Data-driven system for Revenue cycle management in healthcare

Hospitals today integrate their IT and revenue cycle management systems to assure maximum return on the technology investment while delivering top quality patient care.

However, healthcare margins and reimbursements are shrinking every year. The steady stream of new rules, new codes, and new quality measures mean that your ability to optimize performance and make key decisions for your organization are under constant threat. A strong, reliable data environment is your key to making decisions, advancing program performance, and achieving a new level of overall organizational awareness.

Goal:

• Enhance revenue growth, drive administrative efficiency, improve cost and quality of care, and improve the member and patient experience.
• Revenue cycle management in healthcare is essential for the healthcare practice to maintain financial viability and to provide quality care.

Solution:

• Apply business rules and harmonize data for medical, hospital, and pharmacy claims
• Dashboards and Reports for Member eligibility, High cost claimants, Finance paid summary, Monthly claims summary, Claims by Cost Utilization group and Top 10 Procedure and diagnosis codes
• Process data from Claims, enrollments, and pharmacies
• Monitor financial metrics, utilization, and quality
• Member Eligibility coverage rules vs options
• Pharmacy claims summary and detail by drug and claims paid
• Insights into likelihood of claim denials based on human actions throughout revenue cycle management in healthcare.

Results:

• Identify and improve gaps in existing systems used in revenue cycle management.
• Reduce time consuming workflows in Claims submissions.
• Allows Administrators to identify actionable areas for improvement.
• Helps control the costs of High Utilizers by providing proactive reports with cohorts and diagnosis and procedure codes.
• Optimize Care Management by better targeting resources and estimating potential savings at the plan, ACO and employer level

Figure 1: Revenue Cycle management in healthcare