Medical billing is the cornerstone of successful revenue cycle management (RCM). A practice's billing process is directly related to whether it receives quick and adequate reimbursements for services. An effective revenue cycle management strategy can reduce the number of insurance claim denials, speed reimbursements, and discover instances of lost revenue. 

The health care industry is transforming due to efforts like price transparency, patient centricity, and value-based care. These changes, along with new accountability measures for nonprofits, have been driving rapid adoption of health care RCM and billing technology. In this article, we’ll go over the top trends driving changes to existing revenue cycle management medical billing processes and discuss the technology you’ll need to streamline workflows and increase your bottom line.

Trends Driving RCM and Medical Billing 

Health care has changed dramatically since the pandemic began. However, looking back over the last decade, we can see signs of the changes to come in revenue cycle management medical billing processes. These four areas represent areas where there has been significant paradigm shifts in health care billing and revenue cycle management.

1. Health Care Consumerism

In the past, insurance companies and government payers negotiated lower prices for their subscribers. Today, due to the popularity of high-deductible health plans and price transparency laws, patients are increasingly becoming savvy health care consumers — shopping for better prices, a patient-friendly experience, and for perks like the features provided by an electronic health record (EHR) system with a patient portal. 

Patients expect access to a private patient portal where they can conduct contactless check-in, self-schedule their own appointments, access their medical records, request prescription refills, check the status of insurance claims, and make payments.

2. Models of Care

We’ve all heard adages like “The doctor knows best” and “An apple a day keeps the doctor away.” Both examples reveal the underlying provider centricity in medicine. For too long, the health care experience has been designed by and for the health care provider. Indeed, the doctor may usually know best, but we’re finally considering the patient’s experience and asking, “What does the patient want and need?”

Whatever you call it — collaborative care, shared decision-making, patient centricity, patient engagement, the patient experience, or personalized health care — the new models of health care all place the patient first.

3. Value-Based Payments

Patients who receive patient-centered care have better outcomes, utilize health care facilities less often, and incur lower health care costs as a result. Payers and patients both benefit from this arrangement. Therefore, it’s not surprising that government payers like Medicaid and Medicare, as well as public and private health insurance companies, have developed ways to encourage this paradigm shift.

Payment incentives that encourage high-quality, value-based care facilitate a shift away from fee-for-service care — which rewards higher utilization. As part of a value-based approach, specific metrics are monitored, such as readmissions, the use of preventive medicine, and the meaningful use of certified health technology, including interoperable and comprehensive EHRs that include medical billing. 

Other technologies that streamline workflows and support value-based care include clinical documentation, decision support, advanced reporting, automated charge capture, claims submissions, and claims denial management. 

4. Revenue Increases in the Nonprofit Sector

Just as for-profit organizations must optimize their revenue cycle management efforts to remain profitable, nonprofit organizations have to keep track of multiple sources of revenue. As behavioral health demand outpaces the supply of health care providers, and government oversight of nonprofit health organizations is increasing, technology is becoming more important to support RCM.

The value of the tax exemption alone, according to one recent study, covered much of the charitable care and community expenses of nonprofit hospitals between 2011 and 2018. However, that doesn’t mean nonprofits can’t bill for their services. Third-party payers and nonprofit behavioral health organizations may still work together. Major and minor insurance carriers regularly contract with nonprofit clinical agencies. 

Important KPI Metrics for Nonprofit Organizations

Nonprofit behavioral health organizations may (and often do) charge uninsured or disadvantaged patients an amount based on a sliding scale according to their income. However, some of their revenue comes from alternative funding sources such as government grants and reimbursements for providing public health services.

You may be surprised to learn that nonprofit organizations often have higher revenues than similar for-profit companies. As long as your business model is not aiming to make a profit but instead strives to serve your community, you can bill insurance companies or receive reimbursement from other funding sources like grants and donations. The accounting can get a little tricky. As such, it’s crucial to have a robust RCM solution to keep track of who was billed, when, and for what services.

