The New RCM: Going Beyond Billing and Collections

It’s been awhile, but there was a time when the words “Revenue Cycle Management” caused excitement and wonder in the halls of many medical practices. I can remember in 2005 when I started in the industry and the promise of fixing Medical Billing with Revenue Cycle Management was a real conversation. It was a world of wonder back then – boring paper forms being replaced by “wizbang software systems” that automated the claims submission. Some of the systems were even available online, no server or CD-ROM needed.

Software-enabled RCM worked. Electronic submission, programmed-rule engines and faster posting have led to a new standard of efficiency in medical billing. Claims have become easier to process and faster than ever to organize and follow-up on. Multiple systems claim to make this process so clean that only 3-5% of claims will ever require any work. Yet, despite all these efficiencies, providers still have issues with their revenue cycle.

In a 2019 report on the Independent Provider, nearly 70% of respondents are considering a new RCM solution. Why? If medical billing has been solved, then why the dissatisfaction with the revenue cycle? Simple, the revenue cycle involves more than just billing and collections.

Beyond Billing and Collections

If you want to address the revenue cycle in 2019, you must look beyond claims submission. Look to areas which influence the actual revenue associated with these claims, as these are often ignored or significantly under-sourced.

Credentialing, coding education, ancillary services, wellness visits, Medicare programs, fee-for-service contracts and telehealth reimbursement are just a few of these related areas that the modern practice must master.

Here are two quick areas to focus on to fix this incomplete look at the revenue cycle:

Coding Education

Most providers (if given a shot of truth serum) will admit that their practice of coding is mostly influenced by habit rather than their exact medical decision making. Providers feel that if they stay in the middle of the curve with the complexity of visits rather than properly coding due to risk factors, they will avoid attention that could lead to audits, etc. The biggest challenge to this is as the population gets older, the medical decision making gets naturally more complex. Not responding accordingly is costing providers due to spending higher acuity time and documentation while only submitting a lower acuity code.

The American Academy of Professional Coders has found that providers under-code over 15% of all claims amounting to $23,000 in missed revenue for the average primary care physician.

CMS Value Programs

As America’s average population ages, the ranks of Medicare enrollees have swollen. To prevent the Medicare program from becoming bankrupt due to the medical spend of all these enrollees, the Center for Medicare and Medicaid Services (CMS) has rolled out several programs to incentivize providers to take care of their elderly patients. From annual wellness visits for healthy patients to transitional care visits to help patients not be readmitted after a hospital stay, CMS is willing to pay very well for providers to learn these programs. The challenge is providers haven’t gotten onboard. In 2015, CMS reported that more than half of practices (51.2%) have still not adopted an annual wellness program for their Medicare patients. These visits can pay up to twice the amount of an established patient visit and can be scheduled during off-peak times throughout the year.

To win at the new Revenue Cycle Management, you need to win at programs such as these. Do you know your opportunity to improve in these areas? Kareo can help. With a few simple reports, our team of experts can analyze your practice and quantify your opportunity. Get excited about Revenue Cycle management again;  go beyond billing and collections!

About the Author

Wesley Stolp is Kareo's Solutions Director for the Managed Billing business. He has 15 years of SaaS, RCM and Practice Management experience, with a focus on...

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