How to Prevent Underpayments and Denials in Healthcare RCM Performance

Executive summary

Denied claims, poor documentation, and inefficient workflows can negatively impact the bottom line. The good news is that there are plenty of ways to streamline your revenue cycle and boost financial performance.  

12 Steps to Optimize Revenue Cycle Management 

The concept of revenue cycle optimization is more than just a buzzword—it's the foundation of financial sustainability. Picture a vast, intricate machine where every gear, lever, and pulley works in perfect harmony. But denied claims, poor documentation, and inefficient workflows can negatively impact the bottom line.

In this article, we’ll look at 12 steps to optimize your revenue cycle along with software tools to facilitate each one.

We’ll explore how your organization can:

1. Prioritize patient-friendly billing through simplified statements, payment plans, and pricing transparency.

2. Increase point-of-service collections via credit card on file and self-service payment options.

3. Train staff on latest regulations, workflows, and best practices.

4. Leverage data analytics and AI to gain insights into revenue cycle patterns and benchmarks.

5. Streamline communication and data sharing between billing, clinical, and coding teams.

6. Prevent claim denials through payer policy analysis, pre-submission audits, and ML algorithms.

7. Refine scheduling with predictive analytics to optimize bookings and minimize no-shows.

8. Conduct pre-service financial clearance to resolve payment issues upfront.

9. Ensure complete documentation with audits, tracking tools, and physician education.

10. Centralize revenue cycle functions under specialized teams and unified platforms.

11. Engage an RCM partner to apply specialized expertise and technology.

12. Continuously assess KPIs and processes to drive ongoing optimization.

1. Prioritize Patient-Friendly Billing to Decrease Underpayments

Complex medical bills often lead to patient confusion, delayed payments, and a frustrating experience for consumers. Simplifying your billing procedures and statements goes a long way in improving satisfaction.

• Use clear formatting and plain language patients can easily grasp. Avoid technical jargon.

• Make statements easy to digest by grouping related charges.

• Explain each charge line-by-line and provide context on services rendered.

• Offer self-service payment plans through patient portals.

• Improve overall billing transparency with price estimates.

• Send text/email reminders when balances are due.

While these aren’t massive changes, they can make a huge difference in mitigating or even recovering underpayments.

2. Boost Point-of-Service Collections

Collecting payment at the time-of-service increases cash flow while reducing billing expenses.

• Offer credit card on file programs that allow recurring payments.

• Make it easy for patients to pay copays or balances through self-service kiosks.

• Send email/text reminders prior to appointments asking patients to bring payment.

Learn more about transforming your lab billing with healthcare data management.

3. Regularly Train Staff on Revenue Cycle Management

Conduct regular training to ensure staff have the expertise needed to optimize the revenue cycle and mitigate the risks of revenue leakage, underpayments, and underperformance. Training should cover:

• Latest coding guidelines and regulatory changes

• New payer policies and contract provisions

• Denial root cause analysis and prevention

• Patient access and communication best practices

• Workflow optimizations to improve efficiency

Keep in mind that role-specific education is key. For example, train registration staff on obtaining accurate patient insurance information to prevent downstream issues like denied claims. Consider more robust education such as a clinical validation practice brief for RCM professionals.

4. Leverage Your Revenue Data

Leverage your data through analytics to gain visibility into your revenue cycle metrics. Robust revenue cycle management analytics platforms can digest huge volumes of data to uncover actionable insights using AI and advanced algorithms. Key features to look for include:

• AI algorithms to detect patterns and surface insights

• Machine learning models predicting trends and future performance

• Ability to segment data by attributes to isolate issues

• Automated reporting through AI/ML-generated revenue cycle kpi dashboards

• Tools to set benchmarks and track against targets

• Predictive analytics and machine learning algorithms to detect patterns

Segment data to uncover performance gaps and opportunities. Set targets for improvement.

Learn how your healthcare data analytics strategy is failing.