Because of the increased revenue of many nonprofits, the government is looking into ways to make sure these organizations are not receiving an unfair advantage, and that their “community benefit” equals the financial benefit of tax exemption. This additional oversight will likely increase the need for better reporting. Your RCM software should help you keep track of the following metrics:

• Fundraising efficiency ratio: Fundraising costs divided by the total contributions
• Operating reliance ratio: Unrestricted program revenue divided by the total expenditure
• Program efficiency ratio: Program expenses divided by the total expenses
• Donor attrition ratio: Lapsed donors divided by the total of active donors
• Social return on investment ratio: Social impact value divided by the initial investment

Benchmarking is another important tool to look for in RCM software. By comparing your organization's financial sustainability to similar organizations, you’ll discover opportunities to improve and streamline your revenue cycle medical billing processes. 

Benefits of a Unified EHR System for Revenue Cycle Management Medical Billing 

EHRs are becoming more common. As of 2021, 88% of office-based physicians report using an EHR system, while behavioral health professionals have been slower to adopt this technology.

For managing patient care, EHRs can be invaluable: They simplify communication, organize records, improve efficiency, and improve the patient experience. However, clinicians should also consider how EHRs work with revenue cycle management.

To run a successful practice, your EHR and RCM must be integrated seamlessly, since health care RCM intersects with many aspects of patient care. By streamlining these systems, your team will be able to provide better patient care and increase your revenue opportunities. 

For example, in a survey conducted by the Medical Group Management Association, 88% of respondents said they used automated appointment reminders. This is essential because missed appointments impact the revenue cycle directly — and are also associated with poorer health outcomes for the patient. 

According to a 2019 study, the health care industry wastes $265 billion annually in administrative expenses. A successful EHR and RCM integration can improve your billing and revenue cycle efficiency in the following ways: 

• Keep track of insurance eligibility verification and prior authorizations
• Keep accurate patient records and appointment data
• Automate accounts receivable: invoicing, remittance, payment posting
• Automate the claim submission process
• Automate a claim’s denial process with editing and resubmission
• Facilitate online patient payments 
• Streamline the billing process 
• Visualize claim status, denials, and rejections in a clear way
• Illuminate the billing process for patients, payers, and regulators
• Develop a better payer-provider relationship with enhanced communication

When weighing the costs versus the benefits of purchasing a new system, it helps to know how to measure your return on investment (ROI). Here are a few of the most tangible benefits to consider:

• An increase in profitability
• A shortened revenue cycle
• A reduction in no-shows
• Improved compliance
• Increased cash flow
• Capturing more billable charges
• Fewer coder errors
• Improved staff efficiency
• Improved access to care 
• More time with each patient

Another factor to consider is whether the RCM software will work with other practice management and patient engagement solutions. ContinuumCloud offers a comprehensive EHR solution with fully integrated revenue cycle management, medical billing, and a patient portal. Our unified EHR software pairs with our human capital management system (HCM) and works well with the CaredFor app, our patient engagement platform. And there are numerous third-party add-ons that work with ContinuumCloud.

Choose Integrated Revenue Cycle Management Medical Billing

The health care industry is in the process of transformation with price transparency, patient centricity, and value-based care. Additionally, new accountability measures for nonprofits are driving the rapid adoption of new health care RCM and billing technology. There have been major changes in health care since the start of the pandemic, which have prompted paradigm shifts in revenue cycle management and medical billing. Patients nowadays are increasingly becoming savvy health care consumers, comparing prices and seeking a user-friendly experience. 

ContinuumCloud’s revenue cycle management medical billing software is fully integrated into our comprehensive EHR solution. The patient portal offers features, like contactless online payments, that improve the patient experience. These features also make it easier for your office to keep patients’ insurance information up to date and to collect copays and coinsurance upfront. Tools like e-prescribing, clinical decision support, and clinical documentation help keep patients safe from human errors — a key component of patient-centered, value-based care. 

Our EHR with revenue cycle management medical billing software simplifies workflows too. Real-time insurance eligibility verification and automated accounts receivable functions like payment posting, claims processing, and claims denial management shorten the revenue cycle and protect your bottom line. Advanced reporting capabilities are key to evaluating your RCM process end-to-end and are critical to receiving funding and meeting regulatory guidelines. Get in touch to learn how our behavioral health care revenue cycle management solution can help you.