- Patient access and medical billing and collections are among the top healthcare revenue cycle risk areas for hospitals, practices, and other provider organizations in 2019, according to a new report from the public accounting, consulting, and technology firm Crowe.
“Lack of preparation for new risks can cost a healthcare organization money and its reputation at a time when it can least afford to lose either,” the report stated. “In a value-based reimbursement environment, every dollar is at risk. If an organization loses that dollar to a compliance problem, it can’t make it up simply by adding a dollar of revenue elsewhere.”
“Early identification is the best strategy to mitigate those risks,” the healthcare consulting firm stressed.
To determine the top healthcare revenue cycle risk areas in 2019, Crowe researchers analyzed risk assessments performed in 2018 for more than 250 hospitals, physician practices, and other provider organizations.
Researchers defined a risk area as “anything that might impede the organization’s ability to achieve its goals in critical areas such as patient care, regulatory compliance, operations, strategic growth, and financial performance.”
For healthcare revenue cycle management, the data revealed that medical billing and collections will be a major risk area for healthcare organizations in 2019. Provider organizations should specifically look out for completeness and accuracy of billing, lost revenue, inadequate denials management, and lack of visibility into the controls at third-party billing and collections providers, the firm stated.
Medical billing and collections management is a core function of any provider organization. Ensuring claims go to payers clean and reimbursement is collected in a timely manner is key to running a hospital or practice.
But Crowe researchers observed a significant risk related to incomplete and inaccurate billing, which resulted in costly reworking of claims, increased claim denials, and lost reimbursement.
Provider organizations are looking to third-party vendors to outsource medical billing and collections management. But the benefits of outsourcing come with a price, the researchers warned. Provider organizations still need to manage and oversee their vendor’s performance to ensure clean, timely claims.
Patient access will also be a major risk area for healthcare revenue cycles in 2019, the assessments showed.
“Controls over patient access functions such as patient scheduling, registration, and admission processes must be rigorous to minimize the risk of billing and patient accounting issues, lost revenue, and poor patient and physician satisfaction,” researchers advised. “Information gathered during the scheduling, preregistration, and registration processes must be complete and accurate, and processes should include checking medical necessity for outpatient services and providing estimates of cost and patient liability.”
Provider organizations should also be on the lookout for prior authorization requirements and insurance verification in 2019, they added. Proactively verifying insurance and checking for prior authorizations will prevent disruptions to care and billing processes.
Prior authorizations are on the rise. About 86 percent of providers in a 2017 poll said prior authorization requirements increased. And payers are unlikely to ease up on the cost-cutting tool in the near future as the organizations face additional pressure to cut costs and utilization.
In terms of patient access, provider organizations should also be collecting patient financial responsibility upfront and connecting patients with financial counselors in 2019.
Patient financial responsibility has been a growing trend in healthcare. The amount patients owe to their providers increased 11 percent in 2017, and hospital revenue attributable to patient financial responsibility grew 88 percent from 2012 to 2017.
Therefore, financial counselors should visit all uninsured patients prior to discharge to go over patient financial responsibility and the counselors should help patients identify and apply for insurance or other healthcare assistance, researchers added.
Other risk areas for the healthcare revenue cycles in 2019 include charge capture, coding, and denials management, the report stated.
Provider organizations should particularly be aware of the accuracy and completeness of their charges in 2019, especially as they implement new technologies and where high-cost procedures and services are involved.
For coding, researchers advised providers to pay attention to the growing complexity of coding requirements from payers. Providers should ensure adequate physician documentation and if coding is outsourced, ensure regular monitoring of third-party vendor performance.
Finally, provider organizations should always focus on denials management. But in 2019, they should be taking an interdisciplinary approach to denials management to smooth the claims submission process throughout each department involved.
Organizations should also implement a payment variance process in which revenue cycle leaders compare amounts received to expected amount to find and correct payment errors, researchers advised.