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Optimizing Pre-Service Components for a Robust Revenue Cycle

Pre-service tasks—insurance eligibility verification, securing prior authorizations, and clarifying patient financial obligations, are fundamental in establishing a resilient and efficient revenue cycle—sets the stage for both financial health and enhanced patient experience. In the modern healthcare landscape, mastering these components is imperative.

Streamlining Pre-Service Processes

The integration of comprehensive pre-service tools can ensure a seamless journey from initial patient interaction, thereby solidifying the organization’s financial foundation and fostering a sustainable healthcare delivery system.

Automating Prior Authorizations. According to the American Medical Association, prior-authorization denials on inpatient accounts are a key driver behind the dollar value of denials increasing to 2.5% of gross revenue in August 2022 from 1.5% of gross revenue in January 2021.1 Identifying and addressing the root cause of authorization-related denials is critical to improving financial performance.

For example, many provider organizations rely heavily on phone and fax machines to process prior authorizations. CAQH estimates that the majority of providers continue to manually prior authorization requests.2 This forces staff to leave their primary workflow—the EHR. This is often a significant drag on productivity for hospitals and health systems processing a high volume of prior authorizations and referrals.

Leveraging direct integrations with EHR systems and connections with health plans nationwide can significantly streamline the prior authorization process. Automating these tasks for fast and accurate submissions, including determining authorization necessity and clinical documentation attachment, is vital.

Other benefits of automation and direct connections to health plans include:

  • Automated queries to the health plan to determine if authorization is required, eliminating unnecessary tasks if it’s not.
  • Auto-population of prior authorization forms for fast submission with minimal or no human intervention.
  • Provider staff receiving up-to-date authorization status information directly in the EHR workflow, eliminating calls to the health plan or visits to the portal.
  • Improved reporting and analytics free up staff time to focus on high value activities

Efficient Coverage Discovery. Identifying insurance coverage—particularly when not immediately apparent, or with ancillary services where patients don’t see registration, like labs, ERs, or imaging—is a critical pre-service task. Tools that efficiently search for active coverage across multiple payer sources and automatically update EHR systems with relevant payer and plan codes can greatly enhance workflow efficiency and patient record accuracy.

  • Reduce bad debt and lost revenue. Provider organizations are more likely to collect their full payment and less likely to have to write off bad debt charges when patients have active insurance coverage.
  • Streamline registration and pre-service activities. As with many aspects of the revenue cycle, tools that allow provider staff to stay within established EHR workflows are imperative.
  • Improve patient data accuracy. Digital tools that identify coverage for a patient automatically post back to the EHR with the related payer and plan codes, triggering customized workflows to keep the patient record up to date.

Advancing Patient Financial Clearance. Sophisticated tools for patient financial clearance remove the guesswork from patient estimations and coverage screening. Integrated demographic, coverage, and patient responsibility information, combined with government mandate compliance and price transparency tools, are essential for tailoring workflows to specific organizational needs.

Comprehensive Eligibility and Benefits Management

Addressing front-end gaps in the revenue cycle can mitigate issues related to claim denials and patient payments. Accessing comprehensive eligibility and benefits information within user interfaces and through real-time EHR integrations is critical.

Key Takeaways

  • Importance of Pre-Service Processes: The critical role of eligibility, prior authorizations, and patient financial clearance in establishing a resilient and efficient revenue cycle.
  • Benefits of Automation and Integration: How automation within the EHR can significantly improve workflow efficiency, reduce denials, and enhance financial performance.
  • Advancing Patient Financial Clearance: Exploring sophisticated tools for patient financial clearance that integrate demographic, coverage, and patient responsibility information

Conclusion

A robust pre-service strategy is integral to a healthy revenue cycle. Embracing technological solutions and best practices in pre-service components streamlines operations and positions healthcare organizations for financial success and improved patient experiences.

Learn more about what Availity offers and discover informative resources here that can help you get started on the path to revenue cycle success.

About the Author

Krisi Hutson serves as the Senior Director of Solutions at Availity, where she is passionate about creating outcomes that improve the patient experience while easing the burden on both providers and payers. With a passion to serve as a provider advocate in the healthcare ecosystem, she enjoys using technology to allow providers to focus more on their patients, and payers on their members. Krisi’s career in healthcare began more than 25 years ago and she has played a critical role in leading Availity’s revenue cycle management activities over the last decade.

Prior to joining Availity, she held positions as a Compliance Officer and Revenue Cycle Director for a large specialty practice, along with experience at hospital and Ambulatory Surgery Centers. With a personal goal of improving the healthcare ecosystem for all, she enjoys helping clients create efficiencies and meet their revenue goals to be able to improve patient care in their respective communities. Krisi has been named a “Women to Watch in Healthcare IT” by Becker’s Healthcare.