Advancing to Transformative Revenue Cycle

Exhibit 3: RCM digital transformation strategy

Few examples of evolved solutions around ‘transformative RCM’ could be: 

• Patient price estimator tool – Transparent out-of-pocket cost estimates is need of the hour in accordance with the Pricing Transparency Act, 2021. This is provided based on the prior claims data and be customized for highly utilized DRG codes/service codes etc.   
• Automated scheduler – Auto-scheduling patients by using RPA bots; sending automated reminders for first appointment/ follow-up/ already rescheduled appointments will help in reduced no-shows and missed appointments.  
• Real time patient eligibility-check and retrieval - The AI tools can retrieve real time eligibility from the payor and shall create an OOP cost estimates unique to a patient. Out-of-pocket expense amounts to 30% of the total healthcare bill.
• Reengineer patient financial journey - Interactive patient liability reminders at each needed step. Most of the collections can be achieved if patient is involved at the start of the care. Automated patient financial reach out post financial counselling sessions with appropriate outreach channels.
• Out of network alerts on scheduling any appointment with out-network physicians. Special alerts on cancelations across co-located clinics so other patients on wait list can be scheduled. 
• Auto-suggest slots for subsequent services to be performed (e.g.: if booked slot for HbA1C, auto-suggest Creatinine Blood Test available slots within 48 hours).
• Prior authorization – ePA (electronic PA) requests should be initiated at the point of care to avoid any delays in receiving PS response. NLP (Natural Language Processing) to accelerate the required information extraction (authorization number, archived payor screenshots etc.) will help save time to a great extent. 
• Gold carding for high performing providers needs to be introduced which will help increase in care outcome happening due to delay in authorizations.
• CDShooks - The provider doesn’t need to bother about the coverage of a drug. As a drug/ service is entered in the EHR, the hook will trigger a query to payor's data base regarding the coverage.
• CDM Master data management – Chargemaster is always a moving data, snippet of current coding and clinical data flowing from one PAS system to multiple systems. Provide a clear and concise view of Hospital’s CDM data across service lines, Cost center to ensure accurate pricing and coding. 
• Contract modelling leveraging multiple contracts from payor and generating pricing policies based on payor-mix identifying revenue shortfalls for each contracted payor. 
• Focus on expensive denials – Highlighting the outlier denials and possible causes of such denials via means of accurate CARC/RARC codes and ingesting these rules into the claims processing engine will lead to a significant shift from Actionable denial à Preventive denials.
• Digitization in processes like Prior authorization, billing and collections, claims tracking, reasons for denials, claims status etc.