Healthcare Revenue Intelligence: Revealing the Cash at Each Step of the Revenue Cycle

Once a Minnesota ophthalmology group got control over its payer contracts, it relished insights about which of its payers, codes, and combinations of those prompted the most underpayments. Winning those underpayments back was even more thrilling. 

Healthcare revenue intelligence did that. 

When a large orthopedics group tossed their manual and error-prone patient estimate and contract management workflows, their new system uncovered that payers owed them 10 million dollars, an amount they promptly demanded and received. 

Healthcare revenue intelligence did that, too.

Healthcare revenue intelligence (a.k.a. analytics) does a lot for an organization’s revenue cycle. Its real-time dashboards and customizable reports:

• find patterns in and sources of registration errors so they can be fixed before they wind up on prior authorizations and claims
• identify missing charges for services so they can be added before submission
•  pinpoint common root causes of claim denials so they can be rectified
•  identify high-value accounts and those nearing payment deadlines for cost-effective collection
• cross-reference services rendered with billing codes and payer requirements to reduce billing errors and discrepancies

…and much more. 

After experiencing the data goldmine rendered by healthcare revenue intelligence, healthcare leaders are doubling down on it. Market.us reports that the global healthcare analytics market will grow from 36.4 billion where it stood in 2023 to 249.3 billion by 2032, a nearly seven-fold increase in just nine years. Most executives are happy to replace cumbersome, time-consuming, spreadsheet-dependent processes with immediate data-driven insights rendered in lively charts and graphs.  

Here, you’ll learn every area where healthcare revenue intelligence can deliver the data that empowers your contract negotiations, clean claims rate, prior authorization approvals, billing processes, and more. 

What is healthcare revenue intelligence? 

Healthcare revenue intelligence is the strategic use of data analytics to meticulously scrutinize, track, and optimize various facets of revenue cycle management. Synonymous with healthcare revenue analytics, it helps revenue cycle leaders draw conclusions from real-time activity at every point in the revenue cycle, from scheduling and registration to final payment collection. 

 The goal of revenue cycle intelligence (a.k.a. analytics) is to streamline workflows, reduce administrative costs, boost profitability, and ultimately improve patient satisfaction. By leveraging sophisticated analytics tools, healthcare providers can gain actionable insights that enable them to pinpoint inefficiencies, forecast financial performance, and make data-driven decisions and changes that better support sustainable growth and high-quality patient care.

Improving margins at each step of the healthcare revenue cycle with revenue intelligence 

Healthcare revenue intelligence reveals dozens of areas ripe for improvement. With accurate data, healthcare organizations develop strategies to optimize revenue flow. 

Optimizing patient registration with healthcare revenue intelligence

Errors made during patient registration lead to claim denials, delays in treatment, and billing issues. 

Intelligence or analytics tools find patterns and sources of registration errors, as well as bottlenecks at this early point in the patient journey. With this data, you can find the staff and workflow steps causing them. You can then implement training initiatives and workflow improvements to enhance data accuracy, improving your clean claims rate. 

In addition to improving patient data accuracy, intelligence tools uncover peak registration times and patient flow patterns, so you can make better staffing decisions. 

Optimizing patient eligibility

Another important facet of the patient access process is patient eligibility verification. Analytics and intelligence tools enhance this step in several ways. 

First, intelligence tools cross-check patient information against up-to-date insurance records. It helps identify discrepancies and gaps in coverage that could lead to revenue loss. With these gaps flagged, staff can raise the possibility of self-pay or even use discovery tools to find overlooked insurance sources. 

Payer and provider analytics can also identify patterns in past claim denials related to eligibility and benefits issues. By analyzing these patterns, you can proactively address common root causes of denials, such as incorrect patient information or outdated insurance details. This predictive capability helps prevent future denials, ensuring a smoother revenue cycle. 

Finally, intelligence or analytics tools can prioritize verification tasks based on payer requirements and patient demographics. Some even distribute verification tasks to various staff according to pre-set parameters. 

Optimizing prior authorizations with healthcare revenue intelligence

Prior authorizations delay patient care, sometimes putting them at risk for harm and even death. An AMA survey shows that 24 percent of physicians report prior authorization delays caused a “serious adverse event” for their patients. The complexity of prior authorizations combined with the reliance on manual processing continues to interfere with patient access to care. 

