Top vulnerabilities in revenue cycle management

Approximately two-thirds of U.S.-based hospitals and acute-care facility leaders believe diagnosis-related group (DRG) optimization is still a problem that needs to be solved in revenue cycle management, according to a recent survey conducted by BESLER and HIMSS Media.

The study was designed to identify key revenue cycle challenges and areas of vulnerability at U.S.-based hospitals and acute care facilities. The researchers queried 102 respondents who are employed in leadership roles within finance, revenue cycle, reimbursement and health information management. The DRG payment system is how Medicare groups and categorizes hospital costs and payments.

“The opportunity is there for hospitals to bring in the correct amount they are entitled to, and that can often be more than what the hospital has billed for,” Laura Legg, director of revenue integrity solutions, BESLER, said in a corresponding white paper. “Program staff need to look at all the functions and processes across the entire revenue cycle to ensure compliance and ensure processes are performed correctly so the end result is a clean claim.” 

The researchers found 72 percent of healthcare-based financial leaders believe revenue cycle solutions are optimized for inpatient coding and audits. About 68 percent of respondents feel DRG optimization is not a solved problem.

Other notable findings include:

  • The three biggest revenue cycle challenges: payer denials (49 percent), reimbursement (47 percent) and prior authorization (38 percent). 
  • The top three barriers to better revenue integrity are: department and data source silos (51 percent), finding qualified staff (47 percent) and integrating multiple revenue cycle tools/solutions (44 percent).
  • Clinical documentation and coding is the chief area of vulnerability for lost or decreased revenue––84 percent of respondents believe this is a high or medium risk.
  • Of note, the everchanging ICD-10 coding system is a challenge for hospital staff.

The surveyors noted limited budgets (49 percent), proving ROI (48 percent) and competing projects and priorities (45 percent) stand in the way of healthcare facilities adopting new solutions.  

The surveyors also gleaned on opportunities for hospitals and acute-care facilities to boost their revenue cycles. One such opportunity is a revenue integrity program, which has been established by 47 percent of respondents. Additionally, the survey respondents noted a positive impact of net collections, gross revenue capture and reduced compliance risk.

Legg also noted that leadership should look at claims to ensure accuracy before submitting them to insurance carriers will ensure that denials are decreased or eliminated.  

“The bottom line is this: With the right processes and third-party partner support, hospitals can help stop revenue loss and collect more of the money they deserve for the care they provide,” the white paper concluded.