The future of revenue cycle from 3 perspectives: Vendors, providers, and payors

Like seemingly every other facet of healthcare, the way we manage the revenue cycle is evolving. 

Current events such as the great resignation, the shift toward value-based care, and the increased use of artificial intelligence (AI) and automation have affected the foundation of how healthcare revenue is received and managed.

These changes have vendors, providers, and payors alike asking themselves: What will the future of RCM look like? How will it affect my organization? What new processes and technology will we need to succeed?

RCM is vital to any healthcare organization’s financial wellbeing, so these are important questions to consider. The answers will differ between vendors, providers, and payors—here’s how. 

Staffing shortages

It’s no secret that the great resignation is shaking all areas of healthcare to their core. One MGMA study found that staffing was the number one concern of 73% of healthcare leaders in 2022. A Fathom client recently shared that their cost for a coder ballooned from $24/hour two years ago to over $36/hour today!

The RCM workforce is not exempt from these staffing shortages, and the fallout has created both challenges and opportunities for vendors, providers, and payors. 

Vendors

Vendors will see increased opportunities to supplement and/or take on outsourced work from understaffed health systems and practices. 

These opportunities derive from providers not having the scale to leverage technology that takes away tedious tasks from their staff. So, it’ll be up to vendors to become the aggregators that bring this technology to their clients. 

Offshore vendors are seeing staffing challenges in the form of high inflation, driving up their internal costs by >10%.

Providers

Providers must find ways to support their existing staff to reduce burnout and increase employee retention. They can accomplish this by improving processes and eliminating repetitive tasks to free up their time—letting them focus on what they do best, care for their patients. 

Reports show that, on average, up to 25% of a physician’s time is spent on administrative duties. The opportunity cost of the time spent on these administrative burdens is estimated to be around 15.5 billion dollars annually. This high price has caused many organizations that previously had their clinicians perform coding to outsource the function. 

Also, providers’ will find that if they’re unable to retain or hire trained coders, they will see increased backlogs and/or reduced coding quality. 

Payors

Payors will experience a trickle-down from staff shortages at provider organizations that may include more denied claim challenges and lag times in claims submissions.

For payors, this means demand for more staff to manage dispute resolutions, increased difficulty in collecting what patients owe, and reduced cash flow velocity.

The shift toward value-based care

Healthcare is slowly shifting away from fee-for-service and toward value-based care. 

Value-based care challenges the traditional way the revenue cycle works with payments stemming from the quality of care and not for a specific service rendered. 

This disruption of the payment status quo creates ripple effects that touch each point of the care spectrum. 

Vendors

RCM vendors must be up-to-date on the new focus of quality vs. quantity and how it affects their clients. The organizations you serve may look to you to act as an expert and guide their RCM staff through any confusion around documentation requirements and their respective interpretations.

Expect more complex payor or site level guidelines to dictate compliant coding that optimizes revenue or flags documentation deficiencies. Also, coding for value-based arrangements is more exhaustive and labor-intensive than fee-for-service models.

Providers

The value-based care model creates new risk factors that can negatively impact revenue for providers. These risks may require considering different scenarios under the Merit-Based Incentive Payment System (MIPS) and to establish other key measurements to ensure you receive reimbursement. 

Increased risk also means staff must pay closer attention to detail. With value-based care, the importance of accurate clinical documentation and long-tail diagnosis codes is front and center, meaning RCM staff and clinicians will need to work more closely together than ever. RCM staff members will need to comb through pages of notes more diligently to find previously unidentified codes and communicate with clinicians to explain how to change their documentation practices to align with value-based care initiatives. 

Payors

Like providers, payors will experience a shift in their traditional status quo because value-based care creates a new lens to look through when deciding how providers get paid. 

Ultimately, value-based care has the potential to benefit payors because it saves money. This model promotes better patient outcomes, and with better outcomes, less healthcare spending should follow. 

Increased use of Artificial Intelligence (AI) and automation

Many medical organizations are leveraging technology such as AI to automate their revenue cycle operations. 

For example, one other rev cycle tech vendor, Cedar, uses AI to craft personalized billing plans for patients so that providers get paid faster while also improving the patient experience—a win-win for everyone.

Overall, the increased use of AI and automation has created exciting opportunities for vendors, providers, and payors. 

Vendors

Vendors will find an increased opportunity to provide AI and automation services that help medical organizations mitigate revenue leakage, reduce labor costs and staff burnout, and ultimately, help them improve the patient experience. 

Providers

Organizations that adopt AI and automation have the opportunity to improve their financial performance while also reducing employee burnout. One report indicated that the top three areas health systems are deploying AI are claims management, coding, and eligibility verification. 

Because AI/automation can take a lot of the repetitive, tedious tasks off of staff’s hands, it frees up their time to focus on the parts of their job they got into healthcare to do. 

Not to mention, reduced burnout can ultimately lead to better patient experiences, which also helps value-based care initiatives. 

Providers should also expect continuously changing guidelines and requirements that make it more difficult to get paid. Leveraging automation to systematize updates ensures you don't miss important guidelines and requirements that will become more popular.

Payors

Using AI and automation to improve coding and billing accuracy and patient documentation results in fewer mistakes on the provider’s end. Fewer mistakes and discrepancies mean less back-and-forth communication between the payor, provider, and even the patient. 

If a healthcare organization can use AI and automation to get faster payments and realize greater accuracy, they’ll have more confidence in how quickly they’ll receive reimbursements. Ultimately, this means providers will be more willing to accept a wider number of plans, creating more opportunities for payors.

What does your future look like?

The repercussions of staffing shortages, the transition to value-based care, and the increased use of AI and automation will affect vendors, providers, and payors. 

While you may face some challenges, there are also vast opportunities, and those who embrace these changes and shifts will find the most success.

Our medical coding automation services help medical organizations bring their revenue cycles into the future. Want a demonstration of what Fathom can do for you?

Let’s talk.