Managing revenue cycles in healthcare involves many steps. These include patient registration, charge capture, clinical documentation, coding, billing, claim submission, denial management, and accounts receivable (A/R) follow-up. Each part needs special skills and careful attention to avoid mistakes that can cause claim denials.
One key factor that affects how well revenue cycles work is having skilled workers. Medical coders are the hardest roles to fill in RCM. About 34% of practice leaders say they have trouble hiring coders. Billers come next at 26%, schedulers at 18%, and authorization management staff at 15%. These jobs need special training and knowledge of different payer rules, coding standards, and billing laws.
A March 2023 MGMA Stat poll of 469 medical group leaders found many practices have a hard time hiring qualified RCM workers. This is partly because the labor market is tight. The Bureau of Labor Statistics expects about 12,300 new medical record specialist jobs between 2021 and 2031. But this also shows that demand and competition for skilled workers are growing.
Having fewer staff hurts how well revenue cycle teams can handle claims accurately and fast. In 2021, 69% of medical practices said claim denials went up compared to the year before. The average denial rate went up by 17%. Denials often happen because of incomplete or wrong paperwork, missing prior authorizations, coding mistakes, and misunderstanding payer rules.
Not enough staff means there are fewer people to fix billing errors, follow up on denials, and check claims carefully before sending. Because of that, more claims get rejected or denied. This slows down payments and creates backlogs in accounts receivable.
When there are fewer workers, claim processing takes longer and payments get delayed. In 2022, 56% of medical groups saw an increase in the number of days claims stayed in accounts receivable because of staffing problems. Long A/R days put pressure on cash flow. This affects financial health and limits how much medical practices can spend on patient care or improvements.
If denial management is not done on time, claims stay unresolved longer. This can lead to more write-offs or discounts. Poor staffing also lowers productivity and staff morale, which further slows down revenue cycle tasks.
Apart from denials and payment delays, not having enough staff also hurts finances in other ways. Revenue leakage means losing money because of mistakes or inefficiencies. This often happens from incomplete charge capture, downcoding, or poor denial follow-up.
For example, downcoding services like Evaluation and Management (E&M) can cut reimbursements by about 40%. This causes a lot of underpayment. Practices may lose hundreds of thousands of dollars each year due to these issues. Also, when denial rates average 30%, losses from reversed claims can total half a million dollars.
Often, these problems happen because staff lack training or time to do their job well. Staff turnover adds to the problem. The median yearly turnover rate for business operations staff in multispecialty groups was about 16.7%. This means constant changes and ongoing hiring needs.
Healthcare groups have used several ways to manage or deal with the shortage of qualified revenue cycle workers.
Cross-training lets current employees do several roles in the revenue cycle. This makes the workflow more flexible and helps when someone is absent or a position is empty. Offering part-time and shared roles also lets organizations adjust to changing patient needs without paying full-time salaries.
Remote hiring has helped some medical groups reduce staffing pressure. It allows recruiting beyond local areas. Jobs like medical coders, billers, and authorization staff can often be done from home. This gives access to more qualified candidates and removes location limits.
Training workers internally through apprenticeships helps build skills slowly and keeps staff longer. Groups that invest in ongoing training create better revenue cycle teams and lower errors that cause denials.
Technology is playing an important role in fixing staff shortages and improving revenue cycle work. Artificial Intelligence (AI) and automation tools can reduce paperwork, increase accuracy, and improve productivity in healthcare revenue cycles.
AI uses methods like natural language processing (NLP) for automatic coding, claim scrubbing to find errors before submission, predictive analytics to predict and prevent denials, and robotic process automation (RPA) to handle repetitive tasks.
About 46% of U.S. hospitals now use AI in revenue cycle work, and 74% use some type of automation. Here are real examples:
Generative AI also helps call centers. According to McKinsey, call centers using generative AI improve productivity by 15% to 30% by automating tasks like checking patient eligibility and getting prior authorizations.
By automating repetitive and administrative tasks, AI reduces the need for undertrained or short-staffed workers. This lets the staff focus on hard cases and quality work. AI also helps train staff by giving tips, alerts, and data insights to improve accuracy and speed when submitting claims.
Even though AI offers many benefits, human oversight is needed. People must check AI work often to avoid errors, reduce bias, and keep ethics in mind. AI results must be reviewed regularly. Automation should not replace human decisions, especially in sensitive revenue processes.
Combining staffing methods with AI and automation gives medical practices a way to handle staffing shortages that affect claim denials and finances. Cross-training and part-time roles keep human resources flexible. AI tools simplify complex tasks that humans often do wrong.
Organizations should set clear key performance indicators (KPIs) and compare their staffing levels to industry standards for revenue cycle roles. Good measurement helps medical groups find workflow problems, test technology success, and decide the best staff levels.
Medical practice leaders in the United States need to deal with staffing problems in revenue cycle management to reduce claim denials and improve cash flow. Hiring and keeping skilled RCM staff is hard. Technology solutions like AI and automation offer real ways to make this easier.
Using a balanced plan with flexible staff, ongoing training, and technology support can improve accuracy, speed, and overall financial results. Tracking key numbers and adjusting staffing models regularly will help healthcare groups keep stable revenue operations despite labor shortages.
By using smart ideas and technology, U.S. medical practices can lower the chances of more denials and late payments. This helps stabilize their money flow and focus on giving good patient care.
The main challenges include hiring medical coders (34%), billers (26%), schedulers (18%), and authorization managers (15%), with many organizations facing difficulties in hiring qualified candidates due to a tight labor market.
Being short-staffed can lead to an increase in days in accounts receivable, resulting in backlogs of unpaid claims and negatively impacting cash flow.
Short-staffed departments may struggle to manage denials effectively, resulting in increased denied claims, which can escalate as coding changes and discrepancies arise.
Consistently short staffing can lead to decreased productivity and morale among staff, resulting in errors and delays that further impact revenue.
Solutions include cross-training staff for multiple tasks, offering part-time or shared roles, providing remote work options, and implementing technology solutions to streamline workload.
Technology solutions like automated billing systems can reduce workload, minimize errors, and allow staff to focus on higher-level tasks.
Organizations should benchmark against industry staffing levels and utilize key performance indicators (KPIs) to optimize revenue, cash flow, and minimize denials.
Trends include remote hiring practices that expand candidate pools, and increasing interest in apprenticeship programs to develop new talent from within.
Effective hiring processes can help reduce turnover rates, which, according to MGMA data, was around 16.72% for business operations staff in multispecialty groups.
Pros of outsourcing include access to specialized skills and potentially lower costs, while cons include potential loss of control and the need for effective monitoring of performance indicators.
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