The Future of Healthcare Revenue Cycle Management: Challenges and Opportunities

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Sagar Rajgopal is the co-founder and COO of Omnipresencea leading business process outsourcer (BPO) for highly complex industries.

You could be forgiven for thinking that healthcare has made a profit in the past two years. In reality, many healthcare facilities and caregivers faced the greatest threat to their survival ever during Covid-19.

The pandemic severely overwhelmed hospitals and the increased number of hospital admissions threatened to hamper health care. Many facilities cut salaries and laid off staff. Now they seek payments from a patient base that is mentally and financially exhausted.

Unsurprisingly, Covid-19 has served as both an agent and an accelerator in driving key trends in healthcare revenue cycle management (RCM). What we’re seeing is a mixed bag of regulatory changes, increasing burdens on the patient as a payer, a growing reliance on automation, and massive cultural shifts that are placing workers in their homes.

Healthcare providers must deploy a multi-faceted response rooted in knowledgeable agents, data-driven analytics, and quality customer service that can address the looming challenges head-on and seize the opportunities ahead.

More self-paying patients

patients increasingly are selecting high deductible health plans (HDHPs), which charge low monthly premiums but have a high deductible. Patients pay for all or part of their care themselves through HDHP memberships, both of which increase the pressure on collections. The pandemic further exacerbated the problem, with millions of people losing their livelihoods, their health insurance, or both. Companies also canceled employee health insurance when it became clear that they would be closed for a longer period of time, forcing patients to cover the costs of care themselves.

An analysis by the Urban Institute found that more than three million Americans lost job-based cover in the summer of 2020. Providers need to work with, not against, overburdened patients to achieve higher payment rates for patients, as they now make up a larger part of the payment pie.

Improving their early services, such as interacting with patients shortly after discharge to explain the difference between patient and insurer responsibility, has been shown to significantly reduce the number of bills that collect. But that kind of pain point exploration requires more resources, including specialized training and expertise that most providers don’t yet have or can’t manage on their own.

Where automation doesn’t help

The challenges of Covid-19 also forced providers to automate complex workflows to increase efficiency and minimize costs. Providers are automating more components of their revenue cycles, with 78% of healthcare systems RCM automation reporting† Yet processes such as claims management and follow-up communication remain largely manual due to the challenges of running workflows that require collaboration between multi-party systems, which are constantly undergoing configuration changes by their own internal teams.

In addition, patients often find technical customer support for healthcare frustrating. Rate schedules cannot necessarily be automated as they change regularly and are negotiated on a case-by-case basis between insurers and providers. While automation promises a lot, it requires constant monitoring and management.

Improvements to automation within RCM will continue for the foreseeable future, but the challenges remain:

• Fragmentation of the US health care system.

• New risk arrangements that are rapidly replacing fee-for-service models.

• An ever-growing diversification of RCM and claims software.

Because of these factors, human intervention will be critical to ensure that health care providers are reimbursed and compensated in a timely manner. Efficient coordination with payers about rejected or misdirected claims and concise coordination with patients to collect or settle their cash responsibilities will continue to require specialized suppliers dedicated to handling complex healthcare contact center services.

Dealing with bills

There have also been significant legislative and regulatory changes over the past two years. The No Surprises Act took effect on January 1, 2022, for example to protect patients from unexpected medical bills generated by out-of-network emergency care (OON). The law also requires insurers and providers to negotiate payments in final offer arbitration, where each party offers a payment amount and an independent arbitrator chooses one or the other.

This law will undoubtedly have far-reaching consequences for the RCM in healthcare, because healthcare providers must identify OON claims early and assign codes to these claims in their digital file. They will also need to expedite benefits explanation (EPO), group appropriate claims and process accordingly with internal departments or external vendors.

In recent years price transparency rule is also forcing hospitals to provide pricing information online, in both machine-readable and storeable formats. With bipartisan support, the Centers for Medicare & Medicaid Services plan proposed to increase fines to one maximum fine of $2 million for non-compliant hospitals.

Pitfalls and opportunities ahead

Surprisingly, there are no new large RCM companies that are tackling all these challenges integrally. This provides a competitive advantage for business process outsourcers (BPOs) who invest in the most effective implementation software and the right tools for digital systems management. The healthcare industry will appreciate these suppliers who can handle multiple deployments, assimilate diverse systems, and perform process management around RCM operations.

Data analytics is also an important weapon to have in your arsenal, but most healthcare providers don’t have those capabilities in-house. Vendors that provide data analysis of past claims, accounts receivable, denial management processes and other services will help healthcare companies make better use of their time, resources and budget. Data analytics can drive the efficiency of all services and processes. But what many vendors might overlook is the fact that highly trained customer service reps — and agent continuity — could prove to be more valuable than ever.

BPOs committed to providing trained, knowledgeable agents who understand the complicated healthcare payments infrastructure, as well as the industry’s increasingly complex regulations and compliance standards, will have a performance advantage. And finally, the integration of service with robust workflows, seamless communication technologies and practical management support will help caregivers and healthcare facilities improve RCM efficiency and improve customer experiences at the same time.


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