The Healthcare Changes of Yesterday, Today, and Tomorrow and Why It Should Be a Priority

Posted February 22, 2022 by Ashley Sparks

We all know that times have changed and are continuing to change since the onset of COVID. And even though it’s cliché, it’s true – we are all in this together. Most of us have a common thread throughout… to do the very best we can do, every single day.

One of the many things I learned at a young age, and always try to integrate into my daily life, is to embrace change to the best of my ability. Change is the one thing we can count on. The last two years has forced many of us outside our comfort zones.  It is just as true in our professional lives as it has been for us personally. With that being said, because of the magnitude in how quickly things are changing these days, dealing with all the shifts at once can be difficult. This is especially true in revenue cycle where procedure, policy, and prediction are king.

One of the changes that is not wholly guided by personal decisions, is the way healthcare is accessed and provided. I’m going to put my healthcare revenue cycle hat on now and attempt to speak to all the healthcare financial leaders who are responsible for managing the day-to-day health of their hospital or health system. Foremost, this is not an easy task, and judging from recent changes and mandates, ensuring your organization remains financially healthy will only get more complex and challenging.

It’s safe to say things aren’t what they used to be, and this definitely rings true when technology and vendor relations are introduced. The advanced technology, field experts, and ROI that is available today, is a direct result of the changes that have recently occurred, and will continue to occur, for provider organizations. It’s a cause-and-effect scenario. The cause is that providers have recently been forced to deviate from the traditional financial and organizational structure and processes of the revenue cycle. The effect is that there has been a renewed focus on revenue cycle vendors to centralize processes and platforms to create one seamless solution that focuses on making the financial workflow more efficient, cost effective, and ultimately helps provider organizations get paid faster.

Most revenue cycle leaders will tell you that one of the biggest challenges that providers are dealing with today is the steadily increasing denial rates. They will admit to the fact that the traditional and manual processes we are used to are no longer a solution for the denials that are worked in the business office. Our old techniques simply don’t allow for the transparency and labor required to stay ahead.  The good news is that the call for efficiency and profitability is now being answered with the help of artificial intelligence (AI).  Within AI, there are several different types of valuable technology. The two that are already having a significant impact on the revenue cycle process are decision management and data analytics. Decision management takes input from machine learning and Robotic Processing Automation or RPA to limit where human intervention is necessary which allows the team to work smarter, not harder while being more efficient than ever before. Data analytics, like decision management, can be used throughout the entire claim lifecycle and helps to gain insight on significant amounts of historical data. Data analytics is key in determining denial trends, payer behavior, and maybe most importantly giving visibility to denial prevention opportunities.

Many hospitals and health systems have realized the importance of partnering with a third-party vendor (or multiple) as a tool to implement this technology as part of their overall revenue cycle strategy. A great example of this is the growing number of hospitals and health systems that are partnering with an experienced vendor to manage their entire complex claims reimbursement process – a strategy proven to be extremely successful due to the level of expertise needed in the complex claims arena. It’s a win/win for both the provider and the vendor because it allows hospital billing staff to shift their focus to other necessary projects.

Up to this point, I’ve been focusing on provider organizations and third-party vendors, but it’s important to remember that healthcare is a three-pronged approach. Therefore, this blog wouldn’t be complete without mentioning the payer organizations. The changing times have led to staffing shortages, cybersecurity risks, and member coverage loss giving way to pricing ambiguity for the payers.  Payers are left scrutinizing every detail of every claim as a result. We are seeing frequent changes and updates to billing and reimbursement guidelines which are leading to even more denied claims. Under these circumstances, for many providers, even those claims considered “traditional” are proving to be more challenging.

Your priority, ultimately, is patient care. Being a partner who is dedicated to bringing you industry leading technology is ours. EnableComp employs state of the art data modeling to learn payer behavior and requirements for your complex and traditional claims alike. As a valued partner you can expect:

  • Robust analytics and reporting
  • Denial root cause analysis – enabling you to modify processes
  • Industry leading performance benchmarks
  • Full Reimbursement – our proprietary system provides comprehensive payment analysis based on thousands of data markers to ensure payment accuracy and full reimbursement

If your complex or commercial claim reimbursement is being impacted by the many variables we are challenged with today, rest assured that we are here to help and be a resource when you need it.