RCM Challenges Faced by Specialty Healthcare Providers

A robust and efficient revenue cycle management (RCM) plays a significant part in ensuring that healthcare organizations are on a profitable path. The RCM process largely defines the healthcare facility’s ability to collect timely revenues and utilize them to provide high-quality care to build trust among patients and enhance the brand value of the facility. To make sure that your facility’s revenue cycle management is successful and thereby brings you profitability; you must establish clear communication among various parties involved – facility’s management, patients, insurance payers and the revenue cycle management team of your facility, whether it’s an in-house team or you have outsourced the process to RCM services providers.

Despite having set processes and procedures for the RCM process, you may find gaps in some of the RCM processes including speciality healthcare processes. If your organization provides speciality healthcare, you need speciality-specific RCM services experts to understand the nuances of speciality care and the frequent updates in government policies and regulations. Further, revenue cycle management of speciality healthcare processes can be daunting due to the complex financial and administrative challenges they bring along. Let us take a look at some of the common RCM challenges you may face as a speciality healthcare provider and ways you can overcome them.

  • Poor prior authorization process: Prior authorization is the process wherein you take approval from the insurance payers to provide services to a patient before you actually provide the service. If your prior authorization process is not standardized, you may face problems in the form of denials and rejections when you submit claims for reimbursement. According to the top RCM services providers, this can be avoided by implementing a strong prior authorization process that helps you to provide evidence-based treatment to patients thereby adhering to the different requirements of multiple insurance payers so that reimbursements are effortless and unnecessary costs are controlled.
  • Inappropriate coding: Appropriate coding for specialty services is a major and complex contributor to the efficient revenue cycle management process. Inadequate knowledge of specialty services’ coding rules and inaccurate coding can lead to revenue loss. To mitigate such losses, you can outsource your coding and billing processes to RCM services companies that employ the best medical coders and billers with exceptional knowledge of specialty services. Another advantage of outsourcing these processes to such companies is that they ensure that their medical coders and billers are well-versed with frequent updates in the industry.
  • Capturing charges inaccurately: Charge entry is critical in the revenue cycle as it determines the reimbursement you are entitled to for the services rendered. Since the costing and profitability of your services and facility depend on the success rate of your reimbursements, it’s essential that your charge entry process is accurate and for this, you need medical billers who are adept at the billing process of the specialty healthcare you provide. Employing the right medical billers or RCM services providers becomes even more critical when you offer multiple specialties and multiple systems are used to generate different information. In such a scenario, you must implement data interoperability to mitigate challenges in the charge entry process.
  • Inappropriate management of A/R: Your RCM team must be aware of the account receivable benchmarks for various specialty services and ensure that these benchmarks are adhered to. Non-adherence to such benchmarks will impact your revenues negatively. Hence, it’s necessary to draft appropriate standard operating procedures and guidelines to minimize the account receivables days and prevent and manage denials.
  • No credentialing process: By following the credentialing process, your services can be validated by various insurance payers allowing timely payments from the payers. If you are not validated by the insurance payers regarding your licenses and specialty accreditations, they may delay your reimbursements impacting your finances negatively. You must ensure that you are credentialed appropriately for the services you render and get your information updated upon acquiring a new specialty or certification.

As a speciality services provider, you must be aware of these common challenges and be ready with appropriate tools and strategies to overcome them. To eliminate such challenges and improve your financial health, it is better you outsource your revenue cycle process to a reliable RCM services provider with speciality-specific expertise.

RCM Challenges Faced by Specialty Healthcare Providers
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