Revenue Cycle Management: The Key To Achieving Success Under MACRA

By Thomas Schildmeyer, VP RCM Strategy and Development, Modernizing Medicine

The Medicare Access and CHIP Reauthorization Act (MACRA) aims to improve physician and other clinician payments by changing the way Medicare incorporates quality measurement into payments. At its core, the Act repeals the sustainable growth rate and authorizes the U.S. Department of Human and Health Services (HHS) to implement value-based incentives. Regardless of MACRA’s original intent to improve healthcare for both patients and physicians, the new legislation can result in negative implications on practices — particularly as it relates to revenue cycle management.

The final rule for MACRA includes two pathways for provider participation: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). MIPS is designed for providers in traditional, fee-for-service Medicare. Clinicians can earn payment adjustments based on performance in three categories (Quality, Clinical Practice Improvement Activities, and Advancing Care Information) linked to quality and value. The APM is designed for providers who are participating in specific value-based care models.

For a smooth revenue cycle transition, both models rely on more accurate clinical documentation from physicians that want to be both reimbursed properly and have their risk adjustment scored correctly. It is imperative to have advanced technology that captures and reports this information in a cost effective and timely manner.

While this is critical, it is also important to keep your RCM workflow/process in mind. Following are seven tips to improve your RCM process.

• Assess your documentation management process — ask, “Where are my documentation challenges?” and, “Am I able to capture all data accurately through my EMR system?” Identify your top two challenges, then educate all staff in those areas. Make a concerted effort to improve these challenges and work on these weak points.
• Review your coding accuracy — with the new model, it’s more important than ever to ensure coding accuracy. Physician practices should engage expert billers, coders, and the right technology to assess their coding system and look for missing charges and weak points, such as downcoding or upcoding wrong ICD-10 codes or missing modifiers.
• Collect co-payments at time of service — billing patients for their co-payments can delay revenue 30 to 60 days or longer if not paid on time. Take advantage of the patient visit to capture revenue immediately by collecting co-payments up front.
• Collect past due balances at time of service — similar to co-payments, take the opportunity to collect past due balances in person (at initial or follow-up appointment) versus billing them later. This requires communication between your scheduler, receptionist, and billing staff. Using your practice management system should assist in the process by being able to pull a list of balances due.
• Review and adjust your fee schedule — at a minimum, assess your fee schedule annually to ensure you’re capturing the revenue you’re entitled to. Review your schedule against all insurance contracts and make sure you’re charging the maximum allowable amounts. Don’t leave money you’ve earned in the payers’ hands.
• Transfer balances and send statements — yes, as fundamental as it sounds, some practices delay (or overlook) transferring balances to patients. Simply doing so and sending out statements can generate faster payment resulting in more revenue. Technology can be very helpful in automating and managing these processes, so it’s getting done without dramatically increasing administrative burden.
• Consider outsourcing your revenue cycle management (RCM) — by outsourcing your RCM, you can increase your revenue, reduce your costs, and focus on patient care.

Whether employing an internal billing specialist or outsourcing the function, RCM will be key to a successful value-based care transition, especially for smaller practices where a negative reimbursement could result in bankruptcy. Adopting RCM best practices will not only increase a physician’s success under MACRA, it also will lower claim denials, increase patient collections, and help physicians achieve more profitability and grow a business. By adopting RCM best practices, physicians can succeed under the value-based care transition.