12 Ways Purpose-Built RCM Solutions Boost Revenue

A key component of ancillary and outpatient services, diagnostics play a crucial role in the healthcare ecosystem and overall population health. Outpatient labs, and pathology and radiology practices often face financial constraints because of the limitations imposed by the hospital’s EHR and enterprise RCM systems. These systems, designed for more complex, lower-volume clinical work, don’t always support the operational efficiency and financial performance needed for outpatient diagnostics. And as more care transitions to these outpatient venues, it’s especially important to optimize their financial performance in a scalable, sustainable way.

In this post, we will outline how a purpose-built RCM solution more than pays for itself by enhancing health system economics and improving enterprise system ROI.

1. Optimized for Unique Claims
   Outpatient and ancillary services like laboratory, radiology, and pathology generate a large volume of smaller-dollar claims. EHRs and RCM systems, designed for higher-dollar acute events, often overlook these claims. A purpose-built RCM solution, however, is tailored to handle these high-volume, low-dollar claims efficiently, ensuring that they are not automatically written off due to hospital system thresholds.
2. Reduced Unbillable Charges and Write-Offs
   A significant portion of claims can be unbillable due to missing or invalid information from ordering providers. Purpose-built RCM systems automate the capture and correction of this information, drastically reducing the percentage of unbillable charges and minimizing write-offs, thus ensuring more claims are billed and reimbursed.
3. Lower Denial Rates
   Payor policies and regulations change frequently, which can lead to high denial rates if not managed properly. A purpose-built RCM solution incorporates lab- and diagnostic-specific claim edits and coding rules, continuously updates to comply with new policies, and reduces the likelihood of claim denials by ensuring that claims meet payor requirements prior to their submission.
4. Enhanced Data Access and Analytics
   Accurate and detailed analytics are crucial for managing, forecasting, and optimizing financial performance. Purpose-built RCM solutions provide detailed reporting and key performance indicators (KPIs) specific to outpatient and outreach laboratory, radiology, and pathology. This includes insights down to the procedure-code level, which helps in monitoring trends, identifying areas for improvement, and making informed business decisions.
5. Improved Profitability and Resource Utilization
   By automating manual processes and workflows, ensuring compliance with payor-specific edits, and reducing denial rates, purpose-built RCM solutions enable better utilization of staff resources and higher profitability. These systems help in reducing the administrative burden on staff, allowing them to focus on more value-added activities, such as patient service and education.
6. Enhanced Data Quality through Bi-Directional Data Exchange
   Accurate and timely data exchange is critical for effective claim processing. Purpose-built RCM solutions facilitate real-time, bi-directional data exchanges, improving the quality and accuracy of the data that informs billing and reporting. This reduces errors, accelerates the billing process, and enhances overall data integrity.
7. Adaptability and Future Billing Options
   Outpatient and ancillary services often need flexibility in billing processes, such as switching between client-billed and third-party billed services. Ideally, a purpose-built RCM solution will offer seamless transitions between different billing modes and provide the flexibility to outsource billing processes as needed, ensuring that the billing system can adapt to changing needs.
8. AI and Business Intelligence Integration
   Advanced technologies like artificial intelligence (AI) and business intelligence (BI) are integrated into purpose-built RCM solutions to optimize processes and decision-making. AI-enabled workflow automation, claim exception processing, and detailed payor insights help uncover profitability, reimbursement, and efficiency opportunities. BI tools provide macro and granular insights essential for operational and financial success.
9. Complement Enterprise Systems
   While hospital enterprise systems like the EHR are optimized for acute clinical encounters, they may not fully support the unique needs of ancillary and outpatient services. Purpose-built RCM solutions complement these systems by providing specialized functionalities that ensure operations remain profitable and efficient without compromising the benefits of other hospital systems.
10. Flexible Deployment Options
    Different hospitals and health systems organizations have varying needs when it comes to managing their revenue cycle. Purpose-built RCM solutions offer flexible deployment options, from fully in-house to outsourced or hybrid models. Because these solution providers live in this world, they can also provide expertise in managing denials, appeals, and regulatory compliance, partnering strategically to identify opportunities for improvement and growth.
11. Regulatory Compliance
    Compliance with the unique regulatory needs inherent delivering these patient services should be a given; they also don’t have to be painful. Solutions purpose-built RCM for these departments handle complex compliance requirements, such as the 72-hour and 14-day rules and help automate regulatory adherence.
12. Bonus: Specialized Client-Service Tools
    Hospitals with an outreach business have client-service needs uniquely related to dealing with both patients and referring physicians. Specialized tools such as flexible fee schedules, online support functionality, efficient billing options, and client portals help enhance client satisfaction by providing seamless service, accurate billing, and easy access to information.

By turning to an RCM solution purpose-built for the outpatient and ancillary services revenue cycle, hospitals and health systems can optimize their financial performance. In fact, XiFin hospital clients see a 10-30% increase in cash collections—all without compromising the performance and operation of their EHR.

As your hospital or health system navigates the evolving patient care landscape, start by ensuring you’re capturing the revenue for the services delivered through outpatient venues. Because over time, the volume of those encounters is only going to increase.

As the healthcare ecosystem becomes increasingly distributed, legacy organizational cost structures and centralized RCM impede hospitals’ and health systems’ ability to keep pace—and deliver optimal care through outpatient settings. Join us for a webinar panel discussion, “Sustainability at Risk: Reexamining Hospital Cost Structures to Empower Innovation and Outcomes,” hosted through Becker’s Hospital Review, August 28, 2024 at 9:00 AM PT / 12:00 PM CT, where we discuss new strategies to manage those cost structures.