Optimize Financial Performance With Specialty-Specific RCM Tools

By Dan Montzka, M.D., CMO, Nextech

Recent payment reductions from CMS combined with increasing denials and complex coding requirements pose significant challenges to provider revenue cycle management (RCM). According to the Medical Group Management Association (MGMA), it can cost up to $25 to $30 for every claim that has to be reworked.[1] And considering the average claim denial rate is 30 percent for a medical practice’s first submission, this can drastically add up and lead to financial instability.[2]

In this challenging climate, specialty practices need to find new ways to optimize RCM performance and decrease expenses. Implementing a specialty-specific, integrated EMR, practice management and RCM system can help practices leverage valuable data that will not only eliminate potential revenue losses from the CMS fee reductions, but also increase efficiency and accuracy, reducing risk of denials.

Collecting From Patients

As patients seek to control spiraling insurance premiums, many are accepting higher deductibles and self-pay programs. As a result, many people now receive bills with charges exceeding what they expected and medical practices are put in the position of collecting 25 percent[3] of what is due directly from patients. Patients who are shocked by the amount owed or who can’t meet their financial obligations can have a significant negative impact on a provider’s cash flow. Therefore, the first opportunity to protect the revenue cycle is at the front office.

Offering transparency into how much services cost as well as offering a variety of payment options — for example, via point of service, online payment options or setting up customized payment plans that fit the patient’s budget — make patients feel empowered and cared for. These actions boost patient confidence and satisfaction, leading to loyal customers and a strong word-of-mouth reputation that enables a practice to effectively compete.

Billing And Reimbursement

Determining eligibility is essential to protecting the practice’s revenue cycle. Determining insurance eligibility is an important step in successful reimbursement, but it can also be time-consuming. Systems that incorporate an extensive payer list helps you easily obtain the latest information on patients’ coverage, including co-pays and deductibles.

A clearinghouse with an electronic eligibility (e-eligibility) service can minimize the need for patient collections. By automating insurance verification for immediate and accurate identification of coverage — eliminating a time-consuming task for staff — e-eligibility can quickly determine precise patient responsibility before services are rendered, enabling up-front collections. In addition to eliminating potential payment delays and revenue loss associated with post-care patient billing, e-eligibility helps avoid claim rejections due to eligibility verification errors.

Capturing Accurate Documentation

With meaningful use, the transition to ICD-10, and other regulatory changes — including the recently proposed MACRA ruling — the exam room offers further opportunities to improve RCM in addressing methods for documenting clinical care as claim denials due to documentation errors or omissions can be minimized in the fine-tuning of EMR templates.

For most specialty practices, every minute spent on documentation, placing orders, billing, and other tasks means less time with patients. Most specialists use a relatively small number of codes in the course of an average day. Physicians do not need or want to scroll through an exhaustive list of findings, diagnostics, and treatments for every patient.

For example, for ophthalmologists in particular, having an ophthalmology-specific EMR that provides access to a database of patient information captured from other industry peers is essential to viewing only the most relevant ophthalmology-specific codes in an instant. As other physicians add new information to this shared knowledge base, physicians are able to add it to their drop-down menus or other templates. Having this data entered in the chart in a structured, personalized format instead of free text allows specialty practices to capture, measure, and report clinical quality performance faster, easier, and with greater specificity.

Conclusion

Changing payer models, reimbursement cuts, and the trend toward increasing self-pay are realities providers can make into an opportunity to improve financial performance. Getting in front of these changes with automation helps maximize revenue with payers and patients alike.

Specialty practices have unique needs. By implementing an integrated, specialty-specific EMR with automated RCM tools that offer payment options, insurance eligibility verification and accurate documentation, practices can save time, increase accuracy, reduce denials, and optimize financial performance.