Key to an Effective RCM: Collaborate with Payers

Healthcare today is being driven by an increased focus on quality. Unfortunately, quality is not the overall stress factor within this industry. Declining reimbursement, rising costs and competitive markets create pressure that often put hospitals and physicians at odds. The patients experience is a component that the healthcare industry continues to stay focused on. Historically the patient experience was viewed as the clinical care, however this as expanded to include all facets of the overall experience. The pressures, however, can be an opportunity for hospitals and physicians to come together. Excellence within the patient experience requires change. Executives must strive for best practice quality environments and include physicians in hospital initiatives. A key to increasing the billing experience for the patients is maximizing the provider’s relationships with the payers. When a provider maximizes their Payer relationships it can simplify the patient billing and increase collections for any provider. For Nebraska Medicine the payer relationships have always been strong. It is important to utilize Key Performance Indicators (KPIs) to motivate change, such as reducing claim denials, aging and customer service calls. The KPI’s for an individual payer should be shared with the payer on a monthly basis. When the KPI’s continue to be shared on a monthly basis, your provider representatives will become active in assisting with the positive changes. Staff members should also be included in understanding what payer initiatives are taking place to impact change. For example: if a payer starts mistakenly denying claims, it is important that staff understand what is being done to remedy the situation. The open communication with staff assists them in being able to identify any other issues that may be occurring as well.The communication to your Customer Service staff is also crucial to assist them when a patient calls in with questions. Staff members are able to answer the patient’s questions in an accurate and timely manner.

As we all know not all medical claims go out the door and pay themselves, there is manual intervention that has to occur. Creating relationships with your payers will drive your reimbursement. The open dialogue with your payers continues to go both ways. It is an expectation for both sides to quickly identify issues and communicate to one another. The quick responses from both sides continue to increase the overall patient experience. One of the biggest hurdles to overcome when building a positive relationship with a payer is to understand that you will not always see eye to eye on issues however the relationship allows you the ability to constructively work through issues together. Focus on the highest return. Your staff should be working on those initiatives that deliver the most value. For everyone in this room, that means working the big reimbursement opportunities. Items which offer lower reimbursement, such as managing smaller, individual payment plans, should be low on your staff priority list. Find a partner who can support your team on those initiatives and bring increased value to your organization. Communication is essential, not just to staff, but with payers and patients. Set clear expectations, train and educate on processes, proactively identify areas of concern, and always look for ways to improve processes. Empower team members to have positive conversations and build strong, meaningful relationships with both payers and patients. Celebrate wins regularly, something Nebraska Medicine is doing very well. Our continued efforts in building relationships pay off in everyone’s favor.