The job of revenue cycle leaders has grown more challenging year by year, and many are searching for ways to optimize RCM processes to achieve greater efficiencies. Between managing prior authorization so patients can receive timely care, handling denial claims, and navigating new payment models, hospitals are constantly working on the revenue cycle management (RCM) side. At hospitals and health systems across the country, revenue cycle management executives are primarily concerned with ensuring the organization’s financial health.
Throughout the COVID-19 pandemic, there have been a growing interest in Robotic Process Automation (RPA) solutions due to a larger backlog of work coupled with staff shortages in hospital operations. When embarking on a revenue cycle automation project, it’s prudent to crawl before you walk and then walk before you run. This explains why RCM leaders need the right tools and data analytics to accomplish the tasks and embark upon the right implementation strategy.
Implementing RPA in RCM
Financially speaking, one of IPA’s most appealing qualities is the consistency with which it can turn nominal initial investments into meaningful long-term returns. According to a McKinsey report, automation of 50% to 70% of tasks results in a triple-digit return on investment (ROI), while a KPMG study of financial services firms found that RPA can cut costs by up to 75%.
The most strategic RPA or Intelligent Process Automation (IPA) implementation process is a phased-in approach that can deliver sizable financial returns, allowing provider organizations to reinvest the returns for further automation opportunities. The staggered process assists cash-strapped hospitals and offers a smooth cultural transition for change-adverse health systems. Let’s understand with an example- In a hypothetical analysis for a standalone 750-bed hospital, offloading manual work from four areas of RCM resulted in a net benefit of $8 million.
- Prior Authorization had an implementation cost of $1,00,000 and a yearly fee of $75,000
- Additional Information Request had an implementation cost of $85,000 and a yearly fee of $60,000
- Coordination of Benefits had an implementation cost of $85,000 and a yearly fee of $50,000
- Notice of Admission had an implementation cost of $65,000 and a yearly fee of $45,000
A typical deployment period takes over 18 months, requiring just $130,000 in initial cash outlays, which account for the implementation fee and the first four months of subscription for authorization automation and delivers an ROI of 3.5-4.5 times the initial investment plus SaaS subscription for the hypothetical hospital.
Customizing RPA for RCM
Every hospital and health system is unique regarding its challenges in the RCM space; thus, beyond the enticing financial returns, RCM executives should seek out flexibility in digital transformation. Every health system needs a customized deployment roadmap outlining which automation gets implemented. While there is no one-size-fits-all approach to enhancing RCM, that’s a primary reason a thoughtful RPA-based strategy is worthy of consideration. RPA implementation must include transparent analytics capabilities to ensure accountability. Hospitals should be able to easily look at a dashboard and evaluate how their new RPA functionalities are performing. The key metrics to look for include-
- Increasing net revenue, reducing costs, and improving the patient experience.
- RPA implementation must address the inefficiencies across the revenue cycle and provide quantitative benefits yielding operational and qualitative benefits.
As medical billing gets more complex, revenue cycle management is expanding beyond the business office. revenue cycle management includes health information management (HIM) services, coding, case management, clinical documentation improvement (CDI), and patient access, in addition to the business office.
This explains what revenue cycle teams must now ask-
- Are they documenting appropriately and accurately what the patient presented with?
- Is case management following up, and is managing that case to the quality standards needed?
- Are they 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?
While there’s a direct correlation between patient care, CDI, case management, and patient access, Revenue Cycle Management leaders are increasingly focusing on a digital transformation within their revenue cycle to accommodate new billing requirements in a patient-focused manner.
RPA benefits for the Healthcare Industry
Healthcare organizations with RPA technology experience understand that automation has many benefits: quantitative, operational, and qualitative. Let’s discuss them in detail-
- Quantitative
Automation technology can drive labor savings and revenue increases by eliminating rote tasks and reliably taking actions to avoid delayed or denied reimbursement, especially in high-volume clam populations. RPA may not necessarily reduce an organization’s overall headcount but will allow staff to focus on more revenue-generating tasks than they otherwise would.
- Operational
RPA can bring improvements to turnaround times, service levels, and capacity targeted toward streamlining complex processes to work more seamlessly. In the often-fragmented technology landscape health systems face, automation often plays a role in bridging the gaps between systems to facilitate a more unified consumer and caregiver experience.
- Qualitative
Augmenting bots into your workflow can lead to greater accuracy, consistency, compliance, and risk management. The reliability of completing a task, in the same way, every time, with automation working around the clock and monitoring itself, can provide peace of mind and lower an organization’s risk profile. Revenue cycle staff are integral to the successful adoption of RPA technology. Therefore, their leaders are responsible for explaining the benefits of automation and the opportunities it presents for meaningful work.
Pursuing the promise of RPA in Revenue Cycle Management, hospitals are presented with a long-term resource reallocation opportunity that has the potential to produce a higher ROI while freeing up human capital to address more pressing issues. Hospitals should prioritize providing high-quality care to their patients and the untapped potential of RPA to streamline Revenue Cycle Management challenges. We’ll look at some success stories in the following section.
