Integrating Healthcare Denials Management Technology for Flawless RCM

On 21st Feb 2019
technology rcm

The need for revenue cycle management technology has never been greater. As providers seek ways to survive under regulatory pressures like MACRA, daily CMS policy changes, and the switch to value based care, a rugged revenue cycle management system emerges as the best way to protect revenue. Without it, revenue will seep through holes caused by legacy billing processes and old systems. Knowing that technology is needed is Step One; knowing which technology to purchase is just as important.

A recent industry survey showed that practice leaders are in dire need of RCM technology that is sturdy enough to meet multiple needs. Survey respondents listed a number of financial reasons for seeking outside experts to support practice Revenue Cycle Management:  

  • 100% of all practices reported decreasing collections and increased time to collect

  • 96% of practice leaders report inefficient billing processes

  • 95% of practices with less than five physicians self-identify as “not tech savvy”, so investing in new hardware and software was not feasible  

  • 83% of hospital-based physicians report trouble recruiting business office candidates experienced in ICD-10, value-based care, risk contracting and MACRA

  • 77% of physicians believe they need to find more direct patient care time currently taken up by business office-related issues

Each of these highlight one fact; the days of practices adequately handling reimbursement are over. A Black Book Market Research reinforced that in a survey of  1,586 industry leaders. It found that:

  • Nearly two-thirds of providers said they will seek help optimizing their current EHR and Revenue cycle management systems (61%)

  • Nearly half want access to experts for software training and implementation (46%)

These surveys reflect the fact that internal billing offices are struggling to keep up with daily changes in CMS reimbursement policies, 3rd party payer requirements for claims and healthcare denials, and the thousands of complex codes in ICD-10. The right technology can come to the rescue, streamlining workflow, automatically updating 3rd party payer and CMS reimbursement requirements, and capturing healthcare denials and underpayments. It’s the best way for practices large and small to streamline RCM and enhance revenue.


Market growth leads to lots of players

Four years ago, Research and Markets reported that the healthcare RCM software and services industry was projected to grow by 15.51 percent by this year. Total spending on RCM solutions is expected to exceed $7.09 billion by next year. That is a market ripe for numerous technology players; some offering well designed platforms, some not. Conducting due diligence is the only way to find high performing technology that matches your practice’s unique RCM needs.

Before you can select technology, you must first assess the current state of your revenue cycle function. Where are the weakest processes, where is staff overburdened, where is revenue leaking? It can happen at any point in the cycle so review these functions:

  • Pre-authorization and eligibility verification or lack thereof

  • Patient pay collection

  • Billing

  • Claims management

  • Denial and underpayment management

  • Healthcare contract management and modeling

Once you have conducted the initial assessment, secure the technology that best matches the practice’s RCM deficits. Then, carefully vet vendors and the platforms they offer.


Matching technology to RCM needs

Setting expectations and establishing clear communication with prospective vendors is essential to meet the RCM goals of the practice. Ask the following questions:

  • What internal RCM processes with the vendor/technology address?

  • Will it address issues across the RCM cycle from patient pay to contract management?

  • Does the technology include key functions to improve billing and charge capture?

  • Can it oversee the claims process and flag denials and underpayments?

  • Does it offer transparency into performance?

Automating RCM performance is vital, but it needs to work hand-in-glove with the practice and optimize operations in a clearly visible manner.


Avoid putting the cart before the horse

Contract management and modeling is one of the most important functions that RCM technology can handle. To manage other functions from preauthorization to claims management, without also making sure you optimize your healthcare contract management process, is putting the cart before the horse. In order to manage the dollars coming into the practice, you first need to know what you are contractually owed and how to unlock payments. That’s where contract management comes in. The best systems offer:

  • Integrated payer contract modeling and management functions that work with any patient accounting system

  • Cloud based HIPAA compliant platform

  • Set-up and integration with existing systems in as few as 30 days

  • Single and bulk appeal management features to improve workflow

  • High performance contract modeling, updates, and rate tables

The best contract management systems also offer powerful calculators with the bandwidth to pre-calculate expected payer reimbursement and handle complex rate structures. They help practices to know what they should be paid with combined payer contracted rates, contractual language, EDI billing data and remit data not constrained by 835 remits. Look for vendors who can customize calculators to the unique needs of your practice.  

A strong payer contract management and modeling function will also protect revenue by providing the following:

  • Underpayment and denials management: Claims management to identify and overturn underpayments and denials within any HIS system and model any contract.

  • Contract negotiation: Simulate contracts with ease to compare newly proposed contract terms vs. existing contracts for win/lose analysis

  • Contractual net forecasting revenue: Net healthcare revenue forecasting based on your payer contract allowables vs. inaccurate historical or bucket revenue forecasting

In a day and age when practice billing functions can easily be overrun by an onslaught of CMS and 3rd party payor policy changes, it is essential to find the right technology platform. It is the only way to scale the wall of reimbursement obstacles and get every dollar earned, contracted for, and rightfully yours.

Contact Revenue Masters today at  (877) 591-2590 or email us at for more information about a powerful healthcare contract management system & to start recovering 100% collections.