In the ever-evolving landscape of healthcare, refining Revenue Cycle Management (RCM) will be paramount for healthcare leaders to keep pace with operational and clinical efficiency while increasing cost savings. Specialty practices face an additional layer of complexity. The intricacies of specialty care demand an RCM approach as precise as the care itself to ensure practice optimization.
Here are several key areas that can advance overall efficiencies within specialty care practices:
1. Coding & Billing Updates: Staying up to date with coding and billing is crucial for accurate reimbursement. According to the American Association of Professional Coders (AAPC), 80% of improper payments were due to incorrect coding1. Specialty practices can enhance revenue generation through attention to coding guidelines and documentation practices. This involves:
- Consistent investment in staff education and training
- Leveraging reliable sources for information and guidance such as the American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and specialty-focused professional associations
- Integrating coding software and tools that provide real-time updates and compliance validation practices can significantly aid accurate coding and billing processes
- Exploring external audit options and engaging consultants to ensure compliance and uncovering avenues for revenue optimization
- Collaborating among clinicians, coders, and billing teams is crucial for collectively addressing coding and documentation complexities and requisites
2. Value-based Reimbursement Models: The shift towards value-based care in specialty medicine has led to new reimbursement models focusing on quality measures tied to patient outcomes. As of 2021, nearly 60% of healthcare payments had at least some linkage to quality and value2. Linked to these risk-based contracts is a comprehensive transformation of RCM. Providers must address some critical considerations in this transition:
- Preventative Care
- Effective Risk Management
- Quality Measurement
- Enhanced Patient Engagement
- Adaptation of RCM Processes
3. Prior Authorizations: According to The Journal of the American Medical Association (JAMA), the highest rates of specialty services that require prior authorizations are for certain types of oncologists (97%), cardiologists (93%), and radiologists (91%) 3. In specialty care RCM, a pivotal aspect is the optimization of authorizations, which involves a strategic approach to streamlining and automating the prior authorization process for specialty treatments. To achieve this, specialty practices can concentrate their efforts in three crucial domains:
- By integrating advanced technology and automation
- By implementing data standardization and meticulous documentation
- A streamlined workflow coupled with comprehensive training initiatives
With the right RCM approach, practices can be more efficient and effective, maintain an edge within their specialty, and invest in better outcomes and experiences for patients and staff.
Interested in an RCM partner with extensive specialty expertise? Learn how Integra Connect partnered with a specialty practice to unlock critical issues in RCM in this latest case study.
1. KimTorrey. (2020, January 3). CMS identifies E/M codes with high error rates. AAPC Knowledge Center. https://www.aapc.com/blog/49538-cms-identifies-e-m-codes-with-high-error rates/#:~:text=According%20to%20the%20report%3A,were%20due%20to%20insufficient%20documentation.
2. Fry, S., Nierenberg, D., Wynn, G., Murphy, K., & Jain, N. (2023, April 10). Value-based care: Opportunities expand. Bain. https://www.bain.com/insights/value-based-care-global-healthcare-private-equity-and-ma-report-2023/#:~:text=As%20of%202021%2C%20nearly%2060,under%208%25%20of%20spending).
3. Aaron L. Schwartz, M. (2021, May 28). Measuring the scope of prior authorization policies. JAMA Health Forum. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2780396#:~:text=Physician%20specialties%20varied%20widely%20in,%25)%20and%20psychiatrists%20(4%25)