Rising operating costs, shrinking operating margins, and a complex payer landscape characterized by heightened prior authorization requirements and a push to embed advanced technology more deeply into the review process have thrown provider finances into turmoil. Exacerbating it all is a chronic and worsening shortage of skilled revenue cycle management (RCM) professionals, including patient access.
Internally, the inefficiencies created by outdated, time-consuming, and cost-intensive patient access operations hinder timely access to care, contributing to revenue leakage and further weakening the organization’s bottom line. Moreover, many provider organizations lack the insights to identify and remediate systemic issues that undermine patient access operations.
These external and internal forces create a domino effect of front-end RCM issues. Registration, eligibility and benefits verification, and prior authorization all impact the revenue cycle and disrupt patient access workflows. If this increase in administrative tasks is not managed timely and effectively, issues stemming from the patient access create extensive downstream claims rework impacting cash and patient satisfaction.
A centralized patient access model with a global, technology-enabled approach to patient access can combat these forces. Creating a seamless and cohesive approach to all facets of front-end RCM accelerates the revenue cycle by reducing payment delays caused by front-end errors, minimizing rescheduled appointments, and improving patient satisfaction. It improves revenue capture by proactively identifying and addressing patient eligibility and coverage issues before they become denials. It also alleviates workforce shortages by supplementing internal staff with global patient access experts.
Patient Access Challenges
Increased front-end administrative burdens have forced an evolution of patient access delivery models. Front desk employees are spending more time on tasks unrelated to patient interactions. This shift, combined with more complex prior authorization requirements, higher labor costs, and high staff turnover rates, overwhelms traditional models characterized by decentralized teams, manual processes, and limited access to global support. Patient care, staff morale, burnout, and retention rates are also impacted as resources are diverted to prior authorization and other financial clearance tasks.
Exacerbating patient access challenges is the tendency of payers to frequently change the rules of engagement for prior authorization, leaving provider organizations struggling to stay compliant. For example, increasingly rigorous documentation requirements can result in incomplete or inconsistent documentation and higher denial rates. Additionally, automation of medical necessity reviews allows for faster and more efficient denial of procedure coverage. This same technology is leveraged post service to quickly identify claims to deny, creating back and front-end rework to appeal and dispute.
Other patient access challenges include revenue cycle inefficiencies and disconnected processes, contributing to increased denials, financial losses, and patient dissatisfaction. Fragmented workflows and siloed teams create barriers to efficient scheduling, eligibility and benefits checks, and prior authorization, while high turnover creates a continuous need to train and retrain new team members.
Finally, technology gaps exacerbate challenges in the patient access process, particularly for healthcare organizations that continue relying on outdated systems and/or manual processes. Patient access workflows are time-sensitive processes requiring timely support by technology tools to track authorizations, verify eligibility and benefits, and identify at-risk accounts for immediate attention.
Efficiency and effectiveness also depend on access to data-driven insights to inform workforce strategies.
A Stepwise Approach to Centralization
For many providers, centralization can successfully address many of these challenges. Specifically, a stepwise approach for processes, people, and technology mitigates risks associated with abrupt changes, allowing for proactive issue identification and resolution. It standardizes, centralizes, and optimizes the patient access process, then monitors and measures its effectiveness to ensure peak performance.
Standardize
Standardizing patient access workflows is the most crucial step before designing the ideal centralized model. It involves identifying, documenting, and implementing the ideal state processes and technologies after eliminating identified barriers and bottlenecks. After completing this step, a strategic delivery model and vendor strategy can be reviewed across patient access teams.
Establishing organizational accountability through key performance indicators (KPIs) that help achieve organizational goals is essential to baseline current performance. Patient access staff should also be supported through training and defining success measurement programs.
Centralize
Phased implementation of centralization minimizes disruption and allows for effective resource allocation and staffing identification aligned with the organization’s strategic goals. Steps include prioritizing centralization phases, evaluating staffing needs, designing controls and training, and centralizing performance monitoring.
Centralization should also include evaluating whether a hybrid global vendor/in-house delivery model is appropriate and, if so, identifying new partnerships to support it. This model delivers onshore compliance support, provides quality and scalability, and aligns resources with centralized technology-enabled workflows structured for agility and efficiency. It can also provide around-the-clock coverage of time-sensitive prior authorization workflows, easing one of the most significant patient access burdens.
Optimize
Once the ideal delivery model has been achieved, the focus should shift to optimizing existing processes and technology solutions. This step should be driven by tracking performance against KPI benchmarks and goals, identifying gaps, and reviewing for root cause remediation. This is the time to ensure your technology solutions are leveraged to the fullest to gain the maximum benefit from automation to streamline operations, enhance patient experience, and reduce manual touches.
Measure Success
Optimization is not the final step on the maturity journey, as mature providers continuously monitor the impact of a centralized patient access model. This is critical to maintaining expected results. Re-establishing KPI goals and accountability measures also ensures goal alignment and prepares the workforce for centralized operations. Post-centralization performance metrics also help identify improvement areas to maintain and optimize the ideal delivery model as payer policy changes and other issues arise.
