Given labor shortages and financial constraints, fully managed hybrid outsourcing solutions are increasingly gaining prominence. Hospitals and provider organizations grapple with staffing deficiencies across various departments, with the revenue cycle facing considerable strain. A recent survey among medical group leaders highlighted coders as the most challenging role to fill, closely followed by billers, schedulers, authorization specialists, and positions related to credentialing and patient engagement. This struggle could be driving more providers toward seeking assistance from revenue cycle outsourcers.
An April 2023 survey targeted revenue cycle leaders to discern which processes they either were outsourcing or intended to outsource in the subsequent 12 months. The top processes earmarked for potential outsourcing included authorization and medical necessity (19%), denials and appeals management (18%), and underpayment analysis and recovery (18%).
Challenges in outsourcing
Cost remains a significant hurdle in outsourcing, particularly with prevailing inflation rates. For provider organizations grappling with shrinking operating margins, the prospect of engaging another outsourcer, regardless of its advantages, might seem financially unfeasible. Yet, there are alternatives to this perception.
Hybrid international outsourcing frameworks and adaptable commercial options.
Through outsourced models, organizations gain relief in staffing and access to cutting-edge technology capabilities. Instead of constructing in-house teams and systems, outsourcing enables leaders to swiftly acquire vital resources.
Presently, offshore medical coders frequently possess full certification
Now comes the global outsourced model, allowing organizations to harness the worth of offshore resources while coupling it with onshore oversight. This hybrid approach aids providers and staff in sharpening their attention on enriching care delivery and refining the patient experience. Additionally, inventive commercial arrangements within fully managed outsourced models serve to regulate expenditure. Establishing alignment on Key Performance Indicators (KPIs) ensures that the outsourcing partner is held accountable for delivering enhanced outcomes.
Five functions well-suited for hybrid outsourcing
-
Management of Claims and Billing.
Numerous outsourcers harness cutting-edge technologies such as artificial intelligence (AI), machine learning (ML), robotic process automation (RPA), and natural language processing (NLP). These capabilities are often absent within internal resources of many health systems, making outsourcing an avenue to streamline workflows and achieve precise coding. This leads to a reduction in denials and write-offs, thereby enhancing cash flow and expediting timely reimbursements.
-
Processing Payments and Reconciliation.
Contemporary outsourcers employ automation technologies like AI and intelligent character recognition. These innovations significantly reduce the manual aspects of processes, consequently enhancing accuracy, staff efficiency, and turnaround times. As a result, this minimizes Accounts Receivable (A/R) days and optimizes cash flow.
-
Management of Accounts Receivable and Collections.
Global outsourcing firms boast revenue cycle experts well-versed in payer requirements and U.S. regulations. Their proficiency extends to the intricate facets of Accounts Receivable (A/R) management and collections, enabling them to collaborate effectively with payers on behalf of providers. They specialize in crafting tailored standard operating procedures in collaboration with their clients.
-
Management of Denials and Appeals.
Hybrid outsourcing entities leverage automated workflow tools to streamline denial management and appeals. Employing BOTs, they automate the appeals process, enhancing revenue reconciliation. The most efficient partners integrate predictive models to preempt similar denials in the future. Outsourcing denials and appeals eradicates backlogs, freeing onsite staff to concentrate on more strategic responsibilities.
-
Underpayment Recovery and Resolution.
Certain global outsourcing firms dedicate entire teams exclusively to underpayment recovery. These teams possess comprehensive knowledge of payer contracts and discrepancies, conducting thorough cross-verification of payer fee schedules to ensure precise reimbursements. The most reliable partners excel in identifying the root causes of underpayments and assist providers in formulating strategies to diminish such occurrences in the future.
Opportunities in Clinical Outsourcing
Beyond revenue cycle management, numerous outsourcers provide services aimed at mitigating clinician burnout. One such service involves managing clinician inbox messages from patients, a critical area of support. As patient portals witness widespread adoption, clinicians contend with an overwhelming influx of messages—sometimes exceeding 100 in a day. Consequently, they spend extensive hours responding to emails, handling prescription requests, coordinating referrals, and more. Implementing a hybrid outsourcing model incorporating virtual nurses under onshore supervision presents an opportunity to alleviate stress on clinicians while concurrently enhancing the patient experience.
Overseas registered nurses have the potential to attain complete credentials and licensure in the U.S.
Licensed offshore virtual nurses are equipped to address follow-up queries from visits, evaluate patient symptoms, and direct urgent messages to the relevant healthcare provider. Their capabilities extend to prescription refills, addressing non-urgent medical inquiries, and coordinating appointments and referrals. This approach allows clinicians to dedicate their attention to direct patient interactions; ensuring patients receive more prompt and efficient responses to their queries.
The Conclusion
However strenuous their efforts may be, health systems cannot solely overcome their existing staffing challenges through hiring practices. It’s imperative to explore a novel outsourcing model now, one that harnesses a comprehensive, global approach, ensuring end-to-end service delivery.