The Difference Between RCM Applications and Solutions (And Why it Matters)
June 12, 2019
Revenue cycle management applications are software designed to support hospital RCM operations. In contrast, RCM solutions augment RCM technology with account management and consulting.
Revenue cycle management applications are software designed to support hospital RCM operations. In contrast, RCM solutions augment RCM technology
with account management and consulting.
Here's why this distinction matters: RCM applications can neither deliver nor utilize knowledge. They can guide the communication of knowledge, but they're incapable of analyzing situations, identifying the next best action and executing that action.
Sure, many applications include some sort of machine learning logic. However, such technology, for the most part, is limited to making helpful recommendations as to which steps an accounts receivable department should take after a workers' compensation provider denies a claim.
RCM solutions are typically better choices than RCM applications because only humans can navigate complex situations, especially when those situations are a result of complicated legal conditions. In addition, regulations can render relatively new, capable software obsolete.
"93% of hospitals CFOs want to get rid of technology that isn't producing an ROI."
Hospitals Replacing RCM Applications
Last year, Black Book surveyed more than 5,000 health care professionals who were using RCM software. The researchers discovered that 85 percent of participants were either assessing their RCM applications' capabilities or considering replacing those systems altogether.
The purpose of those assessments was to determine whether or not existing RCM technologies could help them manage value-based reimbursement. In fact, 93 percent of CFOs working in health organizations maintained they want to get rid of RCM, financial and coding technology that isn't producing a return on investment.
One of the findings noted that 71 percent of care providers "have not selected end-to-end technology vendors to move towards value-based reimbursements." As a result, many hospitals are turning towards outsourced RCM consultants to guide them through the transition of value-based care.
Doug Brown, managing partner at Black Book, noted that hospital leaders are trying to transform how they approach the revenue cycle:
"As reimbursements come under pressure and costs keep rising, provider CFOs will face unparalleled pressure over the next year to preserve financial solvency, increase productivities in care delivery, implement regulatory mandates and reduce RCM expenses associated with getting paid."
How can RCM solutions help those CFOs reach their goals?
What Makes an RCM Solution?
Identifying how RCM solutions will help hospitals transition to value-based care partly involves assessing how they work.
The typical RCM solution consists of consultants, legal experts, coding specialists and proprietary technology. The latter exists across vendor operations: The hospitals never see the systems themselves. The solution itself is a comprehensive service offered by an RCM partner.
A solution is, in its own way, an infrastructure. Just as a series of highways, tunnels and roads make up a city's transportation infrastructure, an RCM solution consists of the resources required to navigate complex billing issues.
For example, acquiring reimbursement from auto carriers is a common pain point in hospital billing departments. This is due to the fact that each state has its own laws regarding who is the prime payer after an accident.
Digging deeper into the issue, there are 12 states in the U.S. with no-fault auto insurance laws. Under no-fault laws, auto-carriers are always the prime payers when drivers are injured during accidents in no-fault states, regardless of whether those drivers were at fault.
However, what happens when a driver from a fault state is in an accident in a no-fault state? In this instance, the driver's auto carrier may deny a claim as the prime payer.
RCM solutions are designed to handle such circumstances. They draw on the understanding of partner-side experts who are knowledgeable of how state laws affect auto carrier and workers' compensation reimbursement. This knowledge can be incredibly valuable, especially during times of transition.
In 2016, healthcare vendors need the most efficient claims processing systems out there. By now, flexible, web-focused methods for important claims tasks are clearly the industry's path forward, and will play a major role in bridging the gap between patients and providers. A fast, digital claims method makes a direct link from implementation to delivery for workers' compensation and motor vehicle billing alike. Now is the time to invest in better revenue cycle management, with a focus on detail-driven, well-facilitated collection that breaks down barriers. Despite the growing pains involved with adopting any new technology, there are a couple of areas where smarter systems have already improved claims processing online. Direct accessibility With each new convenience, the future of healthcare looks more integrated. Data analytics harvests insights from seemingly unrelated details for fuller results. To make this innovation worthwhile, however, there needs to be a distinct pipeline between entities. "Data analytics harvests insight from seemingly unrelated details." Online healthcare portals are already addressing this need, providing direct communication through smart devices like phones and tablets. By bringing necessary information together in a simple, accessible source, these solutions set the stage for clean claims assembly. Shorter cycles Proper collection from the outset can reduce the amount of work hospitals have to do later if the claim is resubmitted, according to Gary Marlow, Vice President of Finance at Beverly Hospital and Addison Gilbert Hospital. "From a revenue cycle perspective, getting the most accurate information up front starts with patient scheduling and patient registration," Marlow told RevCycleIntelligence in 2015. "That provides the groundwork by which claims can be billed and collected in the most efficient and effective manner possible." The way information enters the claims process can impact how it gets managed. If technology, like artificial intelligence, is present at the beginning and guides the claims throughout, there's a consistent system handling the information the process to meet best practices. PROMEDICAL's benefits With our secure, efficient and comprehensive system, PROMEDICAL is staying ahead of the game. We're doing that by developing the following features: Communication: Users can choose from multiple languages with our online offerings. This allows you to customize your system to better reach patient populations and keep claims moving faster. Customization: If our proprietary options aren't currently meeting your needs, we can change them to do so based on feedback. Adapt to state fee schedules or language demands on a case by case basis. Encryption: A must for secure file exchange, PROMEDICAL ensures a secure file transfer process. Our process protects backup data equally strong as primary data, for efficient security across the board. Planning: Organizations also benefit when a set deadline is involved, putting clear limits on when submissions are set for review. Processing records requests within a preordained period of days helps managers know what to expect, and regular reports set up clear overviews of important statistics. Contact PROMEDICAL today to learn more about our healthcare revenue cycle solutions.