Intelligence or analytics tools can get straight to the issues delaying processing: whether that’s a lack of payer response, an issue with a staff member, an error, or other prior authorization bottlenecks common to your organization. By analyzing data on turnaround times, approval rates, and reasons for prior authorization denials, you can pinpoint specific areas to improve. Data helps win staff buy-in without igniting a “blame game” that can debilitate revenue cycle teams. Together, staff and leadership can develop strategies to optimize turnaround times, accelerating the prior authorization process.  

Revenue intelligence analytics can also reveal patterns in pre-authorization denials, such as frequently missing documentation or specific payer requirements – glitches that are often overlooked.  With extra attention to common errors, staff can improve their prior authorization accuracy. 

In addition to improving turnaround time and accuracy, healthcare revenue intelligence provides predictive insights that help you anticipate pre-authorization needs based on historical data and current trends. For example, intelligence or analytics can predict peak times for pre-authorization requests, so you can allocate resources effectively. This foresight enables better planning and ensures that pre-authorization requests are handled promptly, reducing delays in patient care.

Optimizing charge capture with intelligence  

The managing director of The Claro Group’s Healthcare Consulting Cathy Smith writes in HFMA that hospitals lose up to 1 percent of their potential annual net revenue due charge capture errors. An organization with $200 million in annual net revenue loses two million. Even half of that, one million, is a significant loss. 

Similarly, the average medical practice loses $125,000 per year from poor charge capture processes. Complex processes, decentralized accountability, lack of technology interoperability, changing payer restrictions, and clinician distraction all lead to missed service and supplies charges. 

 By comparing clinical documentation with charge capture data, analytics tools identify discrepancies and missing charges. This step ensures that no billable service is overlooked, leading to accurate documentation of services provided. Additionally, insights into service utilization and billing patterns enable CFOs to make informed strategic decisions that further enhance financial outcomes.

Real-time analytics delivered by dashboards and reports provide up-to-date insights into the charge capture process, allowing revenue cycle leaders to monitor performance and address issues as they arise. These tools surface key metrics such as charge lag, charge capture rates, and revenue per encounter. This real-time monitoring supports data-driven decision-making and continuous improvement.

As with prior authorizations and eligibility verifications, analytics reveals patterns in charge capture errors, such as frequently missed charges, incorrect coding, or duplications. With errors pinpointed, you can implement targeted training for clinical and billing staff, illuminate common errors, refine workflows, and build better charge capture protocols. A proactive, data-driven approach reduces errors, minimizing revenue leakage.

Healthcare revenue intelligence tools provide detailed audit trails and reporting capabilities, helping organizations ensure that all charges comply with relevant guidelines. By maintaining high standards of compliance, organizations reduce the risk of audits and associated penalties.

Optimizing contract management with healthcare revenue intelligence

A Strategic CFO Survey of 600 CFOs and finance leaders from North America and Europe conducted by financial management software and services company Coupa reveals that only 35 percent of executives currently have a contract management plan in place.

This means that 65 percent of provider groups, health systems, and MSOs have their contracts dispersed throughout their organizations, often without a designated individual responsible for managing them. 

When managing contracts from potentially dozens of payers, many short-staffed providers struggle to ensure actual payments align with contracted rates. Studies show that providers lose between one to three percent of their net revenue annually due to underpayments from commercial payers. Payers depend on provider overwhelm to force through rate and term changes that primarily benefit themselves. Providers are only just starting to take control of their contracts by bringing in contract specialists or using contract management and modeling software to track renewal dates, requested changes, and underpayments. 

Take a quick, self-guided tour through a powerful contract management and underpayments recovery tool:

When unleashed on contracts, healthcare revenue intelligence delivers the data that not only helps you recoup underpayments to improve revenue, but determines whether you want to accept a payer’s members at all. It reveals your underpayments from highest to lowest, sorted by payer and CPT code combination. Letting a poor-performing payer know that their performance is disappointing could get them to negotiate more fairly. 

