Challenges, Trends and Disruption in next five years in RCM industry


  • As more hospitals and health systems have invested in automation for revenue cycle operations, it has become clear that the type of automation matters. Organizations have discovered that it can take up to 12+ months to build and deploy a robotic process automation (RPA) bot for one discrete task that may, or may not, deliver the anticipated efficiencies or return on investment. This makes the process of on boarding RPA slower than many organizations can afford.
  • According to a 2019 Forrester report, for every $1 spent on RPA technology an additional $3.41 is spent on consultants and support services to maintain it. As revenue cycle leaders gain insight into the limitations and challenges of RPA, there is increasing demand for artificial intelligence (AI) and machine learning (ML) based solutions that are better able to adapt to process changes, more fully automate complete functions and handle
  • Nearly 60 percent of healthcare Chief Financial Officers (CFOs) and revenue cycle leaders mistakenly consider robotic process automation (RPA) to be a form of artificial intelligence (AI). When statistically evaluated by past or current use of any revenue cycle automation tools, more than 50 percent of revenue cycle leaders in organizations that are actively using automation in their revenue cycle operations demonstrate confusion between RPA and AI
  • 30% of health systems and hospitals using revenue cycle automation require two or more vendors to manage the process. Some organizations use four vendors or more to manage revenue cycle automation

Top Challenges in Speciality Healthcare

Strong Prior Authorization Process

Prior Authorization is the process of obtaining approval from the payers before a provider offers any service to a patient. Prior Authorization helps in controlling cost and allows providers to provide evidence-based treatment to the patients.

In specialty healthcare, prior authorizations are essential as the specialists can arrive at a proper treatment plan that adheres to the distinctive requirements of various payers. Therefore, outsourcing your prior authorization process to an RCM company that understands specialty-specific prior authorization requirements can  improve the clean claim rate, reduce denials, and improve reimbursements. 

Revenue Integrity – Capturing the right charges

Charge entry is one of the most crucial processes in medical billing. In this process, a patient account is involved the correct $ value as per the medical codes and the fee schedule. The charge entry process determines the reimbursement a physician receives for the services rendered. Apart from this, all cost accounting methodologies and financial benchmarking depend on the practice’s ability to get reimbursed effectively, thereby relying immensely on charge entry.

The charge entry process becomes more complex in the specialty ecosystem as it includes many specialists participating in a value-based care program or bundled payment programs. The complexity is due to multiple systems to generate various information that helps diagnose & treat patients with highly complex diseases. Therefore, Healthcare organizations should begin to move towards data interoperability to overcome issues in the charge entry process. Charge entry outsourcing can help you achieve >98% charge capture accuracy and reduce charge entry lag. 

Accurate Medical Coding

Coding for a specialty healthcare provider is one of the complex processes in revenue cycle management. The evolution of ICD-10 guidelines for specialty healthcare is rapid and demands the coders to stay updated with every nuance of the correct practices. Improper knowledge and incorrect coding might result in revenue leakage. Confronting payment challenges due to such frequent changes in guidelines can be done by outsourcing their specialty coding needs to an offshore revenue cycle management company. 

Managing A/R diligently

Accounts receivable benchmarks for the specific specialty must be adhered to while managing the A/R. A team of focused accounts receivable and denial management professionals can keep days in A/R less than 30 days. Creating an iterative feedback look to coders and clinicians based on claim denials can shift the focus to denial prevention and eliminate situations of huge backlogs. CFOs should work with COOs and revenue cycle operations managers to define A/R and collections standard operating procedures to eliminate situations of claims not being addressed due to lack of clarity on the guidelines.


Physicians/providers must credential themselves with the Payer’s network and be authorized to provide services to patients who are members of the Payer’s plans. The credentialing process validates that a physician meets standards for delivering clinical care. The Payer verifies the physician’s education, license, and specialty accreditations. Payers may delay or refuse payments to physicians who are not credentialed and enrolled with them. These impact the financials of the practice negatively.

Providers in specialty healthcare must ensure that they are credentialed appropriately as per their skills. Providers who have been credentialed already should provide up-to-date information on acquiring any new specialty certification. Allowing external credentialing specialists to handle your credentialing requirements will help avoid mishaps in terms of reimbursements.


