In-house teams struggle to manage the revenue cycle. That's not a bad thing.

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When it comes to the revenue cycle, says Sue Perrotty, CEO of Tower Health, “We are never going to be the best in class at doing that because we want to invest in our clinical infrastructure.”??

This is the dilemma faced by many health systems: Why invest internally in an area that differs from your main focus? Providers already have a primary mission: providing the best patient care possible. This is where an end-to-end RCM partner comes in.??

Healthcare leaders need help to compete against payers.?

Partnership is key. From advanced RCM intelligence to payer strategy support or patient experience to physician advisory expertise, Ensemble helps drive value beyond just traditional RCM performance excellence. This support plays out in diverse areas.??

Advanced technology:??

The varied use of artificial intelligence within the revenue cycle has been all over the headlines in the last year. As payers invest in increasingly sophisticated technology to deny claims and prolong the appeals process, providers find themselves unable to marshal the same resources to stay competitive.??

Strategizing with an end-to-end RCM partner can help providers bring this technology to bear in the back-and-forth with payers without requiring providers to divert their financial resources from clinical care. It’s a necessary step — these technologies are critical crafting an efficient, effective revenue cycle.??

The applied AI infused into Ensemble’s decisioning engine, EIQ?, for example, draws on revenue cycle data from hundreds of hospitals to provide actionable RCM intelligence. These innovations help guide operator actions, automate complex workflows and prevent errors before they occur.?

?? Spotlight: Account Prioritization???

Ensemble’s technology prioritizes accounts to deliver better financial outcomes. Building upon AI-driven insights in its proprietary technology that prioritize accounts for insurance follow-up and collection, Ensemble now supports AI-enabled prioritization of clinical appeals. ??

Account prioritization of insurance follow-up has produced a 23% increase in yield per touch and a 57% reduction in low-value touches by operators. Now, using 2.4 million data points and over 200 factors, high-yield accounts are identified and stratified to ensure that every clinical appeal effort maximizes revenue recovery and boosts productivity.?

Hospitals and health systems don’t have the resources to build and maintain these kinds of advanced technologies in-house, but they’re no longer optional when it comes to leveling the playing field with payers.?

Payer strategy:??

Some elements of RCM partner support aren’t measured in tools but rather techniques. The years of expertise brought to bear by an experienced firm can be invaluable for providers strapped thin and needing to focus on clinical demands and patient care.??

Who’s in your corner when things are dire? The right RCM partner understands not only best practices and how to better optimize RCM elements that are already on the right track; It’s also critical to work with a partner who knows what to do when things take a downward turn.??

Should you grant payers direct EMR access, as so many are pushing for providers to do? Do you have a proven strategy in place for going out of network if negotiations come to it? Having the right partner can help ease payer/provider friction through efficient contract negotiations, by offering informed advice and crafting strategies to negotiate successfully, especially in contentious areas like managed care contracts.?

With 100+ payer-provider contract negotiations supported, 6K+ unique payer contracts managed and over $1B in settled disputes with payers, Ensemble helps our partners alleviate this friction and make meaningful traction with payers.?

You need a partner, not just a vendor.??

Any way you look at it, achieving RCM excellence can be nearly impossible for providers focused on clinical care.?

“We're a healthcare organization. We’re people caring for people. That's our purpose. But at the end of the day, we just didn't have the management infrastructure, processes or tools to maintain an excellent revenue cycle.” — Marty Bonick , President + CEO, Ardent Health

An end-to-end RCM partner shapes strategy through all stages of the revenue cycle, driving sustainable growth, whereas traditional vendors operate at a task level. This holistic approach enables a partner to readily manage any interdependencies that arise, unlocking numerous areas of value including regular executive involvement, strategic alignment, enhanced data analytics and scalability.?

Your revenue cycle is too important to be left to chance. Find a partner whose RCM expertise matches your clinical competence, one who can hit the ground running and deliver results immediately. You’re all in; shouldn’t your RCM partner be, as well??

Regulatory Updates?

• CMS recommends that hospitals adopt updated EMTALA signage by September 13, 2024. CMS prepared the updated signage to assist hospitals in informing patients of their rights under EMTALA, including that patients can file a complaint if they believe their rights under EMTALA have been violated. Learn more.?

• The CY 2025 Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule contains a hospital payment increase of only 2.6% for CY 2025. The final rule will be issued in November. Learn more.?

• Medicare released the?Medicare Prescription Payment Plan Part Two Guidance?which states that starting in 2025, the plan provides the option for Medicare beneficiaries with Medicare prescription drug coverage to spread the costs of their prescription drugs over the calendar year rather than paying in full at the pharmacy with an annual out-of-pocket prescription drug cost cap of $2,000. Learn more.?

• CMS released the FY 2025 ICD-10-CM diagnosis codes effective for patient discharges and encounters on or after October 1, 2024, through September 30, 2025. Learn more.?

• A dialysis company with headquarters in Colorado has agreed to pay more than $34.4 million to resolve allegations that it?violated the False Claims Act by paying kickbacks to induce referrals?to a former subsidiary that provided pharmacy services for dialysis patients, and by paying kickbacks to nephrologists and vascular access physicians to refer patients to their dialysis centers.?Learn more.?

• A New York system of skilled nursing and rehabilitation facilities entered into a five-year Corporate Integrity Agreement and agreed to pay $21.3 million to resolve allegations that it engaged in submitting?false claims for rehabilitation therapy which were unreasonable, unnecessary, unskilled or that did not occur as billed. Learn more.???