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Evaluating Your Revenue Cycle: Is It Time for a Tune-Up?

Practice executives today face thousands of industry-altering challenges, from ICD-10 and RAC Audits best defense is a good offenseMeaningful Use to value-based reimbursement models. With so much to think about, revenue cycle management (RCM) solutions tend to fall off the radar unless they’re causing major cash flow disruptions. Too often, however, this situation is like the heart patient who’s finally forced to the emergency department because he skipped the preventive visit that could have identified and proactively treated his condition.

RCM solutions—and clearinghouses in particular—are vital to a practice’s financial health. Even when everything seems fine, a periodic check-up is essential for maintaining peak revenue fitness. The key, of course, is to evaluate RCM solutions in a way that maximizes effectiveness while minimizing the drain on valuable time. To that end, here are some key RCM items on which to focus:

Claim submission: Claims scrubbing is invaluable, but not all scrubbers are created equal. Verify how often (and quickly) your RCM solution updates claims edits, as well as whether edits are payer-specific. Furthermore, note that industry-leading tools are capable of providing front-end rejections (i.e., a clearinghouse’s initial response) in seconds—not days. Make sure your solution can pinpoint and correct front-end rejections online before claims are submitted to the payer. This improves first-pass rate and reduces denials, which ultimately accelerates cash flow and lowers days in accounts receivable (A/R).

Claims Connectivity and Electronic Remittance Advice (ERA): Payer connectivity is crucial for primary and secondary claims—plus ERA. Find out the payers for which your RCM solution can receive ERA. Keep in mind that smaller regional payer connections are just as important as national ones, especially if regional payers make up a large portion of your payer mix. No ERA or electronic payment posting means a slower, less accurate and more labor-intensive manual RCM process—with negative effects on A/R and cash flow.

Client service: How proactive and responsive are your RCM solutions and their support staff? That’s the key question to ask. A responsive clearinghouse will monitor for payer delays and jump on the phone to resolve them instead of leaving your claims to sit in limbo. Industry-leading clearinghouse teams are comprised of seasoned professionals with a minimum five years (ideally more) of EDI experience who can resolve the majority of problems on the first call.

Track record: Past performance is arguably the greatest predictor of future success (or failure). If an RCM vendor had issues with 5010, for example, ask what plans it has to ensure the same problems won’t reappear during the ICD-10 transition.

One thing is certain: The rapid pace of change in healthcare will continue. Your practice’s financial health should not suffer because your technology providers are experiencing “growing pains.” Practices need technology partners they can rely on to help them through transitions like 5010, ICD-10 and more. So take some time to look under the hood, beyond just the visual bells and whistles a system has to offer. Now is a good time to evaluate, and if necessary move to a new solution in time to get comfortable before the arrival of ICD-10.

To see whether you’re truly getting what you paid for from your clearinghouse, download this comprehensive question checklist.