Reduce revenue cycle management workflow costs with AWS

Learn how to reduce revenue cycle management costs in the cloud with Amazon Web Services

Categorized as Technology
Reduce revenue cycle management workflow costs with AWS
Reduce revenue cycle management workflow costs with AWS

Running a revenue cycle management team is not cheap. Healthcare revenue cycle management leaders know that. And it is not getting cheaper – what with payers tightening the ropes each year and the rules ever changing.

It’s fast moving – much like every other billing center but is also burdened heavily with HIPAA, PHI and other severe restrictions.

Our revenue cycle management teams live, breathe and are supposed to thrive in this environment. 

Amazon Connect along with its ecosystem of cloud services helps you reduce your revenue cycle management center costs tremendously. Here’s a short guide on how we achieve economies of scale for our customers. 

Feel free to use this guide within your own RCM center.

Healthcare workflow – where do you spend time and money?

  • Contact center
  • Revenue cycle management 
  • Print
  • Scan
  • Fax
  • Phone tag
  • Data entry
  • Paper.. paper…

Let’s just agree on the above. Healthcare workflows are not rocket science, but are notoriously labor-intensive.

Let’s look at each component next.

Revenue cycle management cost components

If you work at a revenue cycle management center, you know that a large part of your day goes into handling the following:

Provider Enrollment and Credentialing
Eligibility / Insurance verifications 
Prior authorizations 
Charge posting
Denials appeals
Payment posting
Medical and COVID clearances for surgeries
Patient Demographic Entry
CPT and ICD-10 Coding
Patient and payer account receivables follow up
Patient collections
Surgery prior authorizations
Surgery COVID clearances
For certain payers, get PCP referrals as needed
Outreach to patients for demographics updates
Eligibility calls (specific specialties)
Denials payer conversations
Reports, reports… and more reports
Account receivable calls/work
Etc..
Revenue cycle management cost components

Some of these duties do, technically, bleed into the clinical contact center team. Sure. We understand that. 

But, we still have to get these done. There’s always a front end and a backend part of the revenue cycle management teams. You know that very well.

TIME TO DRIVE THOSE COSTS DOWN !

There’s no way to really automate the entire thing. Not possible – we have tried, have been trying for a while now (so have a lot many others in this industry). This is not going to happen anytime in our lifetimes.

So, how we do at least reduce the manual, repetitive, idiotic work that we do so we can elevate ourselves to supervisory work? How do we get to the point where we can actually advise our managers on what needs to be done proactively, rather than chase denials around?

Let’s see what technology in the cloud (in this case using Amazon Web services) can do for us.

Reduce Provider enrollment and credentialing costs

A large part of denials occurs due to providers not being enrolled in various payer plans. And of course, as and when payer plans open up in your neck of the woods, you want your providers to be empanelled. We get that.

Provider enrollment, credentialing, hospital privileges simply involve maintaining credentials, certificates, filling out forms with 100% accurate information, faxing forms to the right places, maintaining absolutely up to date contact information for payers and providers, setting up accurate reminders, being on top of TODOs and reminders.. That’s about it.

Sounds simple, but it does become tedious when you think about the number of providers you work with, multiply that by the number of payers each plan the provider works with, the number of plans from each payer the provider accepts and then finally multiply that with the number of locations that provider is credentialed at, with the plan, for that payer.

We strongly recommend using a regimented approach for this using (at a bare minimum) a spreadsheet, reminders, calendars, faxing software, and the icing on the cake – automatically reading data received via faxes so that you don’t have to type information from faxes into your system back/forth.

That’s why we recommend using a combination of these services from Amazon Web Services.

  • Use Hylafax or Amazon Chime T38
  • Use Amazon Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use Amazon Textract

Or, of course, you could simply use EzHCRM.

Eligibility/ Insurance verifications

If you believe that denials is the heart of an RCM team, then you will soon discover that eligibility and insurance verifications are something that you can control very well – especially since these are easy to get done and very easy to address by reaching out to patients ahead of their appointments.

Whether you use your practice management system’s eligibility system or not, these are crucial to get done. We will also show you how to get these done in bulk using a simple spreadsheet as well (although, it is a bit geeky, to be honest).