5. Streamline Communication

Smooth workflows between billing, clinical and coding teams are vital for efficient revenue cycle automation. Tactics include:

• Integrate core systems like EHR, billing, and coding software

• Standardize protocols for information exchange between departments

• Digitize records to enable seamless data sharing

• Automate claim status updates into patient accounts

• Schedule cross-departmental meetings to discuss issues

With added efficiencies between teams, you minimize your chance of revenue leakage across your healthcare organization. 

6. Prevent Claim Denials

Move beyond tracking to actually preventing denials before they occur. AI-powered denial prevention software checks claims against payer rules to avoid rejections. Features like automated appeals and revenue cycle predictive analytics help manage denials end-to-end.

• Identifying common denial reasons and clinical documentation gaps

• Implementing payer-specific pre-submission claim audits

• Adding automation checks for errors like duplicate claims

• Creating EDI validation rules aligned with payer requirements

• ML algorithms flag claim errors and compliance issues

• Payer policy libraries updated via AI data extraction

• AI-generated tracking logs analyze denial root causes

• Predictive models appeal improper denials for maximum ROI

This is all related to leveraging your data through the use of analytics.

7. Refine Scheduling

Advanced scheduling systems use machine learning to optimize bookings, boost productivity and minimize no-shows by optimizing patient scheduling. Capabilities include:

• Predictive models estimating patient demand

• Automated slot suggestions based on historical data

• Tools to overbook strategically while minimizing risk

• Real-time schedule optimization as openings occur

8. Avoid Underpayments through Pre-Service Financial Clearance

Resolve payment issues proactively by verifying insurance coverage, securing authorization, and collecting payments upfront. Key steps:

• Validating eligibility and benefits prior to visit

• Estimating out-of-pocket costs for patient

• Obtaining pre-approvals before encounter

• Collecting prepayments before services rendered

9. Ensure Complete Documentation

Incomplete physician documentation leads to delayed or denied claims. Improve documentation through:

• EHR documentation tools and templates

• Education on payer requirements

• Regular documentation audits and real-time feedback

• Automated systems to track outstanding charts

• Linking documentation to reimbursement

10. Centralize Key Functions

End-to-end revenue cycle management dashboards centralize core RCM functions to improve efficiency through specialization. This includes:

• Unified systems for scheduling, billing, collections etc.

• Building dedicated teams for pre-registration, authorization management, etc.

• Cross-training staff across different departments

• Revenue Cycle Dashboards keeping all stakeholders aligned by leveraging your data

11. Engage a Revenue Consultant

Healthcare revenue cycle management analytics partners, like Gistia, can help apply their specialized software, analytics, and expertise to execute backend functions:

• Denial monitoring and appeals management software

• Automated workflows for complex billing tasks

• Performance revenue cycle dashboards benchmarking against peers

• Flexible custom solutions not possible in-house

12. Regularly Assess and Improve Your Revenue Cycle Management

Ongoing assessments and analysis are vital to keeping your revenue cycle optimized over time. This involves:

• Regularly reviewing your revenue cycle management metrics and benchmarking performance through data

• Performing periodic audits to identify new issues

• Updating policies/procedures as regulations change

• Monitoring innovations and best practices

• Setting measurable improvement goals across the revenue cycle based on your data

Recover Underpayments to Further Optimize Your Revenue Cycle Management 

Recover Underpayments to Further Optimize Your Revenue Cycle ManagementFollowing these 12 practical steps can significantly boost your financial performance, reduce operating costs, and improve the patient experience.

Optimizing your healthcare revenue cycle takes work but pays major dividends. But knowing what to optimize and how isn’t always so straightforward. Gistia can work with your healthcare organization or medical lab to not only streamline and optimize your revenue cycle management, but also help your revenue cycle teams uncover more underpayments, denied claims, and billing inefficiencies. 

Through our Revenue Recovery Solution, Gistia uses data-driven insights to help your organization:

• Identify and recover underpayments

• Enhance compliance and accuracy

• Find incorrectly denied claims

Want to learn more about how we can help you recover lost revenue and optimize your operations? Contact Gistia to get started.