Clinically-Driven RCM Optimization: What You Need to Know

Sep 20, 2017 1:58:20 PM · by David Kushan


Using a clinically driven, integrated RCM solution as part of an integrated EHR platform offers tremendous opportunities for improving revenue performance. Integrated RCM enables better management of information, in addition to streamlined charge capture and reimbursement processes, but realizing these benefits requires a careful and organized approach. To succeed, the RCM team must have a voice in the process. In order to assure that a project addresses all relevant organizational needs, it’s important for hospitals to establish a project leadership team that understands how to balance the potentially competing concerns of key stakeholders in the process, especially among the RCM team, clinical functions, and IT.

Careful planning goes a long way toward ensuring that an implementation doesn’t “break” your existing revenue systems. One of the potential complications of an integrated RCM-EHR solution is that it eliminates the possibility of manual workarounds and after-the-fact documentation. If a robust system isn’t present on the clinical end, it will make the RCM side much more challenging. This is why extensive planning and coordination are necessary to see the full revenue-boosting benefits of a new EHR system.

Here are some steps your organization can take to ensure that RCM is sufficiently accounted for within your implementation:

Successful Integrated RCM Relies on Clinical Processes

Many hospitals treat their RCM team as a siloed and entirely distinct department, operating separately from other functions. In fact, this team is inextricably bound to clinical and related administrative departments. Once an organization shifts to electronic records and integrates RCM with EHR — as is the case with a clinically driven solution — any division between the two areas will disappear.

RCM will not be effective unless clinicians document all patient activities properly. Failure to do so will often result in claim denials, making it more time-consuming to obtain reimbursement for services already rendered. In some cases, the funds are never collected or are significantly reduced because documentation doesn’t meet key standards. Mistakes on the clinical side directly affect RCM.

As part of the implementation process, RCM concerns must drive some of the process development within the clinical space, in order to ensure that sufficient electronic data is present to process claims. With the greater convenience and accuracy of digital records, hospitals should be able to streamline their pre-authorization processes and reduce their percentage of denials.

RCM begins when the patient first connects with a hospital, through scheduling an appointment, registration, or being admitted. Organizations should develop processes that ensure that this stage in the patient timeline is supporting the inevitable billing procedure. Making these changes is a priority if an organization expects revenue growth following an EHR rollout. 

Avoid the Silo Mentality

Because a clinically driven RCM solution relies on integrations between traditionally siloed teams, organizations must perform integrated project planning that looks at the interdependencies between RCM and other departments, particularly clinical functions and IT. As part of the implementation process, project teams should understand each department’s unique concerns and how they fit into the larger system. An integrated solution is a complex machine, and if any part of the process breaks down, then a disruption in both clinical or RCM operations is likely.

Organizations should assess their current processes and the level of integration between functions. Siloed departments may encounter serious hiccups in the shift to an integrated approach. In such a case, the organization must determine the best ways to bridge this gap. For example, if billing and regulatory coding is solely the domain of RCM in the current state, this may present problems because clinical documentation will drive reimbursement success rates within the new system. Working with both clinical and RCM stakeholders can help inform processes and prevent problems in this area.


Shift the Mindset on RCM

It’s worth repeating that in a fully integrated EHR ecosystem RCM is not an island: It touches many parts of the hospital. Organizations should consider developing an internal revenue integrity role or team to help track how RCM will interact with other functions. This can be especially helpful during the planning stages because it increases the profile of revenue integrity concerns during the implementation.

Although clinicians may feel far removed from RCM, the best approach is to communicate that they are a pivotal piece of the revenue process; their actions can directly affect which clinical activities are reimbursed and the overall financial health of the hospital.

Determine Revenue Goals at the Outset

Two of the major goals of implementing any clinically driven RCM solution are to improve revenue performance and boost cash flow through more timely reimbursement. Hospitals should set clear goals for net revenue improvement from the new platform in order to help align project planning to increase the likelihood of success.

For example, in order to increase revenue by 5% in the year following go-live, an organization may have to significantly reduce bad debt while getting higher reimbursement rates from insurers. To meet this challenge and to determine what is currently preventing the hospital from reaching this goal, the project team must work with RCM and, in some cases, clinicians. Often, the issue could simply be a matter of inadequate documentation, in addition to lax policies regarding pre-authorizations of treatment. Alternatively, increased liquidity may be the primary goal, and therefore faster claim processing may be of paramount concern.

Without clear priorities outlined at the outset, improvements like this may take a backseat to those driven by IT or clinician concerns. It’s essential that the hospital’s financial leaders know what they want to accomplish and have this be a part of the project process.

Develop Metrics to Track Success

Hospital leaders should lay out metrics for RCM success during the project’s early stages. These metrics should match those from historical performance to enable a relevant and meaningful comparison. During the testing phase, it’s essential to track exactly how product development is aligning with these measures of success. By establishing clear goals and metrics to measure progress, financial leaders can ensure that the course of the project leads to concrete system improvements that help reach these targets.

Bring In Consultants if Internal Resources Are Lacking

Hospitals must assess whether they have the necessary internal resources to guide a clinically driven RCM implementation. Some of the key skills include organizational awareness, ability to work across functions, previous experience with platform migration, and knowledge of the challenges of RCM-EHR integration. Many organizations may find that they lack staff with this experience.

To ensure that an implementation has strong leadership, the best course is to bring in consultants who excel in these areas. Consultants should be hired as soon as possible, even before the contract is signed, in order to help with the planning progress.

Learn more about how emerging technologies are leading to exciting healthcare innovations by downloading our latest eBook "The Future of Healthcare: How Technology Could Change the Way Healthcare is Administered".

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