The healthcare provider sector has always faced the challenge of balancing the quality of patient care, efficient cost-to-serve, and rising business margin pressures. There are complexities in navigating the revenue cycle efficiently in the areas of patient billing, intricate insurance policies, multiple payers, and lengthy reimbursement processes, that are further affected by changing regulatory requirements.  

These challenges contribute significantly to delayed payment collection, revenue loss, work efficiency, and customer satisfaction. Healthcare providers need to initiate steps to address these now. 

Pockets of Value Creation Amid Challenges

Workflow Analysis. Understanding the healthcare provider’s operational performance across the end-to-end workflow of the revenue cycle is the first step to understanding both business and technology challenges. Identifying where and what causes the revenue leakage will quantify the potential benefits of the improvements and prioritizations to be made to accelerate overall cash collection. 

Electronic Information Management and Data Analytics. Front-end systems used to capture patient information starting from patient admittance, to sharing collected information across the clinical infrastructure provide transparency and efficiency during payment processing. These also drive Informed business decisions using valuable data-driven insights analyzed in real time.

Standardized and Outsourced Services. Improving service quality with standard processes, automation tools, and scaled execution using trained talents, provides reduced operational investment through an outsourced business model.  

Business Experience. Investing in technology-driven solutions targeted to improve service execution of internal users, simplify workflow with patient-facing self-service solutions, and accelerate 3rd party information exchange with integration solutions.

Overcoming Top 5 Revenue Cycle Challenges

Difficult financial situations hinder a healthcare provider from investing in a comprehensive, large-scale Revenue Cycle Management transformation.   

However, gradual changes can minimize the current gaps. Below are some common challenges and solutions to start addressing these now.  

1. Intricacies of Insurance Verification and Authorization

The first step in getting healthcare services and treatment is ascertaining whether a patient has valid insurance, the policy coverage restrictions, and what may come as an out-of-pocket payment from the patient. The documentation review and exchange across stakeholders become more intricate with secondary insurance that will contribute to the payment of the total cost of medical care. There are also challenges encountered in determining which treatments and services are covered in the policy under a specific health provider network, checking for copays, deductibles, and benefit cap amounts, and the documentation that passes between the healthcare provider and the insurance company for prior authorization.

This process should be thorough to ensure smooth billing and claims processing after the service is rendered.  

Pointwest harnesses process automation, intelligent document processing, and Electronic Health Record (EHR) systems to streamline the verification process. In automating the extraction and analysis of insurance coverage information, manual encoding errors are reduced. An EHR system can integrate with insurance verification, allowing healthcare providers to access information directly from the patient’s medical record. An SOP for eligibility workflows and standardized documentation is utilized to also promote collaboration in the process execution. 

These processes, tools, and technologies can decrease claim denials and potential delays in revenue caused by accuracy issues and manual speed.

2. Insufficient Attention to Charge Capture and Coding

After documenting a patient service in the medical record, healthcare providers assign codes for claims, and then these codes translate to charges. Lags in capturing these charges within 24 hours is a delay in revenue. Missing charges,  under-coding, or over-coding charges may result in claim denials and audits due to non-compliant reimbursements and improper payments.  Accurate capture and coding of healthcare services rendered are critical. There is an extensive list of services and coding standards, such as ICD-10, that can lead to inaccuracies. 

Pointwest incorporates skilled medical coding experts in its process execution to reduce claims delay.  These professionals enhance the precision and efficacy of the charge capture and coding procedures. Additionally, Pointwest also supports the integration and use of EHRs to improve charge capture.

3. Patient Billing and Payment Collection Difficulties

Incorrect billing statements or a lack of understanding from the patients with the pricing may result in payment delays, or worse, non-payment. Health providers need ways to make the collections of out-of-pocket payments more transparent and streamlined. With a rising trend in high-deductible health plans, the diversity in billing systems, and the lack of transparency in pricing, these factors can lead to confusion and dissatisfaction among patients.

Pointwest supports the billing and collection process by enabling healthcare providers to integrate with and utilize electronic transactions to submit claims and monitor the status of claims. Integration with payment solutions also makes it convenient for patients to pay their bills online. For a curated patient experience, Pointwest also develops custom-built online and mobile solutions.

4. Denial Management and Revenue Recovery

Despite best efforts in billing and coding, healthcare providers often face denials from insurance companies. Navigating the denial management process requires a thorough understanding of payer contracts and the reasons for denials, which can be time-consuming and complex. Moreover, recovering revenue from denied claims involves an additional layer of challenge.  

Pointwest applies advanced analytics for healthcare providers to identify patterns in denials and pinpoint systemic issues within the revenue cycle workflow. This insight allows for targeted improvements in processes that significantly reduce denials. 

5. Compliance and Regulatory Challenges

Healthcare providers navigate a web of regulations and standards, including HIPAA and the Affordable Care Act. Compliance with these regulations is non-negotiable, and failure can result in hefty fines and legal complications. 

Pointwest utilizes its deep knowledge of healthcare regulations to develop solutions that maintain compliance and enhance the revenue cycle. These solutions are built to be flexible in response to regulatory adjustments, guaranteeing that healthcare providers stay compliant while maintaining operational effectiveness. 

Healthcare providers are initiating a wide range of improvements to grow their businesses, increase their bottom line, and accelerate cash collection. Legacy platforms are being modernized to leverage cloud computing, data management is receiving focus to enable advanced analytics, and system integration is being adopted for seamless collaboration across departments, third-party business stakeholders, and other health-tech solutions to enhance the overall patient experience.

With combined healthcare compliance experts and technology management specialists, Pointwest can help navigate the challenges that the healthcare revenue cycle presents to providers.

For over two decades, Pointwest has been partnering with global businesses to address its current challenges in growing the business, improving customer satisfaction, and achieving its bottom-line goals. We bridge the gap between today’s challenges and future possibilities through tailored solutions that accelerate digital transformation with precision and speed. Connect with us today at [email protected] to learn more about how Pointwest may help you.