There are few more important decisions for a practice than choosing a revenue cycle management partner. Practices are recognizing that the investment, expertise and infrastructure required to effectively manage this complex process are increasingly out of reach. Collecting every dollar is critical for a practice to remain viable in today's environment of tightening networks and dropping reimbursement. To do this effectively requires significant investment in technology, data scrubbers such as real-time eligibility transactions and coding rules engines, payment confirmation, ability and knowledge to follow up on complex denials, patient pay platforms to make it easy to know what a patient owes and collect.
1. Do you own your technology?
This is important for a number of reasons. Many companies work on third-party systems. They do this because it is hard, complex, costly work to develop a robust revenue cycle management system. It is easier to simply grab something developed by someone else off the shelf, put out a shingle and declare that you are open for business. However, as things evolve rapidly in our industry, it is important to have the capability and resources to adapt front-end systems to keep up with evolving data requirements and workflow needs. If your RCM services provider works on third-party software, they will not have the flexibility to adapt the system to these changes - or accommodate any changes to your workflow. Your partner could be held hostage by the development timelines and priorities of a vendor that doesn't even know you exist. Also, there is no guarantee that your service provider will keep up the upgrades of third-party software as that tends to be a very expensive proposition. That can put your practice even further behind the eight-ball in deploying state-of-the-art technology.
2. Do you have the capability to interface with systems including EMRs, hospital systems, labs, etc.
Interoperability is critical in today's interconnected environment. As provider networks come together in new ways and data requirements get more complex, the ability to seamlessly interface with various EMRs, EHRs, hospital ADT systems, labs and other systems can mean the difference between an efficient workflow and a kludgy workflow filled with redundant, non-value add steps. In addition, if your system isn't interoperable and your RCM partner doesn't have the capability, willingness or resources to build this connectivity with your partners, your practice could be locked out from participating in new organizations like ACOs, patient-centered medical homes, etc.
3. What are the metrics you track to ensure success?
At this point, most practices are aware of the basic metrics that track the health of their revenue cycle - things like Days in AR, adjustments and collection yield. But there are other more sophisticated metrics that are important indicators of an efficient process that will result in consistent outcomes. Metrics such as charge lag time, billing lag time, first pass rate, clean claim rate, secondary collections, patient AR are examples of these sorts of metrics.
4. How is your operation organized?
This may seem like an arcane question but most companies are organized to maximize their efficiency (read: reduce their costs). That generally means that they are organized functionally - that is around the key functions of the RCM process - not around the client. A functional environment can be highly efficient but often suffers from a lack of focus on clients and client outcomes. Conversely, a customer-centric organization puts the customer at the center and organizes itself around customer needs and outcomes. This is a more resource-intensive way to organize an RCM operation but it helps ensure clear accountability around client success.
5. How is your system hosted? Do you have the right levels of redundancy and security?
If you select a cloud-based solution (and there are many good reasons to go this route) or a hosted environment, it is important for you to ask about the redundancy and security of their infrastructure. Do they have an onsite server room at their office with boxes and wires everywhere or do they have access to the resources, redundancy and physical security of a tier one data center facility. Also, ask what sort of third-party audits have been conducted to ensure that your data is safe. These are important questions to ask to understand the level of investment made to keep your data safe and secure and to ensure 100% uptime and system availability.
6. What sort of workflow systems do you have in place to support front-desk processes?
A claim is nothing more than data collected about a patient and an episode of care. If front-end processes are robust and the data are complete and accurate, the claim has a high likelihood of successful adjudication. If parts of the data are missing or riddled with errors, payment will be denied. Most practices today have a busy front office that is stretched to capacity and may resort to inconsistent processes when stressed. It is unrealistic to have constant supervisory oversight of the front office. The answer is an RCM system that ensures rigorous process controls at the front end through workflow design. This sort of system is a cost effective way of ensuring that no matter who is working the front desk or how busy they are, the data collected at this critical step, is complete and accurate and will lead to payment.
7. Do you have threshold dollar amounts for follow up efforts?
Some RCM companies set artificial thresholds on the dollar amount required on a denial before they will do any follow up work. Some companies are known to set this threshold as high as $200! This means that a denied claim with a potential payment value of less than $200 is kicked back to the practice or - worse - automatically adjusted off. This is because with their cost structure, they will lose money if they do any work on that claim. A practice should understand the policies and follow up thresholds so they aren't surprised when denials are not followed up on. Reputable companies will be happy to disclose this information.
8. What are your KPIs for key processes?
Understanding how your partner will measure process success is important to understanding how rigorous they are in managing and monitoring process indicators. Things like turnaround times, response times on questions, patient wait times, call quality indicators, error rates are important leading indicators to the consistency and predictability of your financial performance.
9. What visibility will I have into my financial performance and the status of accounts?
Many practice administrators and doctors believe that they will lose control and/or visibility into their financial state or into their patient accounts if they work with a third-party RCM partner. And with many old school billing companies this was certainly the case. In today's environment, if you work with a company providing you access to a proprietary cloud-native solution, this need not be true. Ask if you will have access to everything happening for each claim for every encounter. You should be able to see your reports and review status for every account.
Being successful in today's healthcare environment with changing mandates, evolving reimbursement structures and increasingly complex billing requirements, practices need to have the ability to invest in systems and highly-skilled teams. Practices with access to that sort of capital are not common. For the practices that don't; luckily, they don't have to go it alone.
The practices that would like to remain independent but don't have unlimited financial or human capital should consider working with an RCM partner. With the right company, practices can leverage the resources and capabilities of a trusted, stable partner that has the significant expertise, technical knowhow and capital required and is focused on ensuring the practice's financial success. In this way, practices can leverage the benefits of operational scale, technical expertise and capital investment of a business partner. The right partner will bring the tools and systems to ensure patient intake procedures are optimized and services are coded accurately and have the skills and knowledge to hold payors accountable to pay for the services provided.
Working with a revenue cycle partner is something most practices should consider. But it is important to know what questions to ask.