Shortcomings of EHR Revenue Cycle Management
Here are the main ways that EHRs fail anyone the financial side of health care. Ultimately this leads to practices just not getting paid or not getting the full amount.
Electronic Health Records (EHRs) are designed to digitize patient care. All the time and effort that EHR companies have in the clinical model is clear. Modeling all the aspects of health care is a massive task. However, it is clear that financial reporting and revenue cycle management (RCM) is not at the same level as clinical care. Additionally, the tools to manage the entirety of all claims is lacking. Everyone can relate to loading a report of 10,000 claims, but not having any context as to the next action to take. This creates problems for everyone that is responsible for the financial performance of the practice.
Great at Getting Bills out the Door
EHRs are great at leveraging the clinical data for the coding and billing process. This ensures that charges and payments are accurately tracked. Unfortunately this is only the foundational pieces of RCM. This is not to say that this is a simple and solved process, but EHRs track charges and claims really well. Managing the entirety of RCM is more than just charges out and payments in.
Challenges of RCM
The major factors that make RCM difficult usually boil down to the particulars of the practice. EHRs cannot model every insurance process add to the complexities of a patient's history filtered through the lens of the actions a physician take. EHR companies will never take on this challenge and this falls on the the practice.
On the reporting side EHRs are built to show specific patients and their financial outcomes. It becomes difficult to view the claims in different ways, ie by Payer, by claim status, by biller, by appeal days left, etc. Viewing what happened to a specific patient in arrears is easy. Proactive Rev Cycle management is difficult.
The Patients. Every practice has a unique mix of patients. Their problems, their histories, their hopes, and their lives. Then layer on top all the insurances that exist in the patient population. There are always niche regional insurances that have to be accounted for.
Claims. Practices are managing hundreds if not thousands of claims in various states of payment (or non-payment). The ability to see where claims are in aggregate allows the practice to see trends and get paid more faster.
The Physicians. Every practice has a unique mix of physicians and their processes. Many times this is augmented by regulations and the EHR, but there are differences in documentation that leads to difficulty in billing and coding.
The Community. Medicaid and local government assistance programs play an important role in serving the patient population's financial responsibliity.
What's at Risk
Financial Performance and Sustainability. This is the key result of exceptional RCM. Keeping the practice open is the only way to continue helping the community.
Patient Experience. Offering clear, correct information to patients about their financial responsibilities is crucial for great patient care. This improves patient satisfaction and more efficient billing.
Compliance. Increasingly regulations are being applied to the RCM process.
Support of RCM staff. Knowledgeable and well-trained staff are the backbone of effective RCM. EHRs usually stand in the way of RCM staff instead of helping them do their job.
Technological Enablement. This is the platform or glue that holds together all the pieces to enhance the entire process. This goes beyond what traditional EHR systems offer. It requires advanced data processing and reporting.
The limitations of EHR financial management are clear. EHRs are a requirement to deliver great clinical outcomes, but the layered complexity and reality of the healthcare ecosystem create many challenges. Breakdowns can happen at any layer and reimbursement can slip through the cracks. An informed approach that takes into account a practice's unique mix of patients, physicians, and insurances augmented by a suite of data, tools, and capabilities to deliver exceptional RCM.