Data De-fragmentation: The First Step to Breaking the Revenue Cycle Cycle

Over the next two years, payers are expected to increase investments in advanced technologies by 30% or more, focusing on payment integrity algorithms that will only add to an already imbalanced equation in the fee-for-service revenue cycle. Driven by artificial intelligence (AI), machine learning (ML), and robotic technologies, these algorithms are expected to drive hundreds of billions in payer-focused savings through improved claim anomaly detection, leading to denials and significantly reduced or often delayed payments.

At the same time, insurance premiums continue to spike. In 2021, the average employee contribution was up 7.2% over 2020, and spiked as high as 12.3% year over year, according to the AHRQ. Even with higher premiums, patients have an increased burden of higher copayments and deductibles, increasing their out-of-pocket expenses that, unfortunately, lead to unmanageable debt and unrecoverable revenue.

Moreover, payers’ reimbursements to providers, designed to offset increases in the cost of care delivery, have only marginally improved between 2.5% and 4%. This reduction in reimbursement serves to further improve financial positions and profitability, paving the way for the expected increased investments in technology; investments that largely serve to further embolden payer financial performance.

But these investments could not come at a worse time. Actual costs for providers have been skyrocketing since the pandemic, according to McKinsey, with labor costs growing 25%, pharmaceuticals up 21%, supplies up 18%, and services up 16%. While these costs moderated in 2022, they’re above the norm, and are now being influenced by inflation and the global macroeconomy. In fact, McKinsey estimates the annual US national health expenditure will be $370 billion higher by 2027, due to inflation, compared with pre-pandemic projections.

To win in this environment, providers need to level the playing field by investing in technologies of their own; technologies that can improve clean claim rates, measure and act on recoverable revenue, and optimize processes that lead to improved revenue velocity and performance overall. To be successful, however, healthcare providers need data—not just more data (we all know there’s no shortage of data in healthcare) but high-quality, useful data fueling insights providers can act on.

Providers need data that is hydrated across clinical, financial, and other operational systems that span facilities and departments. They need data that’s unified and normalized to create a 360-degree patient view of both clinical and financial health. And they need data that supports advanced analytics linked with actionable insights that lead to fast, accurate decisions, and prioritizes (or even automates) work, relieving a constrained and overburdened workforce. In a nutshell: ultra-high quality, unified and actionable data is the kindling providers need to thrive in today’s increasingly competitive and economically challenging environment.

Too Many Systems, Too Much Data, Not Enough Time or People

But how do we get there? It’s no secret that our healthcare system is fragmented. Data lives in disparate systems that use different taxonomies, ontologies, and metadata (data about data) to refer to patients or events throughout the continuum of care. What’s more, our industry has historically lacked or even avoided a common way for systems to talk to one another (data blocking, for example), further exacerbating the frustration created by this problem.

As providers start down the path of data defragmentation, many contemplate the acquisition and deployment of unified, enterprise EHRs and supporting systems—adding more layers to get to what they really need: the data. But while EHRs have made improvements in the digital collection of data, they’re just one piece of the very large (and expanding) data puzzle.

Often, practice management systems, referral and authorization systems, RCM vendor systems, clearinghouses, payers, and EDI transactions live outside of the EHR, creating an ever-growing need to consolidate data into a single unified data model (UDM). Oh, and did I mention the exploding crop of consumer digital apps that are increasingly tied into the rev-cycle processes, fragmenting data even further? Just what we need … more data silos!

Technologies such as FHIR (Fast Healthcare Interoperability Resources) have been a spark to kindle the flame. But they’re still in their infancy. And that leaves the industry to grapple with data acquisition and normalization through home-grown, do-it-yourself mechanisms which lack the true measure of healthcare interoperability—which itself demands we move beyond simple sharing of data and to electronic exchange of high-quality data that’s immediately useful.

But in the absence of a true UDM, hospital leaders face the reality of a hodgepodge IT architecture consisting of myriad hospital EHRs, a vast array of owned clinics and secondary care facilities, and the impossible maze of systems supporting them all. This data-siloed ecosystem prevents a clear view into a patient’s financial journey. To be effective, revenue cycle teams work in “swivel chair processes,” manually pivoting from one system to the next seeking data and information, and often find it difficult if not impossible to make sense of it all.

This disjointed complexity adds to their workload and burden, often leading to burnout and resignations, and leaving open headcount that’s becoming increasingly difficult to fill. These conditions are like an antibiotic-resistant infection that manifests and flourishes without an effective treatment: a true UDM.

An Effective Data Treatment Plan

While Innovaccer cannot solve antibiotic resistance, we have wrestled the UDM problem to the ground, for the sake of clinical clarity and improved population health. And now we’ve expanded our scope to include the defragmentation of financial data to create a single source of clinical and financial truth about the patient—allowing providers to break free of the revenue cycle cycle.

The Innovaccer team is made up of exceptional revenue cycle, operations, healthcare IT, and data science experts. In fact, our team has more than 50 years of collective experience running revenue cycle departments in diverse provider organizations, ranging from medical practices to community hospitals to complex academic medical centers with large physician practice affiliations, and beyond.

We understand billing and large Revenue Cycle Management (RCM) outsourcing engagements, and have used this knowledge to create a world-class solution for better managing and optimizing providers’ revenue cycles. We know what reports are needed. We know how they’re used. And we have more than 100 well-thought-out data visualizations that provide expert insights into the drivers, drainers, and “stagnators” of the revenue cycle—all ready to go, right out of the box.

At their core, Innovaccer’s Revenue Cycle Intelligence solutions address data fragmentation and provide the normalization and data activation required to expose the crucial insights and analytics needed to capture every dollar of revenue you have rightfully earned. But we don’t stop there. Common analytics solutions report simple KPIs and dashboards. But they typically leave revenue cycle departments guessing about what they can do next to improve revenue cycle performance. Factor in the critical shortage of knowledgeable and productive human capital, and revenue cycle leaders are left in the lurch.

We go beyond common analytics solutions by digging into the root causes behind KPI performance, so the revenue cycle team can stop guessing and take action. We offer expert, data-driven counsel on what, when, and how to improve. Beyond intelligent analytics, we also help revenue cycle leaders close staffing and productivity gaps with virtual digital consultants that use AI and ML that tackle organizing, prioritizing, and delegating work.

This includes individualized worklists that point teams to the specific tasks required to improve financial performance—ensuring the right person gets the right task at the right time. Armed with these advanced technologies, revenue cycle teams are suddenly free to work on their most important tasks—those that can return the most value to the organization.

All of this is accomplished through workflow integration at the desktop, eliminating the dizzying “swivel chair” pivots common in revenue cycle environments today (pivots that drive analysts nuts, by the way). And we do all of this at a fraction of the cost of competing solutions, while helping you overcome genuine organizational hurdles, personnel deficits, and process abnormalities.

To learn more about how Innovaccer can help your organization gain unprecedented visibility into your revenue cycle—insights you can actually act on, with intelligent automation you can actually count on—visit Innovaccer Revenue Cycle Intelligence or request a demo today.