Otherwise, simply use one of the best APIs in the market – changehealthcare APIs or Navinet’s APIs. These guys are doing a stellar job of providing API and portal based access to eligibility and insurance verifications (ad hoc / single transaction and batch ones).

The responses you get from your eligibility requests on these vendor sites will vary, and hopefully you understand (by now), how to decipher the response received from payers w.r.t eligibility requests. 

If you are going to use AWS cloud services, here’s the combination we would request. If you are not going to use changehealthcare APIs, you can also connect to each payer’s EDI API endpoint individually as well.

  • Use change healthcare APIs on AWS marketplace 
  • Use Amazon Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS

Or, of course, you could simply use EzHCRM.

Prior authorizations 

Prior authorizations are pure evil but necessary evils 🙂 I have written about how to automate part of your prior authorization workflow here. As you already know, prior authorizations contribute to a significant amount of denials from payers. The more you can automate, the better it is. If you are large enough and can afford it, ChangeHealthcare’s interqual is probably the best way to go (we have no experience with it).

According to a McKeeson study conducted in 2014 with CAQH Index data, the total cost of an authorization is $35-$100 when faxes, phone calls, clinical time and other aspects are considered.

You NEED to reduce these costs as much as possible. For people that cannot afford to use InterQual, you still have to rely on filling out the paper prior authorization forms. 

Have no fear, there are ways to automate that as well. Use a combination of open source software and cloud Amazon Web Services combination as stated below

  • Use change healthcare InterQual Connect if you can afford it
  • OR  Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use PDFKit on AWS EC2
  • Use HylaFax / AWS Chime T38 for faxing

Or, of course, you could simply use EzHCRM.

Charge Posting

Most of your charge posting should already be happening directly from your practice management system. However, much like most of us in revenue cycle management, we tend to want to have control over charge posting and don’t want to automate things outside of the very simple cases of coding (ICD/CPT). We want to double/triple check, scrub the claims, ensure that the chances of denials are next to zero, then only submit the claims to reduce the chances of reworking the claims downstream.

This is done MUCH better if you have almost “spreadsheet” like control over charge posting AND spreadsheet like “reporting” capabilities in your hands (something that most practice management systems do not give you). 

We will also show you how to get these done in bulk using a simple spreadsheet as well (again, like we mentioned above, it is a bit geeky, but gives you a LOT of control).

Otherwise, simply use one of the best APIs in the market – changehealthcare APIs or Navinet’s APIs. These guys are doing a stellar job of providing API and portal based access to eligibility and insurance verifications (ad hoc / single transaction and batch ones).

The responses you get from your claims submission requests on these vendor sites will vary, and hopefully you understand (by now), how to decipher the response received from payers. 

If you are going to use AWS cloud services, here’s the combination we would request. If you are not going to use changehealthcare APIs, you can also connect to each payer’s EDI API endpoint individually as well.

Regardless, you are going to have to extract the information from superbills (we are pretty sure your providers are STILL using superbills and refuse to move over to electronic format. Let’s face it, paper IS faster than the web). Use Amazon Textract for this.

  • Use change healthcare claims APIs on AWS marketplace 
  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use AWS Textract for super bills 

Or, of course, you could simply use EzHCRM.

Payment Posting

Let’s face it. Payment posting is painful.

You receive remittance advice – they are either electronic (ERA) or paper based (RA).

Either way, they are always bundled with multiple payments. Hopefully your practice management system already did the job of reconciling those payments to the correct charge posting / claims line items. 

Regardless, you are going to have to double check them anyways. Otherwise you are going to have to go through them line by line and reconcile the payment information.

Whether your PMS reconciles the information or not, the payment hits your company’s bank directly via ACH payments or your accounting department deposits a paper check – neither of which is part of your PMS anyway.

So, your visibility into that is limited. 

This process is broken, and you have to live with that. And you have to reconcile that.

Along with each remittance advice you are also getting an explanation of benefits (EOBs). This gives you a treasure trove of information – what got paid, what didn’t get paid, what needs more information, what got paid partially, what’s patient’s responsibility etc.

