Why The Right Software is Critical to an Effective Revenue Cycle

Most people think about the revenue cycle from the back end perspective - submitting claims, follow up on denied claims, constructing appeals, effective AR management, sending statements, posting payments, and so on and so forth.

The truth of it is that the most important part of revenue cycle management is the front end - the scheduling and registering of patients and coding the patient encounter. That is where all the critical data for successful adjudication of a claim is collected, screened and collated. Get things wrong there and all the follow up in the world will likely not get you paid. Most traditional practice management systems are “dumb” data input systems - it accepts whatever data is put in regardless of whether it is accurate or even complete. This leads to dirty data and ultimately to lost cash.

A purpose-built revenue cycle management software in contrast should be a robust process control system that ensures data integrity throughout the process of scheduling and documenting an encounter.  Since a claim is simply data - I saw this patient (patient demographics), on this day (DOS encounter data), they have this problem (coding), I did this for them (coding) and they have this insurance (insurance data) - data integrity is critical to the successful adjudication and payment of a claim. It really is quite simple - get those five pieces of data right and you get will get paid; get any of them wrong or miss any data elements and getting paid if at all is a long, hard slog.  Sounds simple, right? And it is conceptually. But actually getting those data elements complete and accurate in a busy practice environment - in an area with the potential for a lot of staff turnover - can be a challenge. That is where a good RCM system comes in. As a tool or set of tools that can be deployed to ensure process rigor and data integrity.

Traditional Practice Management System

Purpose-Built RCM Tools

  • Accepts any data without confirmation

  • Alerts, data confirmations

  • Eligibility is manually checked after appt is scheduled

  • Real-time eligibility while appt setting

  • Payors can pay you what they want

  • Payor contract verification

  • No coding support

  • Smart rules that mirror payor rules to reduce coding-related denials

  • No built in appointment reminders or recalls

  • Appointment reminders and recalls help build volume

The good thing about electronic data is that it can be confirmed and monitored as it is being inputted. Bad data can be highlighted and kicked out. The system can require that complete and accurate data be in place before the next step in the process can happen. In short, a system designed with the right vision can be a process control system that ensures consistent rigor throughout the process of collecting all the data elements to be submitted for payment. That is the type of purpose-built RCM system eMDs has built from the ground up.

In today's environment, a physician practice simply cannot afford to leave money on the table. Denials are simply too costly and complex to manage for the average physician practice. On top of lost money, denials create cost, delay and frustration. They consume time and resources to resolve.

  • Retrospective appeals create high administrative costs
  • Retrospective denials interrupt cash flow and increase days in AR
  • Retrospective denials require an organized workflow to track down missing or inaccurate data
  • Retrospective denials require detailed knowledge and expertise to determine requirements for appeal

The best denial is a prevented denial. Traditional practice management systems don't help with preventing denials because they don’t help with process control and data integrity. Practices cannot survive today with antiquated practice management systems that serve as “dumb” data terminals. They need smart tools and systems that help them ensure process rigor and eliminate denials. They need a web-based practice management software built to support an effective healthcare revenue cycle process. When evaluating systems for the future practices should consider whether they are looking at a practice management system with basic feature/functions or if they are looking at a small system designed with one end in mind - effective workflow leading to payment.