Transactional data promotes an informed and proactive environment, which leads to transformed processes. 

Healthcare organizations have been on a journey to digitalization and higher efficiency for quite some time, continually investing in various technology solutions. All the while, the landscape of healthcare is only increasing in complexity, with organizations continuously seeking new workflow efficiencies. Is it time to adjust our focus to real transformation, rather than merely transactional efficiency?  

Revenue cycle management (RCM) tracks a patient’s episode of care from the point of scheduling to payment posting. While it may appear to be a straightforward process, each facet within RCM has its own unique set of requirements. These requirements create various levels of problems and challenges, of which those in the industry are far too familiar. The overarching function of RCM, which is crucial, yet often overlooked, is the ability to unite the business and clinical sides of healthcare through data.

Data, when accurate, is influential in problem-solving, identifying workflow issues, and most importantly, emphasizing areas of needed improvement. Merging the business and clinical aspects of healthcare with the involvement of the revenue cycle creates a cohesive workflow, which will render indirect and direct value through process improvement and continuity within any organization. 

Establishing connectivity, a seamless flow of communication between the clinical and business sides of a healthcare organization, especially when dealing with denied claims, is essential for any real transformation to be achieved through RCM. The convergence of business and clinical interests will lead to improved  use of data and promote change. As it relates to the data, concurrent efforts for improved clinical documentation are a given; however, without interconnectivity, the result will be far less beneficial.

Inpatient and outpatient services are experiencing an influx of payment denials. There is increasing emphasis being placed on coding accuracy and clinical documentation. Performing in a transactional environment, denied claims are frequently routed to the health information management (HIM) department for coding or clinical documentation review. The HIM department reviews the record, and the appropriate action is taken to remediate a transaction. This then funnels to the business office for proper claim adjudication. 

In a transformational environment, HIM, the revenue cycle department, clinical documentation improvement, and quality improvement have the opportunity to evaluate data of numerous transactions, as mentioned above, and determine areas of issue. This may identify the need to communicate with a payer regarding perceivably illogical denials, as well as needed clinical documentation improvement for specific diagnoses and/or procedures, which may require physician education. Trends may be recognized pertaining to coding accuracy or varying payer guidelines versus coding guidelines. Clinical documentation improvement (CDI) efforts are far-reaching, and require continuous feedback from the revenue cycle to determine areas of focus or inclusion within the CDI specialists’ scope of work.

The power of technology expedites efficiency by integrating various healthcare platforms. The transaction time within a patient’s overall encounter is decreasing as a result of these technologies, and the transaction-based domain continues to improve. However, to transform an environment, data must be monitored and distributed to key contributors, and challenges and methods for continuous improvement within the healthcare continuum must be openly discussed. Collaboration among the departments having the responsibility and the authority to implement change while using transactional data promotes an informed and proactive environment, which leads to transformed processes. 

When done with forethought and planning, positive transformation can be achieved. Healthcare organizations are required to move beyond the mentioned domains and move toward true interconnectedness.

The power of transitional data and unified problem-solving guarantee value and transformation in many areas, with much-needed advancements. Real transformation occurs when newly designed and reconfigured processes are implemented from discoveries that can only be uncovered through transparency and connectivity, resulting in action that creates change serving the entire enterprise.

Programming Note:

Listen to Susan Gatehouse report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.


Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

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