Nine in Ten Integrated Health Systems’ Outpatient Services Losing Revenue Due to Flawed RCM Systems: Deficiencies Erode Ancillaries’ Financial Performance, Reports Black Book

NASHVILLE, Tenn., November 18, 2024 (Newswire.com) - According to the latest findings from Black Book Research, integrated outpatient centers, encompassing a broad range of services such as labs, diagnostic imaging, physical therapy, home health, chemotherapy infusion, and subacute care, are experiencing significant financial challenges due to flaws in their Revenue Cycle Management (RCM) systems. The survey, which involved 772 business office leaders, highlights severe gaps in RCM processes that are leading to higher denial rates, delays in reimbursement, and lost revenue.

Financial Strain Worsens for Integrated Outpatient Centers

“Integrated outpatient centers are vital for delivering efficient, comprehensive care outside of hospitals,” said Doug Brown, Founder of Black Book Research. “However, outdated RCM systems are causing serious revenue losses. Investing in experienced, high-performance RCM vendors is essential to streamline billing, pre-authorizations, and eligibility processes to recover lost revenue.”

Key Findings: Inefficiencies in RCM Impacting Revenue

The survey paints a concerning picture for integrated outpatient facilities, emphasizing the urgent need for optimized RCM solutions in outpatient healthcare delivery settings:

1. High Denial Rates and Reimbursement Delays

o 92% of respondents reported elevated denial rates, particularly for complex, multi-step procedures. Outdated systems lack the sophistication to manage these intricacies, resulting in underpayments and delayed reimbursements.

o Diagnostic imaging and outpatient rehabilitation centers are among those hardest hit, struggling with coding accuracy for bundled services, which leads to frequent denials.

2. Pre-Authorization and Eligibility Verification Bottlenecks

o 93% of respondents cited significant delays in securing pre-authorizations, especially for services like radiology, chemotherapy, and home health. Manual processes slow down approvals, ultimately delaying patient care and reimbursements.

o The challenge of obtaining approvals from multiple insurers for a single patient’s treatment plan further complicates cash flow.

3. Complex Coordination with Multiple Payers

o Notably, 100% of the Black Book survey respondents indicated that their outpatient facilities are struggling and losing money on highly complex claims particularly when dealing with multiple payers such as commercial insurance, motor vehicle accident (MVA) claims, liability insurers, and Veterans Administration (VA) benefits.

o Additionally, 97% of business office leaders serving veterans reported prolonged delays due to stringent VA processing requirements.

4. Coding Errors Leading to Revenue Leakage

o Nearly 79% of facilities lack the necessary tools to accurately code claims involving multiple payers, leading to significant revenue leakage. Labs and imaging centers are particularly affected, where precise coding is critical for reimbursement. Inadequate coding processes not only delay payments but also result in substantial underpayments.

5. Lack of Real-Time Analytics to Drive Financial Performance

o 77% of respondents do not have access to real-time analytics tools, making it difficult to detect patterns in denials or revenue leakage. The absence of actionable insights hampers efforts to optimize revenue cycles and improve cash flow.

The Importance of Selecting Qualified RCM Vendors

The findings emphasize that partnering with qualified, experienced RCM vendors is crucial for outpatient centers aiming to overcome their financial challenges. Selecting the right vendor can help these centers reduce inefficiencies, optimize collections, and improve overall financial sustainability.

Top-rated vendors identified in the Q3-Q4 Black Book survey on outpatient and ancillary provider settings include:

· EnableComp: Specializes in handling complex claims such as workers' compensation, MVA, and VA claims to optimize reimbursements for outpatient centers.

· Optum360: Provides end-to-end RCM solutions that enhance revenue integrity and streamline billing for integrated ancillary services.

· Infinx Healthcare: Focuses on leveraging automation and AI to expedite pre-authorizations and improve claims management for labs, imaging centers, and rehabilitation facilities.

· Inovalon: Delivers advanced RCM software tailored to diagnostic labs and imaging centers, helping reduce billing inefficiencies.

· Ensemble Health Partners: Offers outsourcing services designed to optimize the entire revenue cycle for integrated outpatient facilities, ensuring financial efficiency.

· XiFin, Inc.: Offers a specialized Revenue Cycle Management (RCM) solution tailored for integrated outpatient ancillary services, such as pathology, radiology, pharmacy, and laboratory departments.

· Plutus Health: Specializes in AI-driven RCM services for various healthcare providers, including outpatient and ancillary services. Their offerings include claims management, denial prevention, and revenue optimization through advanced analytics and automation.

Addressing the Urgent Need for RCM Optimization in Ancillary & Outpatient Centers

The survey underscores the necessity for outpatient centers to modernize their RCM processes by partnering with specialized vendors. Without the right systems in place, these facilities will continue to face significant financial pressure, impacting their ability to deliver patient care.

“Providers need to focus on selecting high-performance RCM vendors who understand the complexities of outpatient services,” Brown added. “By optimizing claims management, patient engagement, collections and revenue cycle processes, healthcare systems can recover lost ancillary revenue and improve their total financial outlook.”

About the Survey

The survey conducted by Black Book Research in Q3-Q4 2024 gathered responses from 772 business office leaders representing labs, diagnostic imaging centers, outpatient rehab facilities, home health agencies, and other integrated outpatient services across the United States. Top-rated vendors were selected on the basis of 18 qualitative key performance indicators.

About Black Book Research

Black Book Research, an independent research firm, delivers essential, data-driven insights into the healthcare industry. Its annual survey of ancillary business office leaders provides crucial information on the challenges and opportunities facing outpatient and integrated healthcare services. Committed to impartiality, Black Book neither accepts financial engagements with vendors nor participates in sponsorships, media placement charges, subscriptions, or alliances, ensuring completely unbiased, objective reporting.

Source: Black Book Market Research