So, this is where Amazon and it’s cloud based services can help you with this reconciliation. We recommend using a slew of Amazon cloud services along with Amazon Textract to handle extracting text data from remittance advice documents, EOB documents.

  • Use AWS Textract for EOBs and RAs
  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS

Or, of course, you could simply use EzHCRM.

Denials appeals

Denials.. Ahhh.. denials 🙂 The root of it all. If you understand denials, you can conquer revenue cycle management.

Most denials will come to you via explanation of benefits documents (EOBs). For this, use Amazon Textract to ease your pains. 

Based on the information extracted from EOBs, you will have to take further action upstream (fix eligibility, credentialing, enrollment, charge posting, coding etc) OR, sometimes you would have to appeal the denial from the insurance payer.

It is hard to keep track of all the denials you are appealing. Use a spreadsheet and a very regimented approach to denial appeals.

In general, what you need to do is keep track of the original claim date, original claim number and the denial date, number etc. This way, the payer representative can tie these two together and never claim that a claim has passed the timely filing limits.

As you can imagine, there’s a lot of faxing and mailing documents involved – it’s preferable to do more faxing than postal mail (of course). 

Our recommendation is to use a combination of these Amazon cloud services to reduce the denials workload.

  • Use AWS Textract for EOBs
  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use Hylafax or AWS Chime T38 for faxes.

Or, of course, you could simply use EzHCRM.

Amazon Textract will allow Human intervention- don’t worry!

Medical, COVID clearances

These days, we all have to get COVID clearances before surgeries. This is in addition to the medical clearances that we needed to get for surgeries anyways.

Getting clearances is actually not the tough part – however, this is also what usually derails surgeries and leads to surgery delays or cancellations. 

Our surgery scheduling team usually does not leave medical clearances in the hands of our patients. 

They always triage with the primary care offices to ensure that the patient has an appointment for their medical clearance.

The team always follows up with the patient to ensure that they show up for their own medical clearance appointment.

The surgery scheduling team then follows up with the primary care provider’s office to ensure that they receive the fax with complete details required for the surgery clearance. 

Similar process is followed for COVID clearances as well.

We use Amazon Web Services to reduce our workload a lot. Below is the combination of AWS services we use to achieve maximum automation of these tasks (faxing, phone calls, SMS, reading faxes received etc)

  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use Amazon Pinpoint campaigns.
  • Use Amazon Textract to read faxes

Or, of course, you could simply use EzHCRM.

Patient demographics 

If you look closely at the number of denials caused due to incorrect patient demographics – you’d be amazed. This causes eligibility checks to fail, prior authorizations to fail and therefore claims to be denied as well.

On top of this, when our provider offices receive medical referrals via faxes, there’s the entire patient CCDA that now has to be transferred over to our customers’ EMRs for it to even be of any value. 

Sure, we could simply type in the “required” fields and scan in the rest of the fax – but that would lead the entire data useless for downstream use, wouldn’t it?

We would never be able to mine this data for our own benefit later on as this data would be locked in the PDF document forever.

So, what to do? In most cases, we would have to manually enter all patient demographics manually.

In addition to this, we would also have to enter all patient continuity of care data manually. 

No more – nowadays we utilize Amazon Web Services for this purpose. 

Patient demographics change from time to time. For patients that have not come in to see our providers in more than 6 months, there’s a decent chance that their demographics would have changed – they might have changed addresses, contact information or maybe even their insurances. 

Usually the only way to update this information is when the patient calls you to make an appointment. But, if you do not stay in touch with the patient proactively, and try to get in touch with the patient to recall them when your appointment book seems a little “light” what invariably happens is that you find out – your patient contact database is “outdated”. Your NYC patient is now in Florida, and has been for 3 years!

Or, your patient has deceased, or changed doctors.

Shame on you.

It is so easy to stay in touch with your patients regularly leveraging technology and at the same time not be begging them to come in for an appointment only when your appointment calendar seems “light”.

We recommend that you use a combination of these Amazon Web Services to achieve the same.

  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use Amazon Pinpoint campaigns for patient directed self updates
  • Use Amazon Textract to read from faxes

Or, of course, you could simply use EzHCRM.

