Comprehensive Guide to Clinical Revenue Cycle Management

Converting patient treatment into complete and accurate payments from a payor is a difficult one involving several hospital departments.  Hospitals lose money, meanwhile, when these divisions work separately without a comprehensive payor strategy. Recent years have seen a significant influence on the healthcare business. Resources are at a premium, and labor expenses are rising as operations and patient loads recover to pre-pandemic levels. Organizations must discover methods to do more with less to address this issue head-on, and the only way to do this is to plan well regarding time and employee resources.

Utilization reviews traditionally require going through each instance by hand. Not only is this a resource-intensive task, but it is also ineffective and puts income and compliance at risk.  Due to staffing limitations, the traditional method of adding more personnel to this activity is impractical. Additionally, based on data and experience, we are aware that it does not produce the anticipated financial results. 

A case selection feedback loop is a critical component of a strategic utilization review strategy since it enables prioritizing the most significant possibilities.  We propose a three-step approach to simplify the procedure. To start with, determine which instances need to be reviewed using a set of criteria based on data. The bar has to consider the underlying reasons for poorer-than-expected financial results.  Second, give high-risk situations priority and carry out focused reviews. 

Finally, rather than examining actual and interpreted denial rates, assess the measures correctly, indicating payor denial rates.  Separating out instances that self-denied through compulsory observation status will aid in evaluating the efficacy of case reviews.  Creating platforms for input and widely disseminating the findings fosters a collaborative environment that can help identify new opportunities.

Collaboration across departments is necessary for developing a strategic model, as is the willingness to evaluate and alter old workflows and practices.  Data-driven collaboration raises both departments to greater heights than the sum of their contributions, assisting the hospital in achieving its more giant common objective of lawfully recouping every penny that it is due.

Along the path of a patient's treatment in a hospital, the UM and CDI departments are both crucial elements.  However, historically, these two departments had different objectives, used different KPIs to gauge success, and used various strategies to achieve those objectives.  It is essential to see UM and CDI as components of a larger continuum rather than as alternatives to one another.  Your hospital can be in a much better position to fend off payer non-payment and denial attempts if the goals and operation of UM and CDI are coordinated in a strategic, data-driven, quantifiable, sustainable, and aligned with the organization's compliance and revenue goals.