring the profitability of healthcare providers worldwide by ensuring successful claim processing.

Several companies in India specialize in RCM service, and most healthcare providers outsource their RCM work to the 200+ providers in India.

Let me give you an example.

I worked as a consultant for a large healthcare facility, helping it attract patients for medical tourism. During that time, they were looking for an enterprise-grade hospital management system (HMS).

They identified several vendors who provide this, and they shortlisted two of them. They requested those vendors to come and demonstrate their offerings.

I was also a part of the team that went through these demonstrations. The chosen vendors had a lot of credibility, and they came and presented well. While they were focusing their demonstration on clinical information systems, laboratory information systems, and patient experience, all the questions that were directed at them were related to billing, claims processing, and part payments.

They spent about 120 minutes with us. They demonstrated their product for 30 minutes, and they answered questions related to billing for the remaining 90 minutes.

On their way out, I started chatting with them and asked them how other healthcare providers were using their system and what challenges their system helped address for those customers. They mentioned that most healthcare providers were worried about payments, and everything else was only an additional functionality.

This, along with the profit margins they have, shows that revenue is key and that RCM plays an important role in ensuring the success of the providers.

Some unique challenges exist in the healthcare RCM process, and let us take a moment to understand those.

What Are the Unique Challenges in Healthcare RCM?

Complex Billing Process

The healthcare billing process involves various codes, multiple payers, and reimbursement procedures. This increases the likelihood of errors and delays.

Accuracy in billing is crucial for ensuring that healthcare providers receive timely and accurate payments for services rendered.

Patient Information Accuracy and Privacy

Maintaining accurate and up-to-date patient information is challenging due to diverse healthcare data sources. Privacy concerns add an extra layer of complexity.

Accurate patient information is essential for billing precision, and maintaining patient privacy is crucial for compliance with healthcare regulations.

Claims Denials and Rejections

Healthcare providers often face challenges with claims denials and rejections, leading to delayed payments and increased administrative costs.

Efficiently managing and minimizing claims denials is vital for maintaining the cash flow and reducing the financial impact on healthcare organizations.

Rising Regulatory Compliance Requirements

The healthcare industry is subject to ever-evolving regulatory requirements, making it challenging for providers to stay compliant.

Non-compliance can result in severe penalties and reputational damage, making adherence to regulations a critical aspect of healthcare RCM.

Patient Engagement and Communication

Engaging patients in the billing process and effective communication regarding financial responsibilities can be challenging.

Improved patient engagement not only enhances the patient experience but also contributes to higher rates of payment compliance. 

Technology can play a vital role in removing most of these existing challenges. As an RCM service provider, you should identify the right contact center platform that helps you address the stated and unstated challenges.

How Contact Center Platforms Can Help Remove the RCM Challenges?

Integrated Patient Data Management

Advanced contact center platforms integrate seamlessly with Electronic Health Record (EHR) systems, providing a centralized hub for patient information.

This integration ensures accurate and up-to-date patient data, reducing errors and enhancing the precision of billing processes.

Automated Claims Processing

Contact center platforms leverage automation to streamline claims processing, reducing the likelihood of denials and accelerating reimbursement cycles. Platforms with advanced analytics can identify patterns leading to denials and facilitate corrective actions.

Improved efficiency in claims processing leads to faster payments and reduced administrative burden.

Patient-Centric Communication Channels

Contact center platforms offer diverse communication channels to engage patients in the billing process, including phone, email, and secure messaging.

Enhanced communication increases patients’ understanding of financial responsibilities, improving payment compliance.

Security and Compliance Features

Contact center platforms are equipped with robust security and compliance features, ensuring the secure handling of sensitive healthcare data.

By maintaining compliance with healthcare regulations, these platforms mitigate the risk of legal and financial consequences associated with non-compliance.

Here are some of the specific features that our cloud-based contact center platform brings to the RCM service providers that would help them provide improved collections for healthcare providers.

IVR traversal – Once your agent tries to reach the Payer, the agent typically encounters an IVR, which you will have to wade through before an agent at the Payer end can answer your call. This process is cumbersome and can be error-prone.

With our platform, you don’t have to worry, as our bot helps you traverse the IVR with intelligent automated responses based on the IVR responses. It understands the menu options, response handling, and fallback mechanisms.

Everything is automated till you get to a stage where you are put on hold for the Payer agent to respond.

Agent call hold time – Our Hold Queue Monitoring (HQM) feature helps reduce the agent call hold time to near zero. Once the agent keys in all the DTMF entries, they are put on hold. The hold time can vary anywhere between 20 minutes and 2 hours.

Instead of making the agent wait, our HQM alerts the agents when the Payer responds to the call by detecting the human voice. The agents can switch between calls, and the hold time is reduced to near zero. You can quickly improve the number of calls an agent makes by a factor of 2 to 3.

Besides, you use bots or trainee agents to key in the DTMF entries, and once you detect the human voice (Payer response), calls can be routed to senior agents.  

Alphanumeric character entry – As a part of claim processing, agents enter 8 to 9-digit alphanumeric characters. Manual errors can creep in during this process.

Our platform helps you automate this by using a bot, where the bot types in the alphanumeric characters on the client application. This automation ensures zero errors. 

TCPA regulations – Regulations govern the time of the call in advanced nations. For instance, an agent can call only between 8 am and 8 pm. However, agents are handling different timezones, and whether you are calling at the right time becomes confusing.

Our platform has a meta-data handling functionality that automates whether the call should go through or not based on regulations. It looks at the phone number and identifies the location and time zone, and if it doesn’t fall between the specified times, then it automatically abandons the call.

Automated Data Handling – Our platform comes with a List Management Service, which can pull together data from Excel files, SFTP servers, and client applications. It can automate data management and enrich it by applying rules and priorities. For instance, if you want to prioritize high-invoice values, it can be done in no time.

Voice Analytics – Our platform helps you analyze sentiment and negative searches using its audio mining capabilities. This ensures internal quality and compliance with regulations, standards, and specifications. For instance, you can do a negative search to see if an agent has spoken about a particular feature to a patient or not. Besides, you can also identify whether the patient is happy or angry and raise a green flag or a red one.

The healthcare RCM industry is bound to explode, with more and more healthcare providers seeking their services. RCM service providers must adopt advanced contact center platforms to improve the financial health of healthcare providers.

Besides, now many healthcare providers are looking at engaging with RCM service providers in an outcome-based model. This means the service providers have to be on their toes to ensure better collections. However, this provides a huge opportunity for the service providers as well, as outcome-based models pay a premium.

In essence, technology in the form of contact center platforms serves as an indispensable ally, ensuring the seamless continuance and profitability of healthcare operations.