    • More than 66 percent of health systems and hospitals currently use some form of automation in their revenue cycle operations
    • More than 60 percent of the provider organizations that do not currently use automation plan to do so by the end of 2021
    • 90 percent of financial leaders want automation solutions that are purpose-built for healthcare revenue cycle operations
  • Organizations are looking for automation tools that help bring consistency and continuity to their revenue cycle operations while mitigating the impact of erratic claim volumes to their staff
  • 75% of organizations intend to restructure their revenue cycle operations in response to shifting business dynamics driven by the pandemic
  • Larger healthcare providers with $1B – $10B net patient revenues; organizations that have experience with or currently use automation; and health systems (versus hospitals) are statistically more likely to restructure their revenue cycle operations to increase permanent work-from-home staffing post-pandemic
  • Health systems (77.2% use automation) versus hospitals (62.6% use automation) are statistically more likely to have automation in their revenue cycle operations
  • Adjustment posting and billing edits are top areas where automation is applied in healthcare revenue cycle operations
  • More than 60 percent of health systems that do not currently use revenue cycle automation plan to do so by end of 2021
  • Revenue cycle leaders are expected to focus on automation for claims management (eligibility, prior authorizations, claims status); denials management (how to better predict, work/appeal denials and reduce initial denials and write-offs to improve overall revenue capture); and clinical revenue cycle management (in-patient/ out-patient coding, clinical documentation improvement to reflect acuity and increase appropriate reimbursement, case management or utilization review to reduce unnecessary utilization, and charge capture for overall billing improvements) – all of which are resource intensive. Hospitals and health systems will look for solutions that are purpose-built for their use, with an eye to a partner that can provide an automation platform that has potential applications across the organization


2021 is poised to see more revenue cycle leaders invest in automation and those who already do will expand their programs

As these automation tools roll out across hospitals and health systems, we expect the following aspects to be of utmost importance:

  • Solutions that are purpose-built for hospital and health system revenue cycle operations
  • Speed of automation integration/faster deployment
  • The ability to deploy entirely remotely with limited or no need for staff shadowing
  • The ability to automate full revenue cycle functions
  • Automation that removes tasks from employee queues so staff can focus on more complex work
  • The scalability, resilience and flexibility of the automation solution

There are three fronts major disruption is happening in RCM technology: 

  1. Artificial intelligence
  2. Cloud-based technologies
  3. Patient accounting systems

Each presents its own strengths and brings some attractive features to the table for healthcare businesses to consider.

Disruptive Artificial Intelligence RCM

Disruptive technology with artificial intelligence (AI) capabilities is being employed to help patients better understand their insurance coverages and their out-of-pocket costs for the services they receive. 

Some of the things that RCMs powered by artificial intelligence accomplish for healthcare facilities include:

  • Determining the costs of offering services versus money collected from patients and payers providing them.
  • Identifying opportunities for additional profits.
  • Selecting value-based contracts according to which offer the best returns.
  • Aid in identifying financially beneficial programs according to what best aligns with the needs of a facility’s patient population.

Some of the disruptive technology systems powered by AI that are changing RCM 

  1. Parascript for Revenue Cycle Management

Off the top, Parascript reduces your cost of handling data by 50 percent or more. This creates greater overall efficiency for your practice and saves your practice money by automating many of the processes related to data and documents. Parascript manages all this while helping you reduce costs and increasing your collection efforts and results. Other ways Parascript helps your practice perform more efficiently include:

  • Data matching and capturing to improve claims.
  • Explanation of benefits.
  • Invoice data extraction.
  • Check processing.
  • Document classification.

 By helping you improve your practice’s ability to manage data, documents and information, your entire organization operates with greater efficiency.

  1. Middlegate’s Revenue Cycle Management

With a tagline of “collect more and chase less,” there’s much to love about Middlegate’s artificial intelligence revenue cycle management system, called Grace. Medical practices know the pain of playing the “claims games” with payers that never seem to want to pay up. She is a machine intelligence that solves your payment problems at amazing speeds, freeing up your time to care for your patients. After all, that’s what you got into business to do in the first place. 

