Many hospitals and health systems today believe that denied and rejected claims are an unpredictable and unavoidable reality of providing healthcare, as well as being a revenue loss—a loss that can consume expensive manpower to overcome with little payoff.
Hospital finance leaders continue to strive daily to exhaust all opportunities to minimize denied and rejected claims. However, some are beginning to realize the benefits of a more proactive approach that improves reimbursement and revenue processes; ultimately driving greater transparency, a better patient experience and strengthened financial results.
Here, Laura McIntire-Hansel, director of the Reimbursement Solution at Cardinal Health, discusses revenue and remittance cycle challenges and how transformation can benefit health system current processes and workflows.
Editor's note: responses have been edited for clarity and length.
Question:Why should healthcare leaders rethink standard revenue processes?
Laura McIntire-Hansel:Standard healthcare revenue processes are often fragmented and siloed. Several groups are involved in various steps in the revenue cycle, requiring frequent communication and handoffs. However, if there isn't complete transparency among the various groups and handoffs don't go smoothly which, is often the case, claims can be delayed or may not be submitted at all. To recover and get back on track comes at a cost. The entire process can also impose a burden on patients through high out-of-pocket costs.
Q:How can the revenue process be improved in hospitals?
LMH:There are multiple opportunities to rethink revenue processes and to view the entire process in a holistic manner. Improvement comes by shifting from reacting to what's happening, to becoming more proactive in anticipating everything that could happen to limit the reimbursement opportunity and patient care experience. Process improvement involves redesigning the entire process—from the scheduling process and ordering the medication, to prior authorization and patient assistance.
The idea is to consider the revenue cycle with a “process-to-product" approach; beginning when a physician writes an order and tracking it through each separate department involved in getting the medication to the patient successfully.
Q:What does a hospital leave on the table with status quo processes?
LMH: With the status quo, there are often significant inefficiencies, which may include the hospitals’ processes for queries and less-than-optimal workflows. A proactive and holistic approach can translate into a better patient experience and better financial outcomes. In fact, some hospitals can reduce rejected and denied claims by up to 80%. There is another toll taken by the status quo: Hospitals often face challenges in optimizing the patient experience regarding identification and implementation of patient assistance for everyone who can qualify. This can place a significant hardship for cost of care on the patient, and typically, the need and the opportunity far outweigh the resources and bandwidth of the facility staff.
Ask yourself what it would mean to your facility if you had the ability to proactively know all aspects of coverage criteria for each patient— For example, know which biosimilar is covered, which generic is preferred, what your patient balances would be and how to expedite the remit at the highest possible level. What would these answers mean to your hospital or health system?
To explore these questions and share insights about an innovative solution, join leaders from Cardinal Health forthis July 29 webinar. This webinar will discuss how a proactive, comprehensive approach to revenue cycle processes can benefit hospitals and health systems, particularly those with outpatient infusion services.