Are You Ready for Reimbursement Changes? 

It’s no secret provider reimbursement is changing across the country. The biggest reason for the change? Payer organizations are challenged with limited resources, rising costs and increased demand for care. These complex factors are causing everyone—from policy makers to healthcare consumers—to look for solutions. 

One solution involves the way healthcare providers get paid. As a result, many new regulations include implementing initiatives and guidelines that change how providers are reimbursed.

Quickly slipping away are the days where a provider performs a service, bills for a service and gets paid for that service—regardless of an individual’s improvement. Today’s new reimbursement models—whether you call them fee-for-value, managed care, value-based care, etc.,—place the focus on the individual receiving care and the outcomes achieved. Experts agree these models are key to lowering costs and increasing quality care. 

While these models are supported by many, they can create ripple effects across healthcare organizations, completely disrupting the revenue cycle workflow and impacting revenue streams. 

Protecting your reimbursement in this new climate calls for fully re-evaluating how you manage your organization—from financial to operational and technical areas. 

The main question to ask? Is your business office ready to take on the additional administrative tasks required as new payment models roll out? 

Getting set up for success

Here are four things to consider to help you succeed in today’s changing reimbursement environment. 

1.) Equip your organization with the right people for the right roles

Most important to navigating these reimbursement changes is your people. Do you have enough people in place to tackle the new administrative tasks? Do they have the training, skillsets and resources needed to succeed? Are they okay that their job responsibilities might be changing? 

It’s important to understand if your team is equipped and ready for what’s coming. If not, is it time to look at additional resources to help supplement what you currently have?

2.) Ensure consistent authorization management

It’s essential to have an electronic health record (EHR) system that can track and manage your authorizations. Authorization management modules in your EHR can save your team time and help them work more efficiently.

Your system is only as good as the input of information. Make sure you establish a proper authorization management protocol where you capture all the processes and assign necessary responsibilities, such as who submits authorization requests to the managed care company, who enters the information, and who looks for gaps between services provided and authorization received, so you can get the claims out the door. 

3.) Automate eligibility

Absolutely critical to getting paid is to make sure you verify a person’s insurance eligibility prior to service. Second, you must make sure you bill the correct insurance company. Failing to do so could leave you with an unpaid claim. 

Checking insurance eligibility, however, can come with a cost in the form of cumbersome, manual tasks. Having one person (or more) manually verify eligibility by scanning insurance websites isn’t sustainable, nor is it an effective use of your resources. 

To increase efficiencies and alleviate some of the workload for your staff, you need to automate eligibility verification. Technology can help you with this component of your business. 

4.) Manage denied claims

We all know the backbone of any successful organization is cash. Without cash, it becomes hard to pay staff and keep the lights on. But when you have a solid cash flow, pressure is relieved for everyone. 

How can you keep the cash flowing? You must have a solid denial management process in place. According to the Centers for Medicare & Medicaid Services (CMS), 40 percent of denied claims are written off and not reworked. Yet, many times the denial reasons are vague. With a few modifications, you can resubmit these claims for payment.

Hiring for this skillset, developing workflows and using tools to manage denied claims is essential, because it can impact your revenue significantly. Once you have a plan, you can resubmit claims quickly and receive payment for services.

Plan early to succeed

My biggest piece of advice to healthcare organizations is this: Embrace what’s coming and prepare. Be ready to support new payment models. Don’t wait until your revenue cycle becomes a problem to make a change. By the time it’s identified as a problem, you’re in a hole, making it extremely hard to catch up. 

With an RCM plan in place early, you can experience a smooth transition with reimbursement changes and a steady cash flow.