Keys to Successful Healthcare Revenue Cycle Management

Prevent claim denials through proper provider enrollment.

Prevent claim denials through proper provider enrollment.

The mission of any healthcare organization is to improve and save lives through compassionate, high-quality healthcare. But to fulfill this mission, healthcare organizations must stay financially healthy, a goal constantly at the forefront of revenue cycle management. Revenue cycle management encompasses the administrative and clinical functions associated with the identification, management, and collection of patient service revenue: claims processing, payment, and revenue generation.

Revenue cycle management starts when a patient makes his or her medical appointment and ends when all claims and patient payments have been collected. Submitting claims to health plans involves several back-end processes, including charge capture (documenting services into billable fees) and coding the treatment procedures using ICD-10 codes. Getting paid for medical services can take months because it often requires time-consuming, back-and-forth communications between providers and health plans to resolve claim issues.

Claim denials are a major source of revenue leaks, so taking proactive steps to reduce denials on the front end of the revenue cycle is essential. Claim denials are common and costly. Approximately 5–10 percent of claims are denied by health plans. According to a Change Healthcare analysis of claims, a typical health system can lose up to 3.3 percent of net patient revenue (an average of $4.9M per hospital) due to denials. Registration/eligibility is the leading cause of claim denials, accounting for 24 percent of denials. Although some 63 percent of denied claims are recoverable, it costs providers an average of $118 to rework a single claim.

RELATED EBOOK: The Invisible Impact of Credentialing and Enrollment

Verifying patients’ insurance eligibility before scheduling appointments is essential to prevent claim denials. Your schedulers probably already verify eligibility and suspend the scheduling and registration process until the patient’s ability to pay is confirmed. However, your schedulers may not be checking to be sure the provider is eligible to deliver and be reimbursed for services.

When a provider is not properly enrolled with a health plan, his/her encounters will be written off. If providers see patients before they’re enrolled in a health plan, those claims will be denied, bad debt will accumulate, and surprise bills to the patients may occur. When healthcare providers are not enrolled properly with one or more health plans, or if they have accidentally allowed their enrollment status to lapse (by missing a re-enrollment/revalidation deadline), billing disruption is inevitable. With providers seeing up to 3–4 patients per hour, the financial impact of writing off encounters due to enrollment-related claim denials can be significant. You need to have processes in place for provider enrollment verification.

To improve your revenue cycle management, take these steps to reduce claim denials:

Verify provider enrollment status before scheduling patients. Provider enrollment verification must become a standard part of your patient scheduling process—alongside patient insurance verification. Obtain and publish real-time participation status updates and monitor enrollment via your enrollment software’s enterprise-wide dashboards.

Expecting busy schedulers to call and verify provider enrollment every time a patient schedules an appointment is not realistic. Provider enrollment software simplifies the verification of provider enrollment status by giving schedulers real-time access to providers’ enrollment information. If providers are not participating with a particular health plan or product, they should not be seeing patients. Schedulers should not schedule patients with those health plans or products until the provider is participating, or they should re-direct the patients to a provider who is currently participating.

Assess provider participation status in all contracted health plans. Conduct par/non-par analyses to identify providers who are either not enrolled or enrolled inaccurately with your organization’s contracted health plans. Your goal should be to have all eligible providers enrolled at their respective billable locations prior to seeing patients. Participation does not end after providers are initially enrolled. Pay attention to the re-enrollment/revalidation timeframes of each health plan so your providers remain in-network.

Shorten credentialing and enrollment timeframes. Faster provider enrollment means faster reimbursement. Automate provider credentialing and enrollment to reduce the administrative burden, accelerate provider onboarding, and increase your speed to revenue. Establish a delegated enrollment agreement with health plans to shorten the enrollment timeframe from 120–180 days to 30–45 days.

TractManager’s Provider Enrollment solution simplifies and speeds up enrollment. With one unified solution, we connect your credentialing, privileging, and enrollment processes to streamline provider onboarding, save you time, and help you optimize your revenue cycle. To learn more about Provider Enrollment, watch the OnDemand Webinar: The Digital Transformation of Provider Enrollment.


Allyson Schiff

Senior Director, Strategy & Growth, Provider Management

Allyson Schiff joined Newport Credentialing Solutions in 2009 and joined TractManager when Newport was acquired in 2018.


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