The industry I will be discussing is healthcare revenue cycle management, also known as RCM, and formerly known as medical billing. Information technology is used in the industry during all phases of the revenue cycle. The future has many good things in store for the RCM industry.
Before we look at the present and future of the industry, it is helpful to look at the way things were done in the past. In the past, RCM companies used to receive charts on paper from each hospital, along with a log of all patients seen. The paper charts were given to the medical coders, and the coders coded the charts on paper. The paper charts were then entered manually by a data entry staff for billing. The log was checked to verify that data was received for all patients seen. Payments would come in, and each one would be analyzed and processed manually. At the end of the process, the paper charts were scanned in for historical purposes. In this setting, personnel with little computer expertise were needed for things such as mail room processing and scanning.
Today, things are much more advanced. For starters, let's look at the network. Healthcare data is transmitted via the network from hospitals to the RCM company. Data includes patient demographics, insurance information, and patient charts. Accompanying this is a log of every patient that entered the hospital in the past 24 hours. Electronic bills go out from the RCM to insurance companies and government agencies. These bills are often accompanied by copies of the patient charts. Payments are received electronically, along with data about the payments. This data includes which patients are being paid for, how much is paid, and any messages about the payments. In addition, network communication takes place with other business partners, such as collection agencies and third-party payment services.
In the next ten years, the network will become more advanced and also more common. An increasing number of hospitals will be sending data to the RCM electronically. Also, an increasing number of payers will be able to transact electronically. It will increase security by reducing the amount of paper with personal healthcare information (PHI) circulating. It will also make RCM companies more reliant on the network.
What about the software? When patient data is received by the RCM, it must be coded in a format that the payers will accept. Computer software presents a patient's demographics along with their chart to a medical coder. The medical coder interprets the doctor's notes and applies CPT and ICD codes to the patient account. It requires image OCR and storage, along with a powerful set of tools for the medical coding process. It also requires that all medical coders are computer literate. In the past, coding on paper did not require computer literacy.
Once the bills are sent out, and payments are received, they must be applied to the patient account and reviewed. Automation software performs much of this process. The software handles the easy stuff, such as bills that are paid correctly at the contractual 'allowable' levels. It leaves just the edge cases to employees so that they can apply themselves in the areas where intelligence is needed, rather than just releasing account after account. All employees must be computer literate and ready to analyze these edge cases.
In the next ten years, the software will become more and more refined. More of the revenue cycle will be automated, allowing personnel to work on the hard stuff and not just repetitive items. We will see more automation in the medical coding and payment analysis areas as well. These advances will allow an RCM to scale up and meet the demands of more and more facilities while minimizing manual, repetitive labor.
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