Although the RCM companies prove to be beneficial to healthcare institutes, there are basically 3 KPIs that are the most influential. The primary reason for any healthcare institute to hire RCM companies is for maintaining a smooth revenue flow.
The RCM companies in USA fulfill these three KPIs without much trouble. It is therefore these indicators are not brought in for discussion. It is much like an unsaid rule that RCM companies have to fulfill.
Virtual Healthcare has the experience to handle the complete RCM process with little hassles. The basic KPIs are completely taken care of by the company. The company ensures smooth revenue flow as well as proper maintenance of trends.
KPI 1: DENIAL MANAGEMENT
The primary motive of any healthcare institute is to keep the revenue flowing smoothly. This is possible through the timely settlement of dues. The biggest issue in settlements arises due to denials.
The denial codes generally start with C, like the –
CO11 – Diagnosis not consistent with the procedure,
CO 22 – Coordination of benefits
CO 167 – Diagnosis not covered
The RCM company not only focuses on avoiding denials but also tries to rectify any denials. This is possible by proper following up, identifying the errors, and re-submission of the claim.
The Company analyses each denial to understand the real reason behind rejection. Identifying the root cause helps in permanently rectifying the issue. This will help in avoiding future denials for the same reason. This process of identifying the reason for denial helps in preventing a trend formation. In case of a trend, then it becomes very difficult to handle them all together. Therefore good RCM companies try to rectify the denials as early as possible. The main motive here is not only to rectify the denial but also to minimize the denials.
KPI 2: NUMBER OF CLAIMS
This shows the number of successful claims. Whenever there are delays, and multiple attempts have been made for settlements on the same bill, there should be a proper investigation for finding the reason. Efforts should be put in to solve these issues and minimize the attempts. Generally, if there are more than 3 denials in a week, it shows that there is something
Problems arise because of multiple reasons. Some of them are –
- Failure to update the new policy
- Failure to upload a contract
- Fault in the system.
Generally, RCM companies allow up to 3 attempts to settle any claims. In case the denials are crossing 3 times frequently, then there is a need to look for solutions. Identifying and rectifying the errors at an early stage enables smooth flow. Because with continuous submission, the denials may mount up within a short duration. This may cause stress to the workers as well as disturb the revenue flow.
KPI 3: FORECASTING
Generally, the RCM companies have a weekly review meeting. Discussions about the claims in the past week provide an understanding of the time duration for settling each claim. For an outsider, this half-hour meeting may look like any other team meeting. But the company not only reviews the past week but also lay out plans for the coming week. All this is completed in a short span, so as to have very little impact on the workflow.
The calculation is simple. The amount of money that is billed out and expected to be collected, in comparison to the actual amount billed out and collected. This shows the lag in the expectancy and actuals if the collection is lower than the expected amount. The company then tries to find the reason for this and rectifies any issues as soon as possible.
The process of forecasting also shows a trend pattern. This is useful for analyzing rejection charges, missing charges, and other problems in the payers’ payment cycle.
CONCLUSION
The RCM companies in USA concentrate on KPIs as the primary functions that will help in increasing collections and determining problems if any. The KPIs are like the backbone that holds the entire revenue flow in proper functioning.
Virtual Healthcare is basically renowned for improving these three KPIs. They contribute to the overall improvement of the revenue flow. It is essential for RCM companies to ensure that they ensure a steady flow of revenue. Ensuring this by rectifying any denials and completing settlements with minimum duration.
For running a successful RCM company it is essential for appreciating the work put in by the staff in the form of incentives. This calculation should be dependent on the number of accounts worked upon, not only on the successful payments. Ensuring the maximum number of attempts to three also lowers the delays.