5 Healthcare Revenue Cycle Challenges and How to Overcome Them

Healthcare revenue cycle challenges exist at every stage of the healthcare journey, beginning with patient authorization and extending all the way through claims, billing, payment, and collections. Providers lose billions each year due to inefficient processes, the inability to collect on bills and claims, and the complicated, manual process of claims management. What are the top 5 areas in which Robotic Process Automation (RPA) adds value to the revenue cycle?

Prior Authorization

Providers and hospitals must go through a process to obtain “approval” from health plans for medically necessary procedures, treatment, or medications. This process is called prior authorization (PA). 44% of doctors say PA requests “often or always” hold up care, according to the American Medical Association (AMA). This largely manual process can take anywhere from 10-40 minutes per PA, delaying timely patient care. A study by Health Affairs stated that when time is converted to dollars, the national cost for providers, from interactions with health plans, is between $23-$31 billion each year. According to a 2021 CAQH report, providers could save 16+ minutes per authorization with an automated process, which takes a little less than a minute. That’s a savings of up to two working days a week. This is an area of high return. By automating prior authorization transactions, providers and health plans could save $437 million each year.

Claims Status Checks

When a provider contacts a payer to check a claim status, it takes an average of 14 minutes and costs the provider roughly $7.12. By the time a claim reaches a denied status, the provider has lost at least two weeks. Considering that the time between claims submission and payment can be as long as four weeks, delays again become costly. At Northwestern Medicine, automating claims status checks revealed a 330% ROI within the first year, one that will continue to grow into perpetuity. Northwestern was able to offset 25 full-time employees (FTEs) worth of work on an annual basis. That did not mean reducing their workforce by 25 people, that meant they were able to double in size (from 1,500 to 3,000 providers), without adding one additional team member.

Denial Management

Shifting from tedious, manual tasks to an automated process reduces the time spent on each task from minutes to fractions of a second. According to the Centers for Medicare & Medicaid Services (CMS), 20% of all claims are denied, 60% of lost or denied claims will never be resubmitted, and 18% of claims will never be collected. It generally takes 2-3 minutes and costs about $25 to rework each denied claim. RPA allows claims to be worked and resubmitted in a fraction of seconds, eliminating the burden on people. An interesting RPA initiative focused on automating preparation of “Modifier 62 reconsiderations” (surgical payment appeals) for reimbursement. Under certain circumstances, two surgeons (usually with different expertise) may be needed to perform a specific surgical procedure. Both surgeons bill using the same CPT procedure code, and the Modifier code 62. Boston WorkStation allows them to automate a complex combination of document processing steps (more than 20) necessary for reimbursement. The Modifier 62 reconsiderations are aligned and streamlined for submission to payers, minimizing delays and errors. This significantly accelerates payment to the health system for advanced procedures.

Payment Processing

By automating payment processing, productivity is improved and the manual, time-consuming process of posting insurance payments is streamlined, resulting in reduced operating costs and increased time management. By automating the payment processing tasks, activities like invoice capture, coding, and vendor contract approvals proceed without human intervention. Boston WorkStation has been keeping hospitals on track with payment and collections automations since 1985. On a daily basis, Boston WorkStation queries databases, looks for transactions, and then posts them through multiple EHR modules on the proper patient account. By automating multiple touch-points, errors are reduced or eliminated, collections avoided, and payments expedited.

Collections

RPA can also be used to proactively identify payment/default trends and take preventive measures to reduce the manual burden on collection teams. RPA can be used to configure multiple parameters such as invoice age and credit risk to prioritize collections, or to send periodic reminders to delinquent accounts. Boston WorkStation automated many of the “sticky” areas of collections; which would have been written off as bad debt. Instead, the hospital saved 180 hours per month and $20 million in failed claims resubmissions. Using automation in the collections department allows people to concentrate on higher priority tasks, while automation sorts through and sends out invoices. “Boston WorkStation helps us automate time-consuming tasks and is doing about eight staff hours’ worth of work a day. I know we’re saving money because we are getting accounts into an actionable category, instead of keeping them in a
holding pattern.”

Why Boston Software Systems?

Boston Software Systems is the global leader in healthcare-specific RPA solutions. For over 30 years, Boston WorkStation has been creating efficiencies in hundreds of healthcare organizations, technology partner offerings, and provider offices. Boston WorkStation is implemented on-premise, in a hybrid way or in the AWS cloud. Our project teams understand healthcare workflows and exactly how to implement an RPA project for maximum impact and a fast ROI.

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