Revenue cycle management in the healthcare industry is a complex and constantly changing field. Healthcare providers have the important task of making sure that they are being paid for the services rendered to maintain the quality of service, financial stability, and growth. 

One of the key challenges in revenue management is the complex reimbursement landscape, with patients using a combination of self-pay, Medicaid, Medicare, and private insurance to cover the costs of healthcare. The reimbursement process involves various payers, each with its own rules and requirements. Navigating through this complexity can be daunting for healthcare providers while they are trying to minimize reimbursement denials, provide patients with the necessary clarity on how much they might own out of pocket, and ensure steady revenue.

In this article, we will discuss how Kepler Team’s client, a top laboratory chain in the healthcare sector, discovered hidden sources of revenue, the difficulties they encountered, and the strategies they used to overcome them.

Background

Our client, a prominent chain of laboratories within the healthcare sector, operates on a significant scale, serving a diverse range of patients and hospitals. They have a network of laboratories spread across various locations in the US, each dealing with a substantial volume of patient data and insurance claims.

Like many healthcare providers, our client faced specific challenges in managing insurance claims effectively. These included inadequate compensation for services, lack of transparency regarding patient cost-sharing, which could stress patients with unexpectedly high bills, and time-consuming claims processing with delayed payments. These issues affected not only revenue but also patient satisfaction and operational efficiency. 

Fixing these issues, or, in other words, maximizing revenue streams, became essential to our client in order to provide quality services to their patients while continuing to offer reasonable pricing and peace of mind to everyone involved in the process. To address this, we collaborated with our client to conduct a comprehensive analysis of their operations and help them implement adjusted processes design, which led to the identification of what we termed "revenue bottlenecks.”

Maximizing Revenue Channels: Identifying Revenue Bottlenecks

During the quest to uncover hidden revenue streams, our client identified four critical "revenue bottlenecks" – distinct channels where inefficiencies led to revenue loss:

1. Authorization: Our client has reported that according to the analysis they conducted, the majority of insurance claims were denied due to missing authorization codes. This issue arose because obtaining an authorization code was a manual process that frequently led to complications or oversights on the part of prescribing providers. Thus, streamlining the process for patients to obtain approval for medical procedures became crucial in reducing our client’s revenue loss.

However, automating this process turned out to be complex as prescribing providers and practices work with a very wide range of different Electronic Health Record (EHR) systems. Our client is not the only one facing this challenge; other companies also struggle because each prescribing provider has its preferred system, which poses a significant compatibility challenge. We are actively working towards achieving full compatibility with the EHRs (in addition to Epic, Cerner & AllScripts, Practice Fusion, and eClinical Works are our top priorities) to expedite the approval process.

2. Eligibility: It is important to identify if patients are eligible for insurance early on. In our client’s business, the manual processes resulted in a lot of errors or misconceptions, so we have created an automated solution to check eligibility in real-time. This new process helped reduce risks and improved the patient experience. With the integration engine in place, we have full control over the various specific case scenarios that we can address in 2-72 hours. 

For example, some insurance companies use non-standard delimiter characters for service codes. This issue was resolved within 4 hours of detection, resulting in further improvement of the provided results. 

3. Coordination of Benefits: While checking if the patient qualifies for insurance was an important first step, It's also essential to coordinate benefits with multiple insurance providers and automate this process since oftentimes, the patients might have more than one insurance plan. A common scenario might be a Medicare patient with a supplement insurance plan.

This involves ensuring that claims are accurately coordinated in real-time between primary and secondary insurance providers, to prevent payment disputes and revenue loss for our client. Better coordination leads to increased revenue, which is why we're implementing automated processes and real-time coordination systems. Based on 271 eligibility responses, we identify Primary Payers. We then generate a report with exceptions and send a coverage detection request to define the Member ID for these cases. Finally, we resubmit the Eligibility request based on the updated data.

4. Guidelines Adherence: Following diverse insurance rules is tricky. Each insurance provider has their own unique requirements. While automating guidelines adherence could potentially significantly enhance our client's performance, it would demand a substantial amount of time and effort.

To expedite results, we began our compliance journey focusing on the three prevalent revenue bottlenecks. This decision was based on a financial analysis conducted by the client, which we will discuss in more detail in the following Financial Analysis chapter. 

Navigating Technical Complexities

Our primary integration layer, InterSystems Health Connect, plays a pivotal role in this project. It enables us to seamlessly translate a variety of healthcare messages, including HL7 messages like 270 (eligibility request), 271 (eligibility response), 837 (claim request), and 835 (claim response), as well as X12 EDI messages, into different formats. This robust integration layer provides the essential flexibility required to establish connections with laboratory information systems (LIS), electronic medical record (EMR) systems, and order management portals. This, in turn, streamlines processes across the board, facilitating efficient revenue cycle management workflows. 

When selecting a software development agency, it is crucial to consider the skill set of the developers. It is important to look for experts who can work effectively with complex platforms like InterSystems. We recommend ensuring that they possess not only standard configuration skills but also the ability to work with databases and navigate internal languages of InterSystems, such as ObjectScript.

While the immediate goal is addressing revenue bottlenecks, it's equally important to think long-term. The ultimate objective is a robust system that functions seamlessly both on-premise and in the cloud. In our particular example, we have set up an on-premise server at one of the physical locations that is backed up by a server deployed in AWS Cloud. Such a setup ensures not only interoperability but also stability, leading to lasting revenue optimization.

Preparing Your Healthcare Company for Revenue Maximization

If you are considering a similar journey toward revenue maximization, preparation is key. Here are the essential steps to consider:

1. Financial Analysis: Begin with a comprehensive review of your finances. Determine where the biggest financial losses are occurring and understand the causes behind them. This is important because it will assist the software development agency in prioritizing project objectives and determining which bottleneck to tackle first. 

For instance, consider examining which insurance providers are experiencing the most claim denials and determine the primary reasons for these denials. Additionally, uncover any revenue losses resulting from ineffective processes and identify any challenges that are unique to your organization.

2. Assessing Your Business Processes: Take a close, critical look at how your business operates. Look for areas where manual tasks, unnecessary roles, outdated systems, or inefficient documentation processes are hurting your revenue. 

Keep in mind that simply getting the new software will not improve your revenue management cycle if there are underlying issues like human errors or inadequate procedures. Be prepared to work together with the software development agency to address these issues by simplifying and automating internal processes.

3. Change Management Strategies: Understand that introducing new software and automated processes will bring significant changes to your organization. Set aside resources for effective change management strategies to help your team adjust to these technological shifts. Highlight the importance of maximizing revenue to your staff. 

Get ready for extensive training, possible personnel changes, and the overall transformation that these changes will bring to your organization.

Conclusion

Unlocking hidden revenue streams in healthcare goes beyond financial gains. It involves automating processes, improving efficiency, reducing errors, and enhancing patient outcomes. This comprehensive approach prioritizes patient well-being, elevates the quality of care, and is crucial for establishing a sustainable and patient-centric healthcare system.

This endeavor is complicated, so finding the right technological partner whom you can trust is crucial for long-term success. Building trust goes both ways. Healthcare providers need to trust software development agencies to help improve their systems and internal processes. Similarly, agencies like Kepler Team need to invest time and effort in understanding the client's business and specific challenges, proving that they can be trusted as partners.

If you have a similar project in mind, we invite you to contact us at Kepler Team. Let's schedule an initial conversation and explore how we can contribute our expertise, work together to optimize your revenue and establish a relationship based on trust.