RPA optimizes patient revenue cycle

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The typical flow of the patient revenue cycle can be divided into three sections: Patient Access, Care to Claim, and Claim to Payment. In each of these sections, Robotic Process Automation (RPA) can add value by executing repeatable process traditionally carried out by a human worker. The result: improved efficiency, greater accuracy, reduced cost, and higher employee satisfaction.

Graphic of Opportunities for RPA in Patient Revenue Cycle

PATIENT ACCESS USE CASES

PRIOR AUTHORIZATION VERIFICATION

RPA can be leveraged to:

  • Identify scheduled services without required authorization from scheduling/billing system and access third-party payor portals.
  • Record authorization number/details in scheduling/billing system.
  • Record authorization denial or lack of authorization into scheduling/billing system to drive workflow

Outcomes will include:

  • Ensuring all scheduled services have appropriate authorizations.
  • Directing staff to pursue missing or denied authorizations.
  • Making decisions on rescheduling services without authorization.
  • Ensuring appropriate reimbursement for services performed.


TRANSFER MD ORDERS TO SCHEDULING

RPA can be leveraged to:

  • Transfer physician orders/referrals (CPT/HCPCS code, diagnosis, ordering physician, patient information) from electronic media (e-fax, EHR) to scheduling system.

Outcomes will include:

  • Eliminating the manual transcribing of orders into a scheduling system to facilitate rapid scheduling of services.


RECONCILE SCHEDULES TO ORDERS

RPA can be leveraged to:

  • Identify orders/referrals without a scheduled service date to drive scheduling workflow and follow-up.

Outcomes will include:

  • Rapid and complete scheduling of all ordered or referred services.


PRESUMPTIVE FINANCIAL ASSISTANCE MANAGEMENT

RPA can be leveraged to:

  • Identify patient balances that presumptively qualify for financial assistance, according to the terms of your Financial Assistance Policy, through use of presumptive eligibility software or other scoring.
  • Apply financial assistance discount transactions into billing system.

Outcomes will include:

  • Eliminating the need to manually post transactions into the billing system.
  • Creating more time for business office and/or financial counseling staff to do outcome-focused, mission-oriented work.

CARE TO CLAIM USE CASES

INPATIENT CM/UR (LEVEL OF CARE) VERIFICATION

RPA can be leveraged to:

  • Identify scheduled or concurrent admissions missing authorizations in EHR, case management, billing system and access third-party payor portals.
  • Record authorization number/details in EHR, case management, billing system.
  • Record authorization denial or lack of authorization into EHR, case management system to drive workflow.

Outcomes will include:

  • Ensuring all admissions have appropriate LOC authorizations.
  • Directing UR, CM, Physician Advisors to pursue missing or denied authorization.


CHARGE RECONCILIATION (INPATIENT, OUTPATIENT, AND PHYSICIAN

RPA can be leveraged to:

  • Identify completed visits, exams, procedures, or cases that do not have a billable charge posted in billing system (technical charges and employed physician professional fees).
  • Identify inpatient days attended by an employed physician without a professional fee charged in billing system.
  • Identify completed professional consults in EHR without a consult charge in billing system (employed physicians).

Outcomes will include:

  • Providing information to revenue integrity or business office staff to work with clinical departments, practices, and physicians on charge posting.
  • Ensuring all billable services are charged and billed timely to ensure appropriate reimbursement is received.

CLAIM TO PAYMENT USE CASES

BILLING SYSTEM TO CLEARINGHOUSE RECONCILIATION

RPA can be leveraged to:

  • Import claim file and account acceptance detail into billing system to ensure billed claim files are reconciled (accepted vs. rejected).

Outcomes will include:

  • Allowing for the quick identification of a claim file or individual claim rejection.
  • Ensuring errors are resolved and claims are resubmitted immediately to shorten the time to receive claim payments.


TRACK CLAIM STATUS

RPA can be leveraged to:

  • Identify billed claims without payment or denial transactions from billing system.
  • Access payor portals to identify status in third party payor systems.
  • Record status (paid with payment details, payment pending with expected amount and date, denied with ANSI codes, pending/suspended with reason details) to drive workflow.

Outcomes will include:

  • Eliminating manual inquiries on claim status information.
  • Liberating business office resources to focus on revenue protection efforts (denial management, etc.).
  • Prioritizing and driving workflow to ensure business office resources are working on inventory that will produce the highest yield.

75% of revenue cycle management processes are fully automatable;
96% are at least somewhat automatable.

Automation potential for healthcare systems

Graphic showing automation potential of healthcare processes

About Garnet River

Founded in 2000 and based in Saratoga Springs, N.Y., Garnet River provides comprehensive and flexible staffing and staff augmentation services, innovative robotic process automation (RPA), and managed outsource solutions to public- and private-sector clients. Garnet River is a partner with UiPath, Microsoft, Cisco Meraki, Hewlett Packard Enterprise, and others. For more information, visit garnetriver.com.

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