Revenue Cycle Management

Claims Clearinghouses serve as an intermediary between healthcare providers and insurance payers, ensuring that claims are error-free and in the correct format before submission. These entities streamline the claims process by converting non-standard healthcare data into a standardized format, facilitating electronic data interchange (EDI), and ensuring compliance with HIPAA regulations. By performing "claim scrubbing" to minimize errors, clearinghouses help to accelerate the reimbursement cycle, reducing denials and improving the efficiency of the healthcare billing process.

Claims management is the systematic process of handling healthcare claims from initial submission to final resolution. It ensures that healthcare providers receive accurate and timely reimbursement for services rendered. This process encompasses several key functions: preparing claims with the necessary documentation and accurate coding of diagnoses and procedures, submitting these claims to insurance companies or other payers, tracking the status of claims to ensure they are processed efficiently, addressing any issues or denials that arise, and posting payments once claims are approved.

Clinical Documentation Integrity (CDI) focuses on the accuracy and completeness of patient records to support high-quality care, continuity of care, and proper reimbursement. These products aid providers in capturing detailed and precise documentation of patient care, diagnoses, treatments, and outcomes. They often include features for real-time documentation guidance, automated review and flagging of discrepancies or missing information, and support for adherence to regulatory and billing requirements. By enhancing the quality of clinical documentation, these products support improved patient care, facilitate compliance with health regulations, and optimize reimbursement.

Eligibility Checking products provide healthcare providers with tools to verify a patient's insurance coverage, including in-network status and covered services. They can also assess the cost of procedures in advance, enhancing transparency. Some of these products support the creation of Good Faith Estimates (GFEs), aiding patients and providers in making informed financial decisions regarding care.

Medical Coding products support converting healthcare diagnoses, procedures, services, and equipment into universal medical alphanumeric codes, including ICD-10 and HCPCS codes. Products in this category range from databases and reference materials for manual coding through automated AI tools that generate codes from clinical documentation. These products are designed to enhance accuracy, efficiency, and compliance with evolving standards and regulations in healthcare documentation and billing.

Patient Billing and Collection products are designed to streamline the patient billing process for healthcare providers, enabling them to issue accurate bills through the patient’s preferred channels. These products can offer various financing options to assist patients in making timely payments, enhancing the efficiency of collections and improving patient satisfaction with the billing process.

Patient Price Estimation tools enables providers to generate accurate and transparent cost estimates for patients prior to receiving medical services. This category focuses on tools and products designed to help providers create Good Faith Estimates (GFEs) in compliance with regulatory requirements. Accurate GFEs help patients understand their potential financial obligations, reduce surprise billing, and support informed consent. These products enable key workflows including: - Data Collection: Gathering relevant patient information, including insurance details, medical history, and the specific services or procedures anticipated. - Cost Calculation: Using advanced algorithms and up-to-date pricing information to calculate the estimated cost of services. This includes all potential charges such as procedures, tests, consultations, and any associated fees. - Transparency: Presenting the estimated costs in a clear and understandable format for patients. This helps patients make informed decisions about their healthcare and financial planning. - Compliance: Ensuring that the estimates meet regulatory standards, particularly the requirements set by laws such as the No Surprises Act. This involves providing detailed and accurate GFEs to patients. - Communication: Effectively communicating the cost estimates to patients, including explaining any potential variables that might affect the final bill.

Prior Authorization products serve as the bridge between healthcare providers and payers, streamlining the authorization process for treatments and medications. These tools facilitate the submission of clinical documentation by clinicians, making it easier for payers to review and authorize necessary procedures. On the other side, payers benefit from organized systems to manage and respond to treatment requests from healthcare providers efficiently. AI and machine learning, are increasingly employed within these products to assess the relevance and necessity of treatments, as well as to generate the prior authorization submissions themselves.

Provider Utilization Review solutions are integral to healthcare operations, supporting the assessment of medical necessity and care appropriateness at critical decision points. These tools provide both the content for utilization review decisions and the workflows to streamline case management and prioritization. While most products focus on utilization management (UM) nurses, some EHR-embedded solutions target providers directly, enabling seamless clinical integration. When They Are Used: • Admission Status Decisions: To determine inpatient versus observational status during patient admission. • Escalation of Care: Assessing the need for transfer to intensive care units (ICU) or higher levels of care. • Extended Stays: Reviewing the necessity for prolonged hospital stays to ensure resource optimization. Key Features: • Clinical Content Access: Evidence-based guidelines to inform utilization decisions. • Workflow Management: Tools for automating case reviews and managing utilization workflows efficiently. • Case Prioritization: Identification of high-priority reviews through advanced algorithms or dashboards. • EHR Integration: Provider-focused tools embedded directly into electronic health records for improved usability. These solutions ensure timely, evidence-based decisions, helping healthcare organizations balance resource utilization with high-quality patient care.

Revenue Intelligence products utilize analytics and machine learning to optimize financial performance for provider organizations. Key features and functions include: - Data Integration: These products aggregate data from various sources, including electronic health records (EHRs), billing systems, and payer databases, to create a unified view of the revenue cycle. - Advanced Analytics: They apply sophisticated analytical techniques to identify trends, patterns, and anomalies in revenue data, helping to pinpoint inefficiencies, predict denials, and uncover revenue leakage. - Predictive Modeling: Utilizing machine learning models, these tools forecast future revenue, patient payment behaviors, and potential risks, allowing for proactive management of financial performance. - Performance Dashboards: Offering real-time dashboards and visualizations, these products provide actionable insights into key performance indicators (KPIs). Stakeholders can monitor progress, track financial health, and make data-driven decisions. - Process Optimization: Revenue Intelligence tools identify bottlenecks and areas for improvement within the revenue cycle, optimizing claims processing, enhancing patient billing practices, and streamlining workflows to reduce costs and improve efficiency. - Benchmarking and Reporting: These products compare performance against industry standards and benchmarks, providing detailed reporting that helps understand financial metrics and guide strategic planning.