Front-end RCM Solutions: Improving Revenue Cycle Management
in Healthcare
Revenue Cycle Management (RCM) is a critical component of
the healthcare industry, as it ensures timely and accurate payments for
services rendered to patients. With the increasing complexity of the healthcare
system and the rising cost of care, it is more important than ever for
healthcare organizations to optimize their RCM processes to improve financial
outcomes.
One area of RCM that is gaining significant attention is
front-end solutions. Front-end RCM solutions refer to the processes and technologies
used to manage patient-facing activities, such as registration, eligibility
verification, and pre-authorization. These solutions are designed to improve
the accuracy and completeness of patient information, reduce errors, and
increase the efficiency of the billing process.
Front-end RCM solutions offer several benefits for
healthcare organizations. First and foremost, they help reduce claim denials by
ensuring that patient information is accurate and complete before services are
rendered. This not only improves the accuracy of claims but also reduces the
time and resources needed to address denials, which can be a major burden for
healthcare organizations.
Another benefit of front-end RCM solutions is that they can
help improve patient satisfaction. By streamlining registration and eligibility
verification processes, patients can receive care more quickly and with less
frustration. This can lead to higher patient retention rates and improved
patient outcomes.
Front-end RCM solutions also have a positive impact on the
financial health of healthcare organizations. By reducing denials and improving
the accuracy of claims, organizations can increase revenue and reduce the
administrative costs associated with managing the billing process.
Additionally, by improving patient satisfaction and retention rates,
organizations can attract and retain more patients, further boosting their
bottom line.
In terms of technology, front-end RCM solutions typically
involve the use of software platforms and tools that integrate with other RCM
systems, such as electronic health record (EHR) systems and billing software.
These solutions can be customized to meet the specific needs of healthcare
organizations, and can include features such as patient portals, online payment
processing, and automated eligibility verification.
There are several companies in the healthcare industry that
specialize in front-end RCM solutions. These companies offer a range of
products and services, including software platforms, consulting services, and
outsourced billing and coding services. Some of the leading companies in this
space include Experian Health, Availity, and Change Healthcare.
In conclusion, front-end RCM solutions are becoming
increasingly important for healthcare organizations looking to improve their
financial outcomes and patient satisfaction rates. By streamlining
patient-facing activities, reducing claim denials, and improving the accuracy
of claims, these solutions offer significant benefits for healthcare
organizations of all sizes. With the right technology and expertise, healthcare
organizations can implement front-end RCM solutions that meet their specific
needs and improve their bottom line.
Patient access solutions Market Dynamics
Drivers in Patient
Access Solutions Market
The Patient Access Solutions market is influenced by a range
of drivers and factors, with one of the most significant being the growing
importance of denials management. Insurance companies are increasingly denying
claims and coverage to patients with chronic or persistent illnesses, in order
to reduce costs and maximize profits. This trend places a greater burden on
healthcare providers to manage operating costs, which has led to an increased
adoption of healthcare IT solutions, such as patient access solutions.
Despite the global adoption of healthcare IT solutions, many
healthcare providers still rely on manual and paper-based approaches to manage
denials. Such methods can result in errors, delayed follow-ups, and
miscommunication between healthcare providers and insurance companies. While
some providers use technology to automate aspects of the process, the lack of
integration with workflows often prevents them from using technology to its
full potential. Automated patient access software, including medical necessity,
prior authorization, and denials and appeals management solutions, offer
healthcare providers a means of saving significant revenue, while also
identifying trends in errors to prevent future denials.
Restraints in Patient
Access Solutions Market
The healthcare industry is plagued by a rising number of
data breaches, which are primarily caused by hacking or IT-related incidents.
Unauthorized access or disclosure is the second most common cause of data
breaches, while loss and theft are less prevalent. In the US, the number of
healthcare data breaches recorded by the HIPAA Journal in 2023 has increased by
66% compared to 2018. HIPAA-covered companies and business associates paid
around USD 14 million for HIPAA violations in 2021 and USD 16 million in 2020,
according to a publication by the HIPAA Journal. As a result, developing a
secure communication platform has become a significant challenge for IT vendors
who cater to the healthcare industry.
Opportunities in Patient
Access Solutions Market
There are emerging healthcare IT markets that present
promising growth potential. The Asia Pacific region is a highly lucrative
market for patient access solutions due to the various government initiatives
focused on the adoption of HCIT solutions, rising government spending on
healthcare, and technological advancements in the healthcare sector. In
Australia, there is significant potential for the adoption and implementation
of patient access solutions, such as necessity and claims denial management
solutions. The Australian government's state- and country-wide HCIT initiatives
are supporting the adoption of these solutions, including the development of a
fully integrated statewide electronic health record system by the State of
South Australia. The Indian healthcare industry is also exploring the concept
of a connected healthcare ecosystem, driven by changing demographics, increased
healthcare expenditure, and rising healthcare awareness.
One of the primary challenges associated with patient access
solutions is their relatively high deployment costs. These software solutions
can be quite expensive, and the cost of maintaining and updating the software
can often exceed the initial purchase price. Ongoing support and maintenance
services, which include software upgrades, can account for up to 30% of the
total cost of ownership. In addition, healthcare organizations may need to
invest in training end users if they lack internal IT expertise, further increasing
the cost of ownership.
Given these high costs, many hospitals prioritize investing
in core technologies such as EHR and e-prescribing that are directly linked to
patient care quality, over investing in technologies for other departments
within the organization. This means that smaller healthcare organizations, particularly
in emerging markets across Asia and Latin America, may be unable to invest in
patient access solutions due to their prohibitive cost of deployment and
maintenance.
In 2021, the software segment of the patient access
solutions market is expected to experience the highest growth rate within the
product and service category. This growth can be attributed to the benefits
provided by software, such as efficient error management, a wide variety of
options, and differentiated functions.
Among the various end-user segments, healthcare providers
hold the largest share in the patient access solutions market during the
forecast period. The significant market share of this segment is due to the
increasing adoption of healthcare IT solutions, rising healthcare spending, and
the need to manage escalating healthcare costs, which are the key factors
supporting the adoption of patient access solutions among healthcare providers.
During the forecast period, North America is expected to
hold the largest share of the patient access solutions market. This growth can
be attributed to the region's stringent regulations, increased government
support for improving healthcare infrastructure, and the presence of leading
market players in the region.
Based on application, the data aggregation segment is
expected to be the largest and fastest-growing segment in the patient access
solutions market during the forecast period. This segment's growth can be
attributed to the benefits provided by the solutions, such as on-demand self-serving
analytics, no upfront investment in hardware, extreme capacity flexibility, and
the pay-as-you-go pricing model.
The healthcare providers segment is projected to have the
highest growth rate in the patient access solutions market in 2021. The rising
demand for standardizing patient data, the generation of large amounts of
healthcare data, the focus on patient safety, the significant growth in
healthcare spending, the increasing rate of medical errors, growing denials,
and increasing healthcare costs are expected to drive the demand for patient
access solutions services in the future.
Denial management is an essential component of revenue cycle
management. Hospitals can investigate every unpaid claim, identify trends, and
appeal rejected claims. The importance of denial management is increasing,
driving the need for patient access solutions. The number of denial claims is
increasing, with the average claim denial rate exceeding 12% and increasing by
more than 20% over the past five years, according to an article published in
the Journal of AHIMA in April 2022. Healthcare providers are turning to
healthcare IT solutions, such as patient access solutions, to properly analyze
denial claims, driving the patient access solutions market's growth.
Patient portals help improve physician-patient relationships
and give patients more control over their treatment. They can check lab
results, request prescription refills, update insurance information, manage any
unpaid balances, and more. The increasing demand for health insurance and
accessibility of patient access solutions for maintaining such data is driving
the market's growth. My Healthcare partnered with Amazon and Microsoft in
November 2021 to integrate digital clinical solutions across expansive
healthcare data, creating a patient longitudinal map. This system maintains a
database of patients' insurance information and helps doctors in the fields of
cardiology, pediatrics, and other fields ensure better medical outcomes.
The segment of claims denial and appeal management solutions
is projected to experience substantial growth in the coming years, due to its
ability to leverage both current and historical data to maintain comprehensive
patient records. As healthcare organizations increasingly adopt electronic record
keeping and other forms of data collection and storage, the volume of data
available for analysis is growing exponentially. Numerous companies are now
developing software that can analyze this data, thereby driving growth in this
segment.
Patient access solutions encompass several types of
software, including claims denial and appeal management solutions, payment
estimation solutions, and other tools that facilitate patient registration and
determine insurance eligibility. The increasing awareness of healthcare denial
management has fueled the development of claims denial and appeal management
solutions. For example, a study published in the Journal for Healthcare Quality
in April 2022 found that a shortage of staff, increased workloads, and backlogs
of procedures and claims denials have led to a rise in claim denials.
Healthcare technology company Hayes discovered that 40% of claims related to
COVID-19 care were denied in the first 10 months of 2021. Such issues are
expected to drive the adoption of claims denial and appeal management solutions,
thus promoting market growth.
In addition, the demand for these solutions is being
propelled by technological advancements and the launch of new electronic health
record (EHR) systems. Anomaly, for instance, introduced Anomaly Smart Response
in August 2022, which utilizes AI to enable providers and payers to decrease
avoidable claim denials, increase payment transparency, and reduce rework, all
of which are crucial priorities for healthcare stakeholders. The product
delivers real-time responses, predicting actionable denials and payment amounts
so that providers can avoid and correct denials before they occur. Smart
Response operates directly within providers' native workflows by integrating
with payers, practice management software, and claims clearing houses. These
types of advancements are expected to further drive growth in the claims denial
and appeal management solutions segment in the future.
North America is expected to witness significant growth in
the patient access solutions market over the forecast period. This growth can
be attributed to various factors, including technological advancements,
acquisitions, mergers, and partnerships by key market players. For instance, in
May 2021, Optum collaborated with Bassett Healthcare Network to provide
software and data analytics technology-enabled services, research and advisory,
and revenue cycle management to advance quality care and the patient
experience.
Likewise, in July 2021, Philips and Cognizant partnered to
develop an end-to-end digital health solution that will help life science
companies improve patient care and accelerate clinical trials. The
collaboration combines Philips HealthSuite, a cloud-based platform, and
Cognizant's digital engineering expertise to deliver and maintain leading-edge
digital health solutions at scale, leveraging big data to create actionable
insights. Such collaborations are providing better services to patients,
leading to increased patient engagement on this portal and driving the growth
of the patient access solutions market in the region.
Dominating Companies in Patient Access Solutions Market
- MCKESSON CORPORATION
- OPTUM, INC.
- COGNIZANT
- CERNER CORPORATION
- EXPERIAN PLC
- 3M
- CONIFER HEALTH SOLUTIONS
- CRANEWARE, INC.
- GENENTECH, INC. (ROCHE)
- ALLSCRIPTS HEALTHCARE SOLUTIONS, INC.
- EPIC SYSTEMS CORPORATION
- WAYSTAR
- THE SSI GROUP, LLC
- CIRIUS GROUP, INC.
- ACCUREG SOFTWARE
- PATIENT ACCESS SOLUTIONS, INC.
- KYRUUS
- EXELA TECHNOLOGIES, INC.
- ACCESS ONE, INC.
- VEE TECHNOLOGIES
- CONDUENT, INC.
- FINTHRIVE
- PLEXIS HEALTHCARE SYSTEMS
- HEALTHASYST
- VIRTUSA CORPORATION
Recent Developments in Patient Access Front-end RCM
Solutions Market
In March 2022, DAS Health, a provider of health IT and
management solutions, announced its acquisition of Kno2, a leading provider of
secure interoperability solutions. This acquisition enables DAS Health to
enhance its offerings in the areas of patient access, engagement, and care
coordination.
In September 2021, Waystar, a healthcare technology company
specializing in revenue cycle management, announced its acquisition of
Patientco, a leading provider of patient payment technology. The acquisition
expands Waystar's patient access solutions portfolio, allowing them to offer
end-to-end patient financial engagement services.
In November 2020, Experian Health, a provider of revenue
cycle management and patient access solutions, announced a partnership with
DigiCert, a leading provider of digital certificates and secure identity
solutions. The partnership enables Experian Health to offer enhanced security
and protection for patient data, strengthening their patient access solutions.
In February 2019, NextGen Healthcare, a provider of health
IT solutions, announced its acquisition of Medfusion, a patient experience and
engagement platform provider. The acquisition expands NextGen Healthcare's
patient access solutions portfolio, allowing them to offer patient
self-scheduling and pre-registration capabilities.
In June 2021, HealthStream, a provider of workforce
development and patient experience solutions, announced its acquisition of
Change Healthcare's Nurse Residency Program. This acquisition expands
HealthStream's offerings in the areas of nurse development and retention, and
strengthens their patient access solutions.
In November 2019, Allscripts, a provider of health IT
solutions, announced its acquisition of PatientWorks, a provider of patient
self-service and registration solutions. The acquisition enhances Allscripts'
patient access solutions portfolio, allowing them to offer advanced patient
check-in capabilities and improve the patient experience.
In July 2019, Premier Inc., a healthcare improvement
company, announced a partnership with Medpricer, a provider of cost management
solutions. The partnership enables Premier to offer enhanced supply chain
solutions, including improved access to products and services for patients and
providers.
In December 2018, Waystar, a healthcare technology company
specializing in revenue cycle management, announced its acquisition of
Connance, a provider of predictive analytics solutions for healthcare. The
acquisition strengthens Waystar's patient access solutions portfolio, allowing
them to offer advanced patient scoring and segmentation capabilities.
In conclusion, patient access solutions are transforming
healthcare delivery by improving patient access to care, optimizing resources,
and enhancing patient engagement. Digital health technologies such as
telehealth and patient portals, as well as process optimization and data
analytics, are key components of these solutions. By implementing patient
access solutions, healthcare organizations can improve patient care and
outcomes while reducing costs and optimizing resources.