  1. RCMbrain’s Beth

Beth is the brainchild of RCMbrain. She uses robotic process automation to take on repetitive tasks that bog down your team and often leave them frustrated. In fact, she performs these tasks without making mistakes or becoming aggravated. Some of the tasks she performs tirelessly and accurately, each and every time, include:

  • Posting payments.
  • Scrubbing and tracking clams.
  • Responding to denials.
  • Managing tedious (not to mention time-consuming) workflow problems.

This frees up your practice to focus on more profitable and fulfilling pursuits. 

Disruptive Cloud-Based RCMs

With more medical practices moving away from outdated models of revenue generation that revolved around high volumes of patients to systems focused on adding value to the patient experience, the need for greater efficiency in the revenue cycle management process is more important than ever. 

Cloud-based RCM systems offer medical practices a system that not only transitions well, but also offers full transparency. Benefits of cloud-based RCMs include:

  • Staff support in capturing demographic information concerning patients and verification of personal financial information and insurance coverage.
  • Generates faster, more accurate claims processing.
  • Assists in identifying opportunities for additional revenue by profiling patients.
  • Enables collaboration concerning patients without violating HIPPA requirements.
  • Empowers healthcare practitioners to increase efficiency, improve their cash flow, and get paid for the services they provide.


Some of the cloud-based RCMs currently disrupting the healthcare industry


What sets XIFIN RPM 9 apart from other revenue cycle management systems is that it goes beyond the traditional role of improving cash collections you see in many RCM programs by offering exceptional visibility and control over your financial operations while improving connectivity within your organization and beyond it. XIFIN also offers an entire suite of services designed to help you improve your efficiency, so you can focus your time and attention on delivering an exceptional patient experience rather than on how you’re going to get paid. 

  1. Care Cloud RCM

If you’re looking for a cloud-based RCM solution, then Care Cloud is an excellent place to start. They offer RCM experts who can help you optimize your entire payment cycle with personalized advice, advanced analytics, intelligent billing and local support. Using this technology not only streamlines the payment process for your business, but it also helps you operate more efficiently, improving the overall patient experience. This allows you to earn more profits for your business while allowing you to adapt smoothly to new regulations and other industry changes. 


  1. RCM Cloud

When you’re ready to cut costs, reduce your data and information technology burden, and increase profits, RCM Cloud is a great place to begin. This technology not only helps you boost your collection efforts, but it also improves your clean claim rates, reduces collection costs and increases staff productivity.

Disruptive Patient Accounting Systems

Patient account systems (PAS) are causing major disruptions when it comes to traditional means of revenue cycle management in the healthcare industry. While some organizations see the initial costs as prohibitive or, at the very least, unappealing, those who do adopt this disruptive technology find it to be an investment in greater efficiency, cost savings and improved cash flow overall.

The bottom line is that the long-term benefits resulting from adopting a patient accounting system far outweigh the initial challenges of doing so. These are some of the systems you might consider for your practice:

  1. Experior Practice Management Patient Accounting

Maximize collections, process data more efficiently, and improve your overall standards of patient care and services with the Patient Accounting module from Experior ExpertPM. Effectively managing data and information is one of the costliest tasks modern medical practices must perform. It is tedious, and government regulations and requirements add new levels of pain (and expense) to the process. The PAS from Experior allows you to manage sensitive patient information more efficiently, within regulatory compliance, and reduces your costs for doing so while helping you improve the cash flow of your practice.

  1. McKesson STAR Software

The McKesson STAR system allows healthcare facilities to determine how much insurance coverage patients have as well as their ability to pay for various services. The benefits do not end there, though. It also empowers medical practices to examine the true costs of their services to determine which services are cost-effective and where negotiations with vendors need to be made to reduce the costs of providing certain services. Most importantly, the McKesson STAR software system is scalable to grow with your practice, making it more cost-effective, too. 

  1. FinancialAccess Patient Accounting

When it’s time for your practice to get real results from your collection efforts, it’s time to consider the FinancialAccess patient accounting system. This RCM system offers medical practices a single integrated system to reduce double entries and create a more seamless workflow, while offering advanced collection techniques, so you can enjoy true results from your collections efforts, while allowing your team to focus on providing a better experience for your patients.

