REVENUE CYCLE SLUMP – TOP KPI’S FOR PRACTICE EXCELLENCE

I don’t know about you, but over the past several years, especially in a Post Covid world, good help in the front and back office of a medical practice seems to have a shortage of qualified individuals and is a revolving door for many practices. Not only are turnover costs increasing for many medical offices, but the entire Revenue Cycle Management (RCM) process has suffered exponentially. Practices are bleeding out due to the dwindling number of qualified staff who can tackle this daily process. Overall Accounts Receivables (AR) are in a complete slump. The RCM market grew from upwards of 97 billion dollars in 2022 and is projected to rise to almost 240 billion by 2030. This means the compound annual growth rate (CAGR) will increase by upwards of 12% during this seven (7) year ending in 2030, according to a report from Research and Markets.

The report showed that close to ninety percent of practices had reported ongoing staff shortages in their front and back offices, which include RCM staff. More than half of those surveyed said that the daily strains on the RCM cycle result in frequent billing errors by inexperience staff, longer hold times with payers for questions with customer service, as well as scheduling issues.

Research and Markets delineated a long list of game changers in the RCM market share, and they include the following:

• McKesson Corporation

• Oracle

• Optum

• Change Healthcare

• 3M

• GE Healthcare

• Cognizant

• Athenahealth

• Veradigm

• Conifer Health Solutions & more

Mounting prospective and retrospective payer audits are also a factor in the ongoing decline in RCM, with Federal payers, like CMS and Tricare conducting these types of audits and the Commercial sector looking for low hanging fruit like UHC, Optum Cigna, BCBS and more. These audits are painful for a practice to go through, and I know from experience in my audit reviews for clients who receive these audits like this from payers. They are difficult to avoid, as many payers often request copies of notes on level four and five evaluation and management visits, to review the documentation, but they additionally conduct reviews of billing practices. Not only does this subject a practice to potential criminal and/or civil monetary fines, but it can lead to exclusion from that payer, if any impropriety is found, even if it is unintentional.

The truth is that over 60% of practices will have claims lost or denied, with many never being resubmitted by staff as they either don’t have the time and/or knowledge on how to appeal them. Additionally, upwards of 20% of claims are flat out denied just because the payer has an automatic denial set to certain types of claims as well as, close to 18% of claims will never see the light of day for payment Lastly, the cost for reworking each claim is now estimated to be over $25.00 per claim as you have to factor in the cost per FTE to work these denied claims. All this will be just another part of the RCM bleed out for your practice.

Now more than ever practices should be looking to revamp and streamline their RCM processes to ensure a compliant maximization of the revenue stream that flows instead of the ebbing tide that has been in place. Protecting your practice from overwhelming payer denials and pre and post payment reviews and recoupments. So, the question now becomes – should I outsource my RCM/Billing component of my practice, or is my staff sufficient and capable of RCM and managing it properly?

Consider the following Key Performance Indicators (KPI) components that are critical for a solid RCM Foundation, as you contemplate if you should outsource to a proven RCM company:

• Eligibility Verification Solutions

• Pre-certification & Authorization Solutions

• RCM metrics with KPI Reports Benchmarked with MGMA

• Minimize claim denials with effective denials management

• Gross Collection Ratio

• Top Billed vs Paid vs Denied CPTs

• Avg. Reimbursement vs Avg. Charge per Visit

• Avg. Claim Transfer Days vs Avg. AR Day

• AR Analysis – Insurance & Pt Benchmarked with HFMA & MGMA standard

• RVU Based Provider Productivity & Performance Analysis

• Revenue Lost due to Billing errors and how they can be recovered

• Revenue Lost due to Coding errors and how they can be recovered

• Clinical Documentation & Coding Audits

• Clinical Documentation Improvement Solutions

• Proper Payer Reimbursement per contracts

• Credentialing and Re-credentialing

To achieve practice excellence, it is mission critical to be able to honestly evaluate what is currently not working and openly look towards how it can be salvaged and become profitable and give you not only excellent reimbursement and profitability, but peace of mind. As Einstein said, “What is the definition of insanity? Doing the same thing over and over and expecting a different result”. So don’t be complacent when someone in your office says, “well we’ve been doing it like this for the past ten years”, because this is why you are in an RCM slump.

The G.O.A.T. Wayne Gretzky has many famous quotes, but my two favorites are:

“You miss 100% of the shots you don’t take” and “I skate to where the puck is going to be, not where it has been”

They are both truisms and in RCM, you should always look for opportunities for improvement