Using Revenue Cycle Management Tech to Close Healthcare’s Generation Gap

According to research by the Alliance for Lifetime Income, 4 million Americans will turn 65 this year and annually through 2027, led by retiring Boomers. Healthcare alone is expected to lose over 2 million workers by 2029, the largest number of employees of any sector. As they leave the workforce, these retirees will take with them deep skills and experiential knowledge, making finding their replacements difficult.

This is being particularly felt in the realm of insurance claims follow-up. A poll of over 500 acute care hospitals by healthcare improvement company Premier showed that roughly $10.6 billion was “wasted arguing over claims that should have been paid at the time of submission.” It’s a complex area where employees who know the ropes are worth their weight in gold.

As the retirement exodus continues, generational skills gaps in all areas are increasingly widening, with health systems in small and mid-tier communities, where talent pools are much smaller, being particularly hard hit. Faced with limited resources and rising costs, many hospitals are shuttering, leaving communities without vital services.

What’s Needed: An Evolution or Revolution?

Healthcare has been stuck in a frustrating loop for decades when it comes to the insurance claim process and providers and health systems getting paid. As a common example, a provider submits a claim to an insurer who will pay some but also deny a portion. The provider must then work to resubmit the claim within a window of time set by the insurer. If they don’t get past the required processes in time, those funds can never be recovered.

There are valid reasons payers deny provider claims: missing patient details, wrong billing codes, failure to get prior authorization, and more. But missing a deadline due to payer obstacles hints at a bigger problem. Premier’s poll found that 15% of claims submitted were initially denied, including many that were already pre-approved. About 55% of the claims denied by private payers were eventually overturned after a number of costly appeals, a process draining providers of about $20 billion a year. This is despite payers adopting advanced tech like machine learning, natural language processing, and optical character recognition for faster and more accurate claim reviews.

Insurance companies have little incentive to evolve beyond this process because denials are profitable. This requires healthcare provider staff to stay a few steps ahead. Unfortunately, these personnel’s workloads are considerable and leave little time for staying ahead of claims.

What’s needed is a revolution, and revenue cycle management (RCM) technology is turning the tables. It can help close generational talent gaps while stemming the flow of energy and resources that are wasted trying to collect too little money. The considerable savings that result can then be pumped back into a hospital to drive better care quality.

Consider a 150-bed hospital with 30 employees working claims. If 10 of the most experienced employees retire in the next three years, it won’t be easy to find replacements in a smaller talent pool. RCM technology streamlines workflows, increases collections, and improves a health system’s financial stability by prioritizing high-value claims. It can make the claims process intuitive and collaborative while removing guesswork. And not only does it help bridge experience gaps, it gives recruiters added flexibility to meet hiring demands.

RCM covers tasks including medical billing, collections, payer contracting, enrollment for providers, necessary coding, data analytics, compliance, insurance processing, eligibility, and registration. Technology can:

Create operational efficiencies
Drive cash flow and increase the ability to capture revenue
Provide support for regulatory compliance
Curtail submission of inaccurate information to insurers
Keep all involved aware of healthcare regulations
Improve financial strength and overall stability
Leverage gamification to motivate, engage, and retain employees

This combines to maximize the total revenue collected by providers, which can then be pumped back into improving patient care. Still, the RCM market is projected to exceed $238 billion by 2030. There are a lot of options out there and the volume of solutions will increase as new arrivals hope to cash in on this growing marketplace.

The Human Touch

Healthcare is complicated and providers are constantly inundated with new regulations, data challenges, and community wellness issues. A modern RCM should be designed with simplicity in mind to empower employees and facilitate its adoption. Human involvement and oversight are also essential, so vendors should have RCM veterans to extend a provider’s team and hold a seat on their IT table – and the bigger the table the better.

These pros should guide you and your staff through the complexities of RCM and pitfalls to avoid. They should have your back with best practices and workflow strategies. They should be willing to roll up their sleeves and work alongside your team to overcome payer challenges.

As Boomers continue to retire, healthcare providers must prepare for even greater pressure. Don’t put this off until tomorrow because this is playing out in real-time, today.