As healthcare professionals who want to stay in business, there are two processes that work together that are necessary to get paid and properly compensated for the services you provide: RCM workflows and market access consulting. 

At its most basic form, healthcare revenue cycle management, frequently abbreviated to RCM, is essentially managing the payments brought in through your healthcare services, including tracking and analyzing revenue data to make sure that you’re getting properly compensated for the healthcare services you and/or your clinic or healthcare setting provides. Effective RCM means analyzing profits and losses, how much you’re charging, how many debtors you have, etc., all with secure technology, comprehensive reporting, and effective software.

While getting paid is great, it’s not as simple as just analyzing your revenue stream in the healthcare industry because before a service, pharmaceutical, or device can be billable, the appropriate research, testing, FDA approvals, and more must be completed before it can be billable and have insurance eligibility. If a provider wants to take advantage of new options, they have to follow specific processes. That’s where market access consulting comes in.

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What Is Market Access Consulting, And Why Is It Important?

Market access consulting essentially opens the doors to new opportunities for healthcare providers, bridging the gap between innovative healthcare developments in its infancy and healthcare providers wanting options for their patients. This is important because healthcare is an ever-evolving field, and there are still many conditions, diseases, and medical events for which there is no treatment, medication, preventative, or cure. In order to increase the viable options, new ideas need to be brought to clinicians, or basically, brought to the “market,” just as a new invention gets brought to market in a store.

An example of how this works is that prior to a service (think: a new type of robotic surgery), pharmaceutical, or device being made freely available to healthcare providers and patients, it has to undergo extensive testing. Part of that is done through clinical trials, which are available to healthcare professionals and patients who go through eligibility verification. If a provider participates, they still need to be properly compensated. 

Market access consulting by itself is important to healthcare providers because it creates options and opportunities for patients who might not have otherwise had an option available. However, it is critical that healthcare revenue cycle management be evaluated in consideration of market access consulting.

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How Does Healthcare Revenue Cycle Management Support Market Access?

Healthcare revenue cycle management must be evaluated and considered alongside market access consulting because there are a number of data points that contribute to whether a new option is viable to the end user and whether or not those claims will be paid. The revenue cycle management activities that include eligibility verification of the patient, insurance eligibility, and more will create the best circumstances for the new drug, service, or device to be accurately billed and allow you to be properly compensated. 

By employing healthcare revenue cycle management, you will have the data you need to determine whether or not the novel treatment is something that will work for your patients in your practice. Healthcare market access consulting must consider the RCM in order to derive the desired outcome for all parties involved, including the patient, provider, and market access consultant.

Provide for Accurate Communication Between Billing And Patients

By utilizing revenue cycle management, proper eligibility will be determined, which will hopefully eliminate surprises for the patient. While a market access consultant will provide the guidance to bring a life science product or service to market, incorporating revenue cycle management will get a patient approved efficiently, which means an easier claims process and more streamlined payment with fewer headaches for all involved.

Broaden Payor Coverage

Having proper collaboration between your RCM workflow processes and market access consulting means that you will have a better likelihood that coverage will be complete. This means that by working together, you can clearly define patient eligibility through eligibility verification and determine that there is proper insurance eligibility. It is necessary for the healthcare industry to have a precise medical need identified, and by working together, you can expect coverage to be higher.

Aligning Revenue Integrity, Payments And Reimbursement

Making sure that the patient’s medical need is established, that the proper billing code has been entered, and ensuring that the product or service is within the scope of coverage will mean that claims will be processed correctly. This keeps revenue integrity intact by allowing for efficient, accurate payments and reimbursements from insurance companies. Additionally, there may be more stringent requirements with a new product or service, and as such, working with the RCM workflow will create more favorable odds that the drug/service/product is prescribed in accordance with healthcare compliance standards.

Maintaining Billing Compliance and Healthcare Compliance

The healthcare industry is always changing, especially as new treatments are brought to market. By creating conditions where your revenue cycle management works together with market access consulting, you can encourage a better outcome. This means that the proper billing and coding are enacted in accordance with billing compliance standards and that your healthcare setting is operating within the standards of healthcare compliance.

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Collaboration Between Market Access Consulting And Healthcare Revenue Cycle Management

We’ve discussed how and why it is important for market access consulting to have a symbiotic relationship with revenue cycle management for a favorable RCM workflow, but it’s also important to consider how RCM can positively impact market access consulting.

RCM Gives Market Access Consulting:

Revenue cycle management can positively impact market access consulting by providing necessary data analytics to help strengthen studies relating to efficacy, feasibility, and more; it can also provide revenue forecasting to determine that the product or service is profitable, and it can provide valuable insight and analytics regarding denials, and insight to eligibility verification.

Data Analytics

There are a number of data points that revenue cycle management can provide to support the viability of market access in the future. This data can help strengthen a case’s propensity for full approval and help expedite its progress.

Revenue Forecasting

While the healthcare industry is full of altruistic intentions, in order to actually provide a product or service, it has to pay for itself. Revenue forecasting provides valuable information that can help prove that a product, drug, or service will be a viable option to financial backers supporting the studies by showing that it can be profitable.

Denial For Claims Analytics and Eligibility Verification for Coverage

Analytics regarding the denial of claims can help market access consultants better understand to whom the product, service, or drug should be marketed. If there is a high number of denials, that can indicate that errors are being made regarding eligibility verification or insurance eligibility. By providing this important data derived from revenue cycle management to those involved with market access consulting, providers can uphold ethical standards, achieve proper prescriptive efficacy, and provide data to show that all was done with healthcare compliance in mind.

Market Access Consulting and Healthcare Revenue Cycle Management Services Near Dallas

Understanding market access consulting and the healthcare revenue cycle is complicated, but incorporating these processes into your healthcare facility doesn’t have to be. Choose a local revenue cycle management vendor in Dallas that you can trust. Connect with Credence to uncomplicate your RCM workflow today!