Outcomes should be continuously tracked with carefully defined success metrics for patient access efficiency, including authorization turnaround time, clean claim rate, denial rate, and patient satisfaction.
In addition to monitoring performance, the insights derived from this data can be used for continuous improvement by identifying areas needing attention and tailoring provider and team education and training. Ongoing training and monitoring will reduce errors and support process adherence, fostering continuous improvement.
Benefits of Centralization
For multiple reasons, centralization can be part of an ideal patient access delivery model for many providers. One is its ability to drive operational improvements that align with value-based care models through streamlined workflows and standardized procedures—leveraging technology where possible.
These operational improvements can reduce errors and delays, lowering prior authorization denial rates by 10 percent to 30 percent and improving overall efficiency. They also make it easier to introduce improvements into a centralized delivery model, such as implementing denial-reducing workflows or acting on process change recommendations from steering committees tasked with identifying denial-reduction opportunities.
Centralization should enhance the patient experience by relieving the front desk team of some of its administrative burden and giving them more time to focus on the patient at admission and post-visit follow-up. It also speeds care access by reducing patient wait times, preventing appointment rescheduling and no shows, and providing fast and transparent communication regarding coverage and costs. Finally, accelerating and streamlining prior authorization processes through centralization is paramount for financial outcomes, overall health, and the patient experience.
While establishing a centralized model can involve an up-front cost, the returns are potentially significant, particularly with a global partner. Some organizations report annual benefits ranging from more than 180 percent to approximately 375 percent of their initial investments from streamlined, standardized, and accelerated processes and workflows. Additional value is realized through recouped opportunity costs from reducing the time dedicated to reworking denied claims, increasing net revenue from reduced denial rates, and reallocating front-office resources.
Regarding financial gains, centralization can improve cash flow, lower denial rates, increase reimbursement levels, and reduce A/R denials and claims rework. It also enables highly scalable, cost-efficient models through global or hybrid internal-outsourced teams.
A Tech-First, Hybrid Team Approach
Optimal patient access centers around essential technology features to enable a tech-first approach to maturation. For example, when a patient access model includes achievable and proven prior authorization technologies, organizations can experience up to a twofold increase in authorization productivity rates. Other considerations include automation for real-time eligibility checks, centralized dashboards for tracking authorization status, AI-powered analytics for proactive decision-making, and automation tools embedded in EHRs and patient portals.
The right strategic partner is also crucial to patient access success. Regardless of workflow complexity, deep expertise across the patient access process continuum and a proven track record of deploying patient access technology and managing compliance risks are required. The right partner will also be well-versed in multiple advanced technologies, have mastered the complex authorization process, and can deliver an approach that streamlines integrations and avoids bottlenecks. This will ensure a smooth patient experience while allowing the organization to collect the appropriate net revenue.
Other aspects to consider with partner selection and management include:
- Return on Investment (ROI) forecasting
- Service Level Agreements (SLAs)
- Investment in transformation and knowledge sharing
- Access to internal and external analytics to monitor effectiveness
- Governance models to prevent misalignment between parties
- Executive support
With the right partner in place, building an effective patient access team requires empowering team members to prioritize patient needs and satisfaction. In addition to collecting and acting on patient feedback for continuous improvement, this includes aligning patient access processes with organizational goals. Processes should be standardized to create unified workflows to reduce variability and train staff on procedures and compliance requirements while ensuring cross-system interoperability.
Finally, regularly track metrics such as appointment wait times, authorization turnaround, and patient satisfaction and use data-driven insights to refine operations. This allows for more effective performance evaluation and rapid response to identified issues and ensures a cost-effective hybrid patient access model that delivers a rapid ROI.
Conclusion
Prioritizing centralizing patient access model allows healthcare finance leaders to effectively combat the internal and external forces driving the front-end RCM issues at the heart of denial rates and patient access workflow disruptions. Doing so also delivers operational improvements that align with value-based care, enhance the patient experience, and deliver financial gains.
Success requires a global, technology-enabled approach to patient access featuring actionable strategies and leveraging advanced AI and automation tools to eliminate administrative inefficiencies, enhance financial outcomes, and improve workflows and care access. It also requires the right global partner to overcome workforce shortages and streamline complex prior authorization and other patient access processes.
With a stepwise approach to centralization, finance and RCM leaders can leverage innovation and expertise to build a high-performing patient access team.
About Ryan Chapin
As Executive Director of Strategic Solutions at AGS Health. Ryan Chapin assists with strategic growth initiatives for the company’s Patient Access and Patient Financial Services business units. He possesses more than 8 years of experience in professional and managed services with expertise in delivering clients transformational engagements focused on improving financial and operational metrics, and the patient experience. Leveraging his background in Revenue Cycle Consulting, Ryan brings a true consultative approach to how AGS conducts business with our customers.
