EDITOR’S NOTE:
Matt Bridge continues his three-part series on how to achieve a high-performing revenue cycle for your facility. Bridge reports that you need an understanding as to where your organization falls on the RCM Maturity Framework. Here is Part Three in this exclusive series for ICD10monitor.
The journey toward fully mature revenue cycle management (RCM) is typically a five-step process that starts with evaluating the maturity of the current state of operations to determine where the organization falls on the RCM Maturity Framework, outlined in the first two articles of this three-part series. This is followed by the establishment of a realistic long-term maturity target, followed by the development of iterative annual goals to achieve it.
Step four is the cultivation of an alliance partner ecosystem to accelerate
growth, and the final step is conducting annual reviews based on iterative goals and refocusing as needed for the long term.
This process and the efficacy of the RCM Maturity Framework is best illustrated by the transformation journey underway at a multi-state, not-for-profit health system with more than 40 hospitals and over 350 health and urgent-care centers along the southern U.S.
The health system was struggling, with a ballooning accounts receivable (A/R) that was impacting cash collections/receivables on both the hospital and physician sides, and a 15-percent increase in post-pandemic denials. There were limited automation tools in place, creating a high reliance on manual intervention and insights into the leading factors impacting key performance indicators (KPIs).
A baseline assessment revealed that the organization’s maturity stage was split across the lower two levels: Emerging and Foundational. Technology and Interoperability and Analytics were at the Emerging stage, with minimal integration between the electronic medical record/practice management (EMR/PM) systems and other RCM technologies, limited automation of core processes, and no intelligent automation. There was no unified analytics strategy, KPIs were typically tracked manually and without benchmarks, and data integrity challenges were widespread.
Service delivery was determined to be at the Foundational stage. There was a limited degree of centralization, but no scalability, and staff augmentation vendors existed only in pockets.
Armed with this knowledge, the organization was able to design an effective strategy to advance toward its goal of full maturity. A complementary offshore partnership strategy (Champion/Challenger model) was implemented, and by-exception workflows were instituted. These included the use of application programming interface (API)-integrated real-time claims status to improve the efficiency of A/R processes. An analytics suite was also developed to provide insights into the RCM operations, including benchmarks to gauge performance against peers.
Today, the organization has advanced in all three pillars. Service delivery is now High-Performing, with strategically leveraged global partnerships that limit reliance on in-house staff and a scalable delivery model with a high degree of centralization.
Technology and Interoperability are now Advanced, with an integrated infrastructure and exception-based processing. Analytics has also improved to the Advanced stage with a consolidated business intelligence (BI) platform, benchmarking, system-wide metric definition and adoption, minimal data integrity issues, and strong visibility into global service partners.
Each healthcare organization’s journey across the RCM Maturity Framework will be unique and based on multiple factors, including size, resources, budget, and tolerance for innovation. It also requires agility, adaptability, and a deep understanding of the revenue cycle and its impact on the patient’s financial experience.
As such, it is wise to seek the support of an advisor with proven experience capable of providing the guidance needed to steer an organization through its RCM growth plans. The right advisor should have deep expertise in revenue cycle management and be committed to the long-term well-being of the organization, its providers, and their patients.
The right advisor will be able to assess the current state of RCM operations and recommend practical solutions for sustained financial health. They should become part of the organization’s team and act as a committed partner and trusted advisor able to truly understand its operations, culture, and strategic growth plans. This includes working on-site to get to know the healthcare organization’s internal team and to gain a deeper understanding of its revenue cycle operations.
Leveraging advanced automation and global partnerships is key to alleviating the intense and unprecedented financial pressures currently crushing the healthcare industry, but it’s not simply a matter of globalizing resources and buying the latest technology. Success requires a comprehensive understanding of your organization’s RCM maturity, which can be gauged through an assessment utilizing the RCM Framework to form a roadmap for a strategic approach to maturation.
Analytics should form the underpinning of the roadmap, allowing organizations to measure progress and determine when operations are ready to move on to the next level of automation, centralization, and augmentation. Performance metrics will also determine when a pivot is necessary and when the organization’s revenue cycle has successfully achieved full maturity.
Ultimately, a strategic, thoughtful approach to achieving High-Performing status is worth the effort, as it will not only put the organization on sound financial footing but maximize the return it receives on its investments.
As discussed last week, payments to Medicare Advantage (MA) plans are adjusted to account for expected healthcare resource consumption by enrollees. Higher risk scores increase
EDITOR’S NOTE: This piece on RADV audits, written by Frank Cohen, was published on RACmonitor on Aug. 25, 2025. It’s being republished on ICD10monitor because
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