According to Pew Research, 15 percent of U.S. adults have used ridesharing services . Where does insurance enter the picture? Uber, Lyft and other ridesharing apps throw a proverbial wrench in hospitals' revenue cycle management operations. Billing is already a major pain point in hospitals – Black Book Research noted most facilities are outsourcing their RCM because in-house teams lack the resources to efficiently handle motor vehicle reimbursement. Ridesharing will only exacerbate the issue. For example, if a rider gets injured and has to go to the hospital, from which institution does the hospital receive reimbursement : The driver's insurance? The passenger's? Uber's? As Uber and Lyft are the most popular ridesharing apps, we'll focus on how these companies handle driver insurance. How do Lyft and Uber insure drivers? Lyft has three types of coverage within its insurance policies: Contingent Liability activates when a driver logs into the app and requests to accept rides – a state Lyft designates as "Driver mode." This coverage provides up to $100,000 per accident for bodily injury. Contingent Comprehensive and Collision kicks in when a driver has picked up a passenger. This coverage applies when a non-collision event damages the driver's vehicle. Uninsured/Underinsured Motorist applies when an at-fault driver who is uninsured or underinsured causes bodily injury to himself, his passengers or any third parties. The coverage provides $1 million per incident, and includes no deductible. For example, if a driver is injured in an accident at a time when he is not working for Lyft, his personal insurance will cover him (assuming he lives in a no-fault state, but that's another issue). However, when the driver activates Driver mode, Lyft's Contingent Liability will protect him even if he hasn't accepted a ride from a passenger. What if the driver's at fault? According to Rideshare Dashboard, Lyft's commercial insurance will cover all damages to third parties and the passenger, but the driver will have to cover his own medical expenses. That's when state laws dictate payment. In Massachusetts, for example, which also happens to be a no-fault state and requires all motor vehicle owners to possess auto insurance, the rider's personal auto insurance will cover the medical bills. Uber's insurance system is somewhat similar to Lyft's but possesses a few minor differences. For example, when an Uber driver is transporting a passenger, and another motorist causes an accident that results in bodily injury to the driver, the passenger and anyone else involved, Uber's UM/UMI will cover bodily injury of anyone in the rideshare vehicle.
With new, transformative technological advancements on the rise, it's no surprise that nearly every industry is feeling the impact of the digital age. From a healthcare provider's perspective, new resources can be used to revamp the current revenue cycle management processes you have in place. To reap the benefits of an optimized approach, you must be willing to take advantage of such emerging technological tools and resources, as stated by Chad Sandefur, Director and Healthcare Analyst at AArete. "Generally speaking, in order to strengthen the revenue cycle management, embracing technology within the revenue cycle is key," Sandefur shared with RevCycleIntelligence.com. "Having the platforms to seamlessly facilitate provider-payer interactions are really integral. In many cases, it's mostly about bad debt avoidance. With that in mind, there are a few specific points." Let's take a closer look at the benefits of utilizing technology, plus some of the emerging resources your facility can use to revamp your current RCM processes: The benefits of an optimized approach By paying attention to the new digital advancements that can benefit your RCM, you can ultimately impact the workflow of your staff members while better streamlining services for consumers. Here are some of the advantages of an optimized approach: Reduced chance for human error – Human error is inevitable when handling large amounts of data. Management software can be used to keep track of patient data input and maintenance. Better opportunity for precise, automated data entry – Between appointment scheduling, data input and claims submission, employees have a lot of duties. Automated software can take care of some of these responsibilities, allowing staff members to better focus on a single task at a time. I ncreased cash flow – Claims management technology can expedite claims quickly and produce clean, accurate claims, ultimately increasing cash flow , as stated by Becker's Hospital Review. Optimizing your RCM approach can lead directly to a significant return on investment and improve the overall reputation of your billing department.
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