Plutus Health Revenue Cycle Management Challenges Index, 2023

Navigating the complex landscape of healthcare revenue cycle management has never been more critical. Discover how Plutus Health's latest survey sheds light on the challenges faced by over 200 healthcare providers and the transformative potential of AI and RPA solutions.

Our survey, Plutus Health Revenue Cycle Management Challenges Index, 2023, offers new insights into the top challenges providers face — claims denials, payor issues, and staffing challenges — and how organizations can solve them.

Robotic process automation (RPA) and artificial intelligence (AI) offer many benefits to those willing to implement them, such as a decrease in human error, lower backlog, and faster turnaround.

The results of the survey, Plutus Health Revenue Cycle Management Challenges Index, 2023, offer a glimpse into the real-world struggles many providers face, while revealing how some providers are solving them.

Healthcare providers share revenue cycle management challenges

Denials present the greatest challenge for healthcare providers when it comes to revenue cycle management.

In the survey, 59% of respondents said it was their greatest challenge, while 45% cited, “specific payor challenges” as their greatest challenge.

In total, the top RCM challenges facing healthcare providers include:

Healthcare providers also shared which stages of their RCM process are regularly backlogged. They were able to select multiple answers, and the top responses were:

Looking to the rest of 2023, healthcare providers shared what issues in RCM are their greatest priority for the rest of the year.

The data makes it clear that insurance denials are a big issue for providers, and they aren’t just inconvenient. Denials cost healthcare providers a lot of money.

In fact, more than 40% of respondents said that they lose more than half a million U.S. dollars in annual revenue each year due to denied insurance claims. Of those, 18% reported losing more than a million annually.

Where do healthcare providers turn to for support with revenue cycle management?

Most respondents said they use external support for executing their RCM.

When asked, “How is your healthcare organization executing revenue cycle management?,” many replies included an element of external support.

Nearly half of the respondents (47%) chose a response that included using external support:

When it comes to verifying provider credentialing information at their clinic, many healthcare providers said they relied on an internal enrollment department.

The top five responses included:

Healthcare providers share plans to overcome revenue cycle management challenges

Healthcare providers shared their plans for improving their RCM analytics over the next few years.

The top responses included:

Healthcare providers also shared their plans for improving the integrity of their revenue in 2023. Respondents were allowed to choose multiple answers.

The top responses included:

Multiple respondents chose an answer that included working with external support and using new tools, including:

How AI and RPA help healthcare providers with Revenue Cycle Management

Despite the hype around artificial intelligence (AI) and robotic process automation (RPA), there is a notable lack of proactive planning around such solutions. Even though providers reported strong results with both AI and RPA, many healthcare providers said they did not have plans to utilize it in 2023.

Some healthcare providers reported that they are using AI to support their RCM processes.

As for robotic process automation, healthcare providers are using RPA to assist with:

The results offer hope for healthcare providers looking for solutions to their revenue cycle management challenges.

Respondents shared how AI and RPA have helped their overall healthcare operations. They were asked to select all that apply, and the top responses included:

Healthcare providers also shared the greatest improvements they’ve seen since implementing AI and RPA for RCM. They were asked to select all that apply, and the top responses included:

Potential RPA Solutions

Zeus stands ready for deployment, offering robust support for customers' revenue cycle management processes. Zeus uses RPA and machine learning (ML) technologies to reduce human error, minimize denials, keep medical billing data continually updated, and provide data analytics that help improve KPIs.

Plutus Health’s solutions help customers decrease their average turnaround time to 48 hours, boost their clean claim percentage by an average of 97%, and reduce denials by an average of 5%.

Plutus Health Inc. offers complete solutions for denial management in healthcare. Our team offers the ability to:

• Determine the reason(s) for each denied claim
• Identify the third-party claims pricing or administrator to process the claim
• Review the patient benefits and remittance to ensure the proper claim adjudication
• Resubmit corrected claims to the payer/insurance on the original denial
• File appeals as necessary
• Resolve the issue
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Plutus’ custom approach to each denial case ensures effective and timely resolutions. Depending on the case, we may:

• Correct invalid medical codes and add/remove appropriate modifiers
• Revalidate clinical information before resubmission
• Collect relevant and/or corrected patient info and documentation
• Verify eligibility and benefits before the appointment to minimize the eligibility and COB denials
• Revalidate the state-specific guidelines for each specialty
• We understand payer network administrative directives and send the claims as per the payer guidelines to ensure faster payment
• Revalidate provider qualifications and state licensure and other regulatory requirements by the payer
• Decode the CARC and RARC denial codes to challenge/supply the required information to resolve the payer denials to payment
• Act as your expert for In Network provider enrolment, contracting and credentialing to comply with regulatory requirements
• Send appeal letters to address repeated denials for a claim
• Submit supporting clinical documentation
• Obtain and complete all required forms specific to payer requirements
• Resend appeals that don't include all payer required documentation
• Appeal prior authorization denials timely
• Obtain and document reference numbers when communicating with insurance
• Detect the root cause of denial early to collect from the payer or patient to keep the bad debt at 2%
• Track 100+ KPIs to monitor the health of the practice and perform correct action in a timely fashion to improve the poor KPI process or replicate the positive KPI functions.
• Guides/trains clients in CDI/ medical documentation improvements as per payor guidelines to ensure prompt appeals processing and/or assisting clients to come out of payor audits successfully.
• Automated prebilling checks to ensure denials are prevented before billing out claims incorporating validation of codes, modifiers, EV, provider and payor guidelines.
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