Top 5 Challenges in Revenue Cycle Management for Specialists 

April 4th, 2022 /
Shani Yellin
/ 5 Min Read

Revenue cycle management (RCM) plays a key role in creating a profitable path in the healthcare industry, no matter the area of practice. RCM defines everything from the ability to collect payments in a timely way to how to utilize the revenue to best serve patients. Clear documentation and efficient communication between patients, providers, and payers drive timely payments and claims reimbursements. 

Unfortunately, specialists often face challenges with RCM because of disruptions in the communication chain. Take a closer look at revenue cycle management healthcare challenges for specialty practitioners. 

Why Revenue Cycle Management Can Be Challenging for Specialists 

One of the major financial challenges in healthcare is adequately managing the revenue cycle to sustain the organization and make a profit at the same time.

Research shows that around 54 percent of CFOs (Chief Financial Officers) of health organizations believe it’s a wise move to outsource certain RCM processes. And, at least 83 percent of hospitals outsource things like accounts collections to better support RCM. 

Specialty care comes with specific nuances, complex financials, and even administrative burdens not typical for standard providers. Certain disciplines like oncology, gastroenterology, and Rheumatology, for example, may need prior authorizations for the bulk of patients they see.

Specialists consistently deal with problems like claims denials due to improper pre-authorization or medical coding errors resulting due to the complexity of equipment used during a patient visit. Likewise, insurance eligibility for specialty levels of care is not always as clear-cut as it should be. Therefore, RCM processes can be a bit more complicated. 

Challenges in Revenue Cycle Management

5 Healthcare Revenue Cycle Management Challenges for Specialists 

1. Appropriate Revenue Capture 

Revenue integrity is highly reliant on capturing the appropriate level of revenue for the care provided. In short, if the correct dollar value is not entered, a physician may not be adequately reimbursed for the services provided. However, specialists can be more vulnerable to inadequate charge entry processes than standard care providers. 

In specialty care, this process is a challenge simply because charge entry processes and fee schedules are not always as straightforward. Conditions treated can be more complex. This can mean more face-time with the patient during an appointment. Further, multiple systems may be used to gather information because many specialists participate in things like bundled payments or value-based care protocols. 

2. Managing Prior Authorizations for Treatment 

Because insurance eligibility is most unpredictable in specialty disciplines of medicine, prior authorizations to care for a patient are critical. Yet, any specialist or specialty care group manager will tell you that dealing with pre-authorization is a time-consuming task. Even worse, if anything is done improperly during submission to a payer, this means inconvenience and delays in care. 

If your practice currently handles prior authorizations manually, it may be time to consider an automated option. Transitioning to automated prior authorization processes can free up a ton of administrative time and save revenue.

According to the CAQH 2019 Index, the cost to manually create prior authorization is around $10.92 per patient, whereas automated prior authorization processes cost just $1.88. 

3. Maintaining Regulatory Compliance 

Regulatory compliance comes as a challenge for all providers, but specialists may have even more to contend with. Specialists spend a lot more time dealing with policies and procedures related to things like referral arrangements and prior authorizations for care 

Of course, missing key regulatory standards can interfere with revenue cycles tremendously. Something as simple as putting a single patient’s health information at risk can generate a host of issues that affect revenue. For example, a HIPAA violation penalty for “unknowing” violations can mean a $100 civic penalty. 

4. Monitoring Drug and Treatment Pricing and Payer Contracts 

It is not uncommon for specialists to deliver care that involves some of the most cutting-edge treatments and pharmaceuticals. Unfortunately, more recent and innovative levels of care can also mean higher price points on the cost spectrum. To make sure your practice is properly reimbursed for certain types of care, it is important to know the current drug and treatment pricing with specific payer contracts. 

Because treatment is consistently evolving in medicine, reimbursement rates are adjusted by payers on an ongoing basis. For example, the Centers for Medicare and Medicaid Services (CMS) updates its drug reimbursement pricing quarterly. 

5. Following Proper Medical Coding Practices 

One of the most complex financial challenges in specialty healthcare is accurate medical coding. Coders must stay up to date with the ever-changing guidelines for specialty areas and how specific treatments should be reflected in medical billing. Revenue leakage is bound to occur if the coders the specialist relies on are not properly monitoring guidelines and changes. 

medical coding

For this reason, it is common for specialists to rely on outsourced medical billing and revenue cycle specialists instead of in-office staff. Specialists spend the bulk of their time familiarizing themselves with things like ICD-10 guidelines and rapidly changing coding requirements. 

Find the Support Your Specialty Practice Needs for RCM 

Not all specialists have a dedicated RCM staff or manager who oversees the revenue cycle functions to optimize cash flow and improve customer relations. In today’s world of modern technology, your practice may only need a combination of an effective EHR workflow, medical billing services, and well-designed revenue cycle management software

PrognoCIS can be your single source for all three. Our RCM solutions streamline finances, so you can focus on taking care of patients. Contact us today to request a demo and see how our solutions revolutionize your specialty practice. 

Here are some helpful resources to look into:

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