Finding underpayments is just the first step. After identifying them, robust contract intelligence solutions automatically delegate each case to the appropriate staff member for reconciliation, all without the need for a manual and time-intensive spreadsheet process. It lets you stack your top underpaid payer and CPT code combinations against each other, rendering critical contract performance data. Use this competitive intelligence in negotiations to show poorly performing payers that you expect them to raise their rates and improve their terms. You have options after all.  

Beyond payer performance, contract intelligence also gives you a window into which of your facilities have the highest underpayments so you can uncover facility-specific issues at the root of the discrepancies. 

Optimizing medical coding with intelligence 

The biggest issue with medical coding is accuracy. The AMA 2024 coding updates include 230 additions, 49 deletions, and 70 revisions. With 11,163 codes that describe the medical procedures and services available to patients, it’s not surprising that even experienced, trained coders make errors. 

Accurate coding ensures that services are billed correctly, maximizing revenue potential and reducing the likelihood of denied claims. 

Coding intelligence cross-references clinical documentation with coding guidelines, identifying discrepancies and errors. More clean claims mean fewer claim denials and appropriate reimbursement for services rendered.

In addition to catching coding errors one by one, analytics can reveal patterns in coding errors and omissions, such as frequently miscoded procedures or missed codes. When you identify these trends, you can implement targeted training programs for coders, update coding practices, and refine documentation processes. This proactive approach reduces the incidence of coding errors, leading to fewer denied claims and improved revenue capture.

With coding intelligence finding errors and trends, staff can breathe a sigh of relief. They finally have some support! But then it’s up to them to carry out the claim. Insights into workflow dynamics help leaders streamline processes, another step in cleaning up the claims department.

Of course, dashboards provide visibility into key metrics such as coding accuracy, coding turnaround times, and coding-related denials. This real-time monitoring supports data-driven decision-making and continuous improvement.

Optimizing denial management with healthcare revenue intelligence

Front-end revenue cycle steps have a way of either reinforcing or damaging the back end. Healthcare revenue intelligence unleashed on denial management 

Healthcare revenue intelligence tools analyze denial data to identify common root causes of claim denials. It then categorizes denials based on reasons like coding errors, missing documentation, or prior authorization. When you identify high-risk areas, you can act proactively to create new training and workflows to prevent future denials.

Root cause analysis is not the only tactic to shave your denials rates. Communication with payers also figures into provider revenue, making the data surrounding it as important as CPT code analysis. Healthcare revenue intelligence tools track and analyze interactions with payers, identifying opportunities to improve communication and negotiation strategies. Getting clarity on communication issues like response and resolution times helps you make decisions about your payer mix. You can use a payer’s high “hassle factor” as a negotiating point or even a reason to drop them if rates and terms fall short. 

Accessing real-time analytics in your dashboards and reports provides visibility into denial rates, resolution times, and financial impact, supporting data-driven decision-making. This transparency enables you to continuously refine denial management strategies and improve outcomes. 

Optimizing accounts receivable

According to an MGMA Stat poll, medical practice days in accounts receivable have increased, often significantly. With high-deductible health plans becoming more common, patients are now responsible for a larger portion of healthcare costs. Unfortunately, many patients struggle to pay these higher amounts. A Kodiak study mentioned in Becker’s Hospital CFO Report found that collections from patients dropped from 54.8 percent in 2021 to 47.8 percent in 2023. Patients are paying less than half of their bills.

Additionally, the study finds that 53 percent of total bad debt write-offs in 2023 came from patients with some form of insurance, including commercial plans, managed care plans, and Medicare. Overall, self-pay patients accounted for the highest percentage of bad debt write-offs.

Accounts receivable intelligence helps you collect more of what patients and even payers owe. 

Using a quick, accessible way to track outstanding balances and prioritize collections gets A/R tasks completed faster. Analytics reveals patterns and trends in payment delays across different payers, service lines, and patient demographics. By understanding these patterns, you can implement targeted strategies to reduce days in A/R (DAR). Refining billing practices, enhancing follow-up procedures, and improving payer communication all expedite payments.

Healthcare revenue intelligence tools can also reveal the reasons behind payment delays, such as claims denials, patient disputes, or slow payer processing times. This data backs up your drive to improve claims accuracy, enhance patient billing transparency, or negotiate better terms with payers. 

Analytics can spot communