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As Revenue Cycle Management Expands, Automation Is Key

Revenue cycle management is no longer just what happens in the business office, now hospitals must coordinate patient access, CDI, quality, and other aspects of care in order to get paid.

Jacqueline LaPointe
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Published: 27 Sep 2021

In its simplest form, revenue cycle management is the process healthcare providers use to ask for, track, and collect revenue for services rendered to patients. But as medical billing gets more complex, revenue cycle management is expanding beyond the business office.

At Jackson Hospital in Montgomery, Alabama, for example, revenue cycle management also includes health information management (HIM) services, coding, case management, clinical documentation improvement (CDI), and patient access, in addition to the business office.

“Revenue cycle is becoming really broad, looking at the clinical side, as well as the operational side, for the treatment and care of patients within our community,” David Ralston, vice president of revenue cycle at Jackson Hospital, recently told RevCycleIntelligence.

The reason for this spread, as the revenue cycle leader of 20 years called it, is the increased complexity around medical billing.

“It’s gotten more complicated from the payers,” Ralston explained.

“It's not just dropping a bill anymore. There are so many things that have to be looked at and reviewed from all aspects of the claim before it goes out, and each payer requires something different to be done or certain criteria to be met to get the actual claim paid.”

Revenue cycle teams must now ask: Are we documenting appropriately and accurately for what the patient presented with? Is case management following up and are we managing that case to the quality standards that need to be done? Are we determining what's best for the patient’s next step? Is it going to a skilled nursing facility or another post-acute care facility, or are they cleared to go home?

“All of that comes down to what your reimbursement is going to be,” Ralston said.

For hospitals, revenue cycle spread also ensures high-quality care for patients and quick, accurate revenue capture to keep that care coming.

“There's a direct correlation between patient care, CDI, case management, patient access, even in the beginning,” Ralston explained. “Then, how that claim goes out the door to show a true representation of that patient's care and treatment and meeting the criteria to get that claim paid the first time.”

But while this spread is helping hospitals and their patients, revenue cycle management isn’t traditionally set up to accommodate so many responsibilities outside the business office.

“Everyone is going through staffing issues,” Ralston, who is also an adjunct professor at Murray State University where he teaches revenue cycle finance to aspiring healthcare professionals.

“There seems to be a lack of people wanting to go into revenue cycle management,” Ralston observed.

Ralston is doing his part by encouraging interested folks to pursue a career in revenue cycle management, but the issue still comes down to people, process, and technology at hospitals and health systems.

“It’s the oldest thing in the book,” said Ralston. “We have limited resources of people, so we need to work on process to make revenue cycle more efficient. So, we look at technologies to augment the staffing that we have.”

Revenue cycle automation is really stepping in to enable the spread needed to ask for, track, and collect revenue while ensuring high-quality care for patients.

Automating from front to back

Jackson Hospital is focusing on a digital transformation within its revenue cycle to accommodate new billing requirements in a patient-focused manner. The hospital is taking a front-to-back approach to start.

“If you can get the front-end automation, then the back-end automation, then you can work towards the middle where patient care happens,” Ralston stated.

On the front end, Jackson Hospital’s revenue cycle management team has implemented a number of technologies to overcome the “garbage in, garbage out” challenges that most hospitals face with creating clean claims. Those technologies include a patient self-service platform from Firstsource, which reduced the need for a call center, and additional automation for self-pay accounts that confirms items like insurance eligibility at the point of service. Ultimately, front-end automation supported the creation of Jackson Hospital’s digital front door—a virtual experience that enables patients to access the healthcare system beyond a patient portal or online bill payment or scheduling.

“The idea is to reduce the denials. So by having accurate information from the beginning in patient access, you'll have less denials after you drop the bill. That’s the main emphasis of what we're doing here,” Ralston said.

So far, the revenue cycle automation has improved front-end metrics. With the help of self-pay automation, for example, revenue cycle staff have been able to give patients an estimate for their services and collect it upfront, which according to Ralston, is the “most effective, economical place for collections.” Point-of-service collections have increased by about 70 percent since implementing the technology.

The hospital is also seeing improvements on the back end of the revenue cycle with the support of automation. Ralston explained that, in addition to front-end automation, Jackson Hospital has invested in technology to help the revenue cycle team send out clean claims the first time.

“What it does is it looks at each claim as it is getting ready to go out the door and scrubs it to identify what is missing,” Ralston said. “Then, what we do is put that claim in a work queue to identify the information that is needed, and we get the information put in so a clean claim goes out the door.”

Jackson Hospital also recently tapped technology to identify self-pay amounts after insurance processes a claim. The technology solution also informs patients of the resulting amount either through a secure text or email and allows them to make payments electronically. The hospital is collecting about 43 percent of what is sent via the solution, a significant improvement from the high teens the hospital was seeing when it sent out self-pay amounts manually.

With improvements being realized on the front and back ends of the revenue cycle, Jackson Hospital is now looking toward the middle with “high data analytics,” Ralston said.

The data analytics tool helps case managers by determining a propensity for hospital readmission—a major expense for hospitals and an indicator of poor-quality care. Armed with the data, case managers can follow high-risk patients after discharge and work with them to prevent readmission.

“We are an anchor in Montgomery, Alabama, so we want to ensure that we’re providing great services, and the data analytics and information really help do that to the next level,” Ralston said.

Continuing digital transformation in revenue cycle

Revenue cycle automation is helping Jackson Hospital take on the expanded responsibilities of revenue cycle and doing so successfully. But the digital transformation will not stop there.

“Our next move will be to look at some RPA modeling and bots to see how we’re going to use technology to continue to move us forward quickly,” Ralston said referring to robotic process automation (RPA) and artificial intelligence.

Jackson Hospital is looking to leverage the more advanced technology “to have a bot work for us 24/7 to do some of the mundane, standard processes that a person does.”

“You can have that technology brought in and replicate computer keystrokes to move forward with some of the simpler tasks and they can do it 24 hours a day,” Ralston added.

Leveraging RPA and artificial intelligence for the revenue cycle enables staff—which is a limited resource for most hospitals—to focus on value-adding activities, such as working complex claims and accounts.

Jackson Hospital is also planning to focus more on pre-registration to collect accurate data for claims reimbursement before a patient even steps through the doors for an appointment. With more and better data collection, the likelihood of smooth financial experience increases.

But this is just the start of Jackson Hospital, Ralston emphasized. “We’re going to be scrutinizing every single function and process to determine if automation deployment can assist us.”

Next Steps

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