How a Clinically Integrated Revenue Cycle Addresses Denials Management Challenges
For many years, healthcare organizations operated exclusively under fee-for-service reimbursement models. The more services provided, the more healthcare providers were paid. But the model was allowing costs to spiral out of control and quality to suffer. Value-based healthcare is now poised to address this cost/quality challenge by reimbursing provider organizations based on the quality of care delivered and the clinical outcomes achieved.
Taking on more risk under value-based arrangements, of course, brings a bevy of challenges. Among the most pressing: Healthcare provider organizations need to make significant changes to their revenue cycle operations to meet the requirements of a value-based world. And denials management and prevention is one of the main reasons that the clinical and financial side of the organization must collaborate and partner closer than ever before. This merging of the clinical and financial pathways in healthcare is bringing about a revenue cycle revolution, and at the heart of that revolution is the Clinically Integrated Revenue Cycle (CIRC).
Defining the Clinically Integrated Revenue Cycle
The Clinically Integrated Revenue Cycle captures a holistic view of the patient experience, which is required to support value-based care models. Clinical and financial resources, processes and technology are no longer siloed but instead are integrated. Under such models, when a patient begins their healthcare journey, clinical and financial pathways alike are opened up, and their relationship is far more interwoven. Clinical and financial professionals do not move along two separate pathways but instead, traverse along a merged “clinancial” pathway. As a result, under these integrated models, the formerly separate health information management (HIM) and revenue cycle management (RCM) departments come together and work in unison.
HIM professionals have the knowledge and skillsets, as well as an understanding of the connectors that are required to support a CIRC. For this reason, they are well-positioned to serve as change agents to move organizations from the “traditional” to the “clinancial” pathway. Why? Because HIM professionals have always operated in the “middle” between clinical and financial and are experts in the requirements, rules, and regulations for complete and accurate billing. Additionally, HIM professionals understand the importance of capturing the True Clinical Picture in today’s value-based environment.
Addressing Denials Through Integration
Denial management and prevention in the value-based world is one area that clearly illustrates the need for a CIRC. Denials are fiscally painful, which is why processing denials quickly is so critical for healthcare organizations. However, doing so is a complicated endeavor under traditional revenue cycle models.
With a CIRC-driven denials process, RCM staff can request records from HIM systematically, without gaining entry to the complete electronic health record system. When the request is connected to both the primary RCM workflow tool and HIM’s release of information process and system, requests for records tied to a denial can be prioritized above other records requests that don’t have the financial repercussion a denial does.
A Call to Action for HIM Professionals
The Clinically Integrated Revenue Cycle is not a single person, process or technology. It is a cumulation of many different people, processes, and technologies that bring varying skill sets to the table to ingest information and make informed decisions based on data. Who better than HIM professionals to lead the charge towards the CIRC? HIM professionals are uniquely qualified to understand and utilize data, advocate for complete documentation, drive a shift from denials management to denials prevention, and to guide the integration of clinical and financial processes.
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