Specialized Revenue Cycle Management: A Must for Specialty Care

 Erika Regulsky RCM
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Why do Specialty Care Practices Need Specialized Revenue Cycle Management?

In the continually evolving realm of healthcare, the imperative of refining Revenue Cycle Management (RCM) cannot be overstated. For healthcare leaders, keeping pace with operational and clinical efficiency while bolstering cost savings hinges on an adept approach to RCM. However, specialty care practices encounter an additional layer of complexity. The intricacies inherent to specialty care necessitate an RCM strategy as intricate as the care itself to ensure practice optimization.

The Significance of Coding & Billing Updates

One of the pivotal domains that can substantially enhance overall efficiencies within specialty care practices is the continual pursuit of up-to-date coding and billing practices. An alarming statistic from the American Association of Professional Coders (AAPC) underscores this importance: a staggering 80% of improper payments in healthcare stem from inaccuracies in coding. To bolster revenue generation, it is paramount for specialty practices to exhibit unwavering attention to coding guidelines and documentation practices.

Sustained Investment in Staff Education and Training

Specialty care practices should place a premium on ongoing education and training for their coding and billing personnel. Ensuring that coders and billing professionals remain well-versed in the latest coding guidelines is not merely beneficial but crucial for ensuring accurate reimbursement.

Harnessing Reliable Sources

Specialized care practices can glean significant advantages by tapping into credible sources for coding guidance. Esteemed organizations such as the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and specialty-focused professional associations furnish invaluable insights into the ever-evolving landscape of coding and billing requirements.

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Integration of Coding Software and Tools

Leveraging coding software and tools that provide real-time updates and compliance validation practices can serve as a linchpin for accurate coding and billing procedures. These sophisticated tools can effectively identify potential errors prior to claims submission, substantially mitigating the risk of claim denials.

Exploring External Audit Solutions

Specialized practices would do well to explore the option of external audits and enlist consultants to bolster compliance and unearth avenues for revenue optimization. External audits furnish an objective evaluation of coding and billing processes, empowering practices to identify areas ripe for improvement.

Fostering Collaboration Among Clinicians, Coders, and Billing Teams

Effective collaboration among clinicians, coders, and billing teams constitutes a linchpin for jointly addressing the complexities and prerequisites of coding and documentation. Facilitating clear communication ensures that clinical documentation faithfully mirrors the care delivered, thereby buttressing proper coding and billing practices.

Value-based Reimbursement Models in the Realm of Specialty Care

The seismic shift towards value-based care in specialty medicine has ushered in novel reimbursement models laser-focused on quality metrics intertwined with patient outcomes. As of 2021, nearly 60% of healthcare payments had some degree of linkage to quality and value metrics. Tied to these risk-based contracts is an overarching metamorphosis of RCM. Providers find themselves confronted with pivotal considerations in navigating this transformative journey.

Emphasis on Preventative Care

Value-based reimbursement models place preventative care at the vanguard, compelling specialty practices to proactively address patients’ health with a view to averting costly complications. Effectuating this paradigm shift mandates substantial investments in prevention-centric strategies.

Effective Risk Mitigation

Risk mitigation assumes a central role within the ambit of value-based care. Specialty practices must diligently pinpoint and mitigate risks that could imperil both patient outcomes and revenue. This entails the identification of high-risk patients and the implementation of targeted interventions to enhance their health prospects.

Rigorous Quality Measurement and Reporting

Specialty practices are duty-bound to perpetually measure and report on the quality of care dispensed. This encompassing endeavor involves the systematic tracking of patient outcomes, adherence to clinical protocols, and gauging patient satisfaction levels. The integrity of these reports is sine qua non for securing reimbursement under the aegis of value-based contracts.

Elevated Emphasis on Patient Engagement

The linchpin for success in the realm of value-based care lies in fostering active patient engagement. Specialty practices must chart strategies aimed at engrossing patients in the decision-making process, amplifying adherence to prescribed treatment regimens, and elevating the overall patient experience.

Alignment of RCM Processes with the Tenets of Value-Based Contracts

As the healthcare terrain continues its ceaseless evolution, the reorientation of RCM processes is imperative. This calls for the judicious integration of emerging technologies, the fortification of data analytics capabilities, and the seamless harmonization of RCM processes with the overarching objectives of value-based contracts.

Streamlining Prior Authorizations within Specialty Care RCM

The Journal of the American Medical Association (JAMA) casts a glaring spotlight on the issue of prior authorizations, revealing that certain types of oncologists (97%), cardiologists (93%), and radiologists (91%) face the highest rates of specialty services that mandate prior authorizations. Within the realm of specialty care RCM, a pivotal facet lies in the optimization of authorizations, entailing a judicious strategy for streamlining and automating the prior authorization process for specialized treatments.

Harnessing Advanced Technology and Automation

Specialty practices can derive substantial benefits from the integration of advanced technology and automation into the prior authorization process. This encompasses the adoption of electronic prior authorization systems designed to streamline the submission and approval process, thereby alleviating administrative burdens and expediting patient care.

Promoting Data Standardization and Meticulous Documentation

The bedrock of successful prior authorizations rests on data standardization and assiduous documentation. Specialty practices ought to institute a framework characterized by the consistent standardization of data and the meticulous upkeep of documentation. This ensures that all requisite information is readily accessible for authorization requests.

Cultivating a Streamlined Workflow Coupled with Comprehensive Training Initiatives

As the healthcare tapestry continues its relentless evolution, the vanguard position in Revenue Cycle Management becomes indispensable for specialty care practices, affording them the means to thrive and perpetuate the delivery of exemplary care to their valued patients.

Pioneering a streamlined workflow for prior authorizations assumes pivotal importance in enhancing efficiency. In concert with this, the provision of comprehensive training initiatives for staff involved in the authorization process ensures that they are suitably equipped to navigate the labyrinthine intricacies of specialty care authorizations.

The bedrock of specialized Revenue Cycle Management is not a mere luxury but an exigent strategic imperative for specialty care in the contemporary healthcare landscape. It stands as a bulwark against the complexities inherent to specialty care practices. By assiduously addressing critical domains, ranging from coding and billing updates to the adaptation to value-based reimbursement models and the streamlining of prior authorizations, specialty practices can orchestrate the optimization of their revenue cycles and furnish superlative care to their patients.

Promoting Data Standardization and Meticulous Documentation

The bedrock of successful prior authorizations rests on data standardization and assiduous documentation. Specialty practices ought to institute a framework characterized by the consistent standardization of data and the meticulous upkeep of documentation. This ensures that all requisite information is readily accessible for authorization requests.

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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