Just as medical practices are not “one-size-fits-all” organizations, neither are the revenue cycle management systems on the market today – even the disruptive variety. Take a little time to learn about your options, like these mentioned above, and make an informed decision about the best disruptive technologies to spur your RCM efforts to new levels of success and your practice to bigger, better, faster and more profits.

Value-based healthcare (VBC)

Value-based healthcare has already transformed much of the health sector—a trend that will continue to change operations, payment structures and, ultimately, the way health organizations approach delivering and evaluating services.

The shift toward value-based care was recently documented in a survey commissioned by health technology company Change Healthcare, which found more than 80% of payers are considering or have already implemented one of the models of VBC studied.

Though VBC healthcare is broadly focused on creating positive outcomes for patients, it also often yields advantages for health organizations by creating efficiencies, reducing error and increasing the accuracy of quality assessments. In the Change Healthcare report cited above, the average medical cost savings for implementing VBC strategies was 5.6 percent.

Some popular value-based healthcare models:

Medicare Quality Incentive Programs

The Centers for Medicare & Medicaid Services have developed a full range of quality incentive programs that are designed to improve patient care as well as transparency. They achieve this mission through payment incentives or reductions as well as through incentives for improving transparency between health organizations and the public. For example, one of the goals driving the Medicare Advantage Quality Improvement program is for Medicare Advantage Organizations (MAOs) to provide incentives to providers for excelling in quality assessments.


Although many pay-for-performance VBC initiatives come from Medicare Quality Incentive programs, some private insurance companies have also leveraged this model. Pay-for-performance revolves around offering financial incentives to providers for meeting quality of care objectives. This is typically achieved through adjustments to typical fee-for-service pricing. For example, payers may penalize providers who fail to meet performance thresholds.

Accountable Care Organization

The primary goal behind accountable care organizations is to better coordinate care across different specialties and services. One such model is to treat a hospital and “extended hospital staff” as a focal point of accountability. Under this strategy, care is coordinated so that performance measurement considers services throughout the hospital and extends to referrals made by doctors.

Bundled Payments

With bundled payments, reimbursement models shift toward paying for an entire cycle of care, rather than paying ad-hoc for different services provided to treat the same condition. The objective for this model is to encourage providers to optimize the procedures and services they offer so that positive patient outcomes can be achieved more efficiently.

Patient Centered Medical Home

The patient-centered medical home is a framework and model of organizing care to focus on better coordination of services, higher quality of care, improved accessibility of services and accountability for considering the entirety of a patient’s needs. This often translates to primary care facilities serving as the focal points for coordinated services and providers.

Benefits of Value-Based Healthcare

Although the primary goal driving the implementation of value-based healthcare is centered on quality, organizations have seen benefits that extend to their operations and reduced costs. In February 2019, for example, health services provider Cigna announced that it exceeded its goal of using alternative models for 50 percent of its payments, which translates to roughly 3.6 million patients receiving care through a value-based model. Between 2013 and 2017, this transition helped save Cigna more than $600 million, and the company highlighted data analytics as a critical element of this success.

Adopting value-based models can create efficiencies when implemented and executed well. For example, an accountable care organization could help better coordinate services, reducing the chances that unnecessary procedures are performed. Because there is a greater focus on communication between different services offered, this model can also ensure that diagnoses and effective treatments are performed more quickly.

When looking at accountable care organizations (ACOs), one study noted a 4.9% reduction in per-patient spending with physician group ACOs. However, it is important to note that hospital-centric ACOs didn’t achieve the same benefit.

Moving Forward with Health Analytics

The momentum for value-based care shows little sign of stopping, with nearly half of payers having implemented accountable care organizations and more than one-fifth developing other VBC models. Between 2015 and 2017, the number of health payments tied to VBC grew from 23% to 34%, showing the same growth span across many organizations within the health sector.

The increasing adoption of value-based healthcare puts even more emphasis on making smarter decisions, mitigating risk and delivering preventative care. Health analytics is a key driver for empowering these decisions because it enables health organizations to better use their data, find missed opportunities and identify the variables that most affect patient outcomes. At the same time, utilizing health analytics technology effectively is not without challenges.

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