Implementing RPA in RCM: Case Studies
Case study 1
- Industry: Healthcare Provider
Automated Prior Authorizations assist a hospital medical system provider to achieve a >98% Successful Authorization Rate.
- Client Overview:
The client is a large healthcare provider specializing in cancer, cardiac, neurosurgery, surgery, electrophysiology, orthopedics, and primary and urgent care. Even though most of their prior authorizations were eventually approved, the client noticed that the lengthy process of obtaining authorization approval negatively impacted patient care. The traditional method of prior authorization was insufficient to meet the provider’s changing demands, resulting in patient care delays.
The hospital employed the traditional method of prior manual authorization. The prior authorization process required one physician hour, 13 nursing hours, and an additional 22 back-office staff hours per week, totaling $4,100 to $24,000 per FTE per physician annually. This time-consuming procedure resulted in massive backlogs and delays in care, causing patients to discontinue treatment.
The client noticed that the lengthy, time-consuming, and costly prior authorization process was wasting valuable time and causing scalability issues. Because there are no industry standards for prior authorizations, the administrative costs can be enormous—the client requires outside expertise to address these issues and streamline the initial authorization process.
- The Diligent Group created an end-to-end authorization platform capable of automating prior authorization.
The Diligent group of healthcare automation experts created an end-to-end authorization solution to automate prior authorization using machine learning and AI technologies to assist clinical staff in providing timely medical care. The solution could determine whether or not the patient needs prior authorization. An ML algorithm was used in the end-to-end authorization platform to recognize CPT or HCSPCS codes, match them with the payer’s LCD/NCD policies to determine medical necessity, and submit required data for prior approval.
Benefits of Automation
The Diligent Group’s solution proved extremely beneficial in streamlining the prior authorization process. Following deployment, the client reported the following benefits:
Client Benefits
The Diligent Group’s solution proved extremely beneficial in streamlining the prior authorization process. Following deployment, the client reported the following benefits:
- 40% of FTEs have been repurposed to higher-value tasks.
- 11 hours saved per week per administrative staff >98% success rate on prior authorizations
Case Study 2:
- Industry: Healthcare Provider
A hospital medical system provider can reduce patient wait time by 70% with automated real-time verification.
- Overview of the Client:
The client is a 162-bed hospital that provides a wide range of healthcare services, including an emergency department that sees more than 50,000 patients annually. For existing patients, the provider’s FTEs would manually verify details from multiple tabs such as payable benefits, co-pays, patient policy status, type of coverage plans, and so on. Similarly, to retrieve data for a new patient, provider front desk staff had to visit several payer sites, resulting in an additional 15-30 minute wait time.
The accuracy of any manual procedure is determined by the number of allotted FTEs and the time each FTE is given to complete the work. Due to an increase in attendance and a lack of adequate resources, the provider saw an increase in errors. This had a substantial impact on patient satisfaction with the service. The client required a solution to improve the accuracy and efficiency of patient eligibility verification.
Accurate eligibility verification is critical in the claims filing and reimbursement process. The team’s efficiency, however, was severely hampered by the increasing volume of work they were processing manually. The team had to check the eligibility of hundreds of patients for scheduled visits every day by manually cross-verifying the details with the payer portal. This time-consuming procedure resulted in longer patient wait times and significant backlogs for hospital FTEs. The client was looking for a real-time solution to automate the eligibility verification process to reduce errors and wait time.
- Diligent Group was contacted to provide a solution to the client’s operational constraints to alleviate front-desk challenges.
The RPA experts at Diligent Group created a solution that uses RPA and OCR to collect eligibility information and up-to-date benefit levels from payer sites.
The bot is set up to retrieve appointment information from the provider API, send emails, and look up patient coverage information on various payer websites (mentioned by the client). The solution uses OCR to retrieve the information required if the data is in pdf format.
Historically, manual verification has been providers’ responsibility on the front lines. This indicates that a hospital staff member is in charge of confirming the patient’s eligibility, which entails contacting the insurance company and using various insurance portals to ensure that the patient’s information is correct and that the treatments requested are covered.
With automated patient eligibility checks, hospital personnel can better manage and utilize their time. As a result, instead of wasting hours of their day searching for payer information, they can focus on more patient-critical duties. Furthermore, automated technologies ensure that your team has immediate access to the required data.
At check-in, the Diligent group’s Automated Real-time Verification system performs an automated patient eligibility check. When this information is automatically available at the start of the visit, the check-in and invoicing processes are streamlined. Once coverage has been validated, providers can proceed with their scheduled visit.
If a patient’s visit is not covered by insurance, they can find out how much they will have to pay out of pocket. This gives patients transparency in the billing process, which they value from their doctors.
At check-in, the client reported the Diligent group’s Automated Real-tiThe following advantages of implementing the system.
- Patient wait time is reduced by 70%.
- Verification of eligibility and benefits in real-time
- Savings of 25% in the first year
- Eligibility-related claim denials were reduced by 60%.
Do you want to cut costs while improving the patient experience? The Diligent Group is here for your business with Analytics and Automation solutions that meet your needs.
Send us a message at info@thediligentgroup.com to know more!
