Patient access operations – financial clearance activities in particular – play a critical role in laying the foundation for a high-performance revenue cycle. The challenge for many provider organizations is that they lack the staffing, technology, and operational processes needed to capture the full scope of critical information, eligibility, and authorizations in advance of a patient’s visit.
The result of these limitations is denials.
In fact, about 50% of denials can be traced back to front-end revenue cycle management (RCM) issues, including registration, eligibility, authorization, and non-covered services – issues that can be avoided with a robust integrated financial clearance (IFC) process. As we shared in our recent webinar, Integrated Financial Clearance and Patient Access Processes to Improve Revenue, when correctly designed and implemented, IFC creates a seamless and cohesive approach to all facets of the long journey between scheduling to authorization to payment.
Misalignment Leads to Process Breakdowns
The revenue cycle can be impacted by a misalignment among any of the front-end RCM functions that create the IFC value chain, which include:
- Pre-registration and Registration components, including trending analysis, point-of-service collections, scheduling, eligibility, and demographics.
- Insurance Verification components, including insurance validation, financial care estimates, and authorizations.
- SOI/ROM (Severity of Illness/Risk of Mortality) Capture Rates
For example, scheduling is one of the most significant outliers for an integrated approach to financial clearance. Problems typically start in the organizational chart with failure to align scheduling under the purview of revenue cycle leadership and instead characterizing it as an operations role. This can lead to process breakdowns related to key financial checkpoints, such as ensuring the right information is being collected to enable a seamless and, ideally, automated benefit check and authorization approach.
When complete data isn’t collected at the time of scheduling, someone will need to reach back out to the patient to gather what’s missing so benefits can be properly verified – a critical step on the authorization path. This extra step not only delays authorization, but it can impact pricing transparency and the ability to fully understand out-of-pocket liabilities, which is important to ensuring the right deductibles and co-pays are collected at pre- or point of service.
Thus, proper alignment among all RCM functions is crucial to ensuring appropriate controls are in place to mitigate revenue leakage – which is what an IFC approach accomplishes.
Executing the Strategy
Implementing an IFC approach built upon a shared technology solution enables a seamless process that follows the patient journey from scheduling all the way through to authorization and preservice or point-of-service collections. IFC can also help reduce or eliminate the 86% of denials that are preventable – representing a significant opportunity to reduce A/R days and duplicate re-work – and supports the demands of an increasingly consumer-minded healthcare market where 81% of patients want to know the cost of their care prior to the time of service. The foundation of a successful IFC strategy is built upon three pillars:
- High skill and experience across key financial checkpoints based on the organization’s specialties and payer network.
- Bespoke technology solutions from industry leading partners or built for the purposes of automation that close the gaps between checkpoints and/or eliminate redundant tasks.
- Macro level visibility with downstream AR feedback loops that provides analytics across financial checkpoints and accountability at all levels.
A proper IFC strategy will take advantage of multiple technology approaches, including automation, real-time eligibility, and automation and will be tailored to the organization’s specific needs. The key is to work with industry leaders who have mastered the complex authorization process and can deliver an approach that streamlines rather than creates bottlenecks and ensures a smooth patient experience while allowing the organization to collect the appropriate level of net revenue.
For a deeper dive into IFC, download our webinar: Integrated Financial Clearance and Patient Access Processes to Improve Revenue
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