CPT ICD-10 coding

This is a VERY interesting one. CPT and ICD coding is the heart of getting reimbursed correctly. There are denials related to upcoding and downcoding. Rules change each year and your team needs to be in compliance with payer guidelines each year. This is manual work and you either need super experienced coders on your team (which not everyone can afford to hire) or you need to hire experienced medical coding teams.

Regardless, you can also collaborate with your doctors (if they are amenable to it) by using Amazon Comprehend Medical and stretching it to its limits. Keep in mind that at the time of writing Comprehend Medical is still finding its feet (beta). They recently announced that they added ontology linking. So, what you can do is that you can take a visit note and superbill to construct your coding of CPT + ICD needed for the claim. A superbill typically contains Procedure Codes (CPT), Diagnosis Codes (ICD-10), Modifiers and that’s supposed to be enough information for you to submit the claim with that data – but it hardly ever is. 

  • Use Amazon Comprehend Medical to its limits
  • Use Amazon Textract on Superbills
  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS

Or, of course, you could simply use EzHCRM.

Patient receivables, collections

After you have received the explanation of benefits and adjudication from your payers, now it is time to take care of the final mile. 

Your patient has a balance due and is, in all probability, not going to be very happy to pay.

The older a balance due gets, the harder it is to collect. There are very strict laws around how you can collect from patients as well (i.e. collection calls have very strict rules around how and when you can call, what you can say etc).

But, the job has to be done – either by you or by call centre staff like ours.

You can very easily make your life easier with the help of Amazon Web Services here as well. As usual, you are going to have to use Amazon Textract to extract information from the faxes. You are going to have to use Amazon Pinpoint to run payment reminder campaigns on these patients. You are going to have to make it super easy for these patients to pay their balance dues. You are going to have to be able to explain to patients WHY they have a balance due (i.e show them a breakdown of what your charges were, what their insurance company paid, what is due from them etc). In other words, you are going to have to show them the EOB (even though they themselves received the same).

Here’s the combination of AWS services that we recommend you use. Keep in mind that stripe.com partners with plaid.com and hence you can cover both credit card and ACH payments with the same APIs

  • Use Amazon Textract on EOBs
  • Use AWS Step Functions
  • Use AWS Lambda
  • Use HIPAA secure EMR data dips
  • Use DynamoDB or RDS
  • Use Amazon Pinpoint campaigns 
  • Use stripe.com for payments

Or, of course, you could simply use EzHCRM.

Reports, reports, reports….

Typically, in revenue cycle management, you are not going to need the kind of real time reporting that contact centers need. But you will need a LOT more analytics that contact center teams need and a lot more slicing and dicing of data than your contact center leads need.

You are going to need a lot more on the anomaly detection when it comes to payments.

You are going to need to understand whether you have any underpayments as we are sure you are doing underpayment audits and recovery to some extent in your organization.

You are going to need to understand your net days in A/R, the trends etc – much beyond what your practice management system provides you.

Usually, you put all this data into some kind of relational database and run analysis on top of it. However, with Amazon’s Athena and AWS S3 storage, you can simply upload giant spreadsheets (CSV files) and run queries extremely fast, extremely efficiently and DIRT cheap.

Ever since we started using Amazon Athena, we have not looked back. No more waiting for IT folks to create, maintain and tune databases – our business analysts can get most of the job done by themselves! 

Next up, for visualization, we highly recommend you use Amazon Quicksight – it’s the world’s first “pay per use” business intelligence tool. Wow.

Amazon did it again.

Not only for business intelligence, you can use it for forecasting – something that all of us managers can appreciate.

On top of this, it looks back at your data and using machine learning, it can also do anomaly detection for you – taking care of all the back breaking spreadsheet work we used to do with our teams.

Here’s the recommended stack of AWS services for reporting – the heart and soul of revenue cycle management!

  • Use Amazon QuickSight for reporting, forecasting, anomaly detection 
  • Use Amazon S3, Amazon Athena for data storage and analytics of historical data
  • Use Amazon Kinesis for real time data

Or, of course, you could simply use EzHCRM.