Prior authorization, government regulations and payer relationships are among the challenges three Healthcare Financial Management Association MAP-award-winning revenue cycle leaders told Becker’s they are facing right now.
John Maschger, vice president of revenue cycle at Liberty (Mo.) Hospital, said the biggest challenge remains the “ever-changing complexities of successfully being reimbursed for the services we provide.”
“Of these, prior authorization has become increasingly difficult and can adversely affect patients through delays in treatment,” he said. “While we have greatly improved balance after insurance options for our patients, they often have difficulty understanding these other nuances of receiving care in our healthcare system.”
Brad Gibson, vice president of revenue cycle and treasurer of Houston-based University of Texas MD Anderson Cancer Center, agreed that prior authorization and claim denials are a challenge and added so too are exponential government regulations. These include regulations around price transparency and the No Surprise Act.
“A lot of these require us to retool things to adopt, and adapt to change management, while we all have increasing patient volumes,” he said. “So having dedicated resources to work on all these policy changes is certainly difficult.”
Girish Dighe, PharmD, system vice president of revenue cycle at Columbus-based OhioHealth, said one of the biggest challenges he faces is figuring out ways to work with payers.
“The payer mix and the payer landscape is changing,” he said. “You see a lot of vertical integration happening in that space.”
Figuring out ways to make the relationship more of a partnership remains a challenge, he said, adding that, at the end of the day, both sides are trying to support the same patient.
“How do we find those ways, whether it’s through technology advancements together, whether it’s ways that we can partner on other types of programs and initiatives to help support the patient, but also costs?”
“We have administrative burdens that we deal with. For example, maybe it’s prior authorization or denial management. I would say the payers have the same things as well. They have to think about cost containment strategies. But how do we do that without compromising patient care or the patient at the center of what we do?”
Dr. Dighe said he’s hopeful they’ll find ways to move that relationship forward.
The other challenge Dr. Dighe sees revolves around automation.
“How do we find the right partners or even within our own system, find opportunities to help us drive efficiencies through each part of the cycle? And I think the challenges we see are maybe there isn’t a one size fits all [solution]. And I think it goes back to being a high performing revenue cycle. It goes back to taking calculated risks to understand that we need to test and pilot and innovate, because you’re not going to find the exact piece of the puzzle. You’re going to have to figure out a way that you can find the customizing, the partnering with the right tool, solution, vendor in the automation space. It’s really going to help you transcend to the future.”