Being a nurse by training, I tend to focus on clinical trends and issues but lately have become much more interested in the financial and reimbursement issues. I am beginning to realize the enormous complexities inherent in the revenue cycle and how changing reimbursement models included under the broad banner of healthcare reform impact the financial health of the healthcare delivery organization.
Healthcare providers are challenged by high-deductible health plans and increased self-pay, decreasing reimbursement rates, claim denials, the mandate to improve productivity, and the need to control costs. In this environment, a successful organization is dependent on the ability to easily monitor and manage its financial and operational health. The question then becomes how can one manage something if you can’t measure it? While regulators and payers have a deep view of reimbursement, Physicians, who control 80% – 90% of expenditures are often the least informed.
High on the list of megatrends in healthcare1 is the need to change the payment paradigm. But how do you change the paradigm? Traditional Business Intelligence solutions enable organizations to collect and analyze information specific to their business but often lack the ability to compare benchmarks against their peers.
To change the payment paradigm, physicians and practices need actionable information to help them quickly respond to changes in key performance metrics such as:
- Reimbursement: How are your payers treating you and how this compares to your peers?
- Utilization: What is your E&M coding usage and how do you compare to peers? How do you determine outliers and ensure that you are receiving appropriate reimbursement for services provided?
- Productivity: How is your staff is performing compared to your peers?
Physician and practice access to real-time business intelligence is needed to be profitable, manage audit exposure and find improvement opportunities in a changing, challenging market. Amongst the myriad of issues facing practices, business intelligence and comparative analytics gives the practice the tools to monitor and understand where their issues are. Again – if you can’t measure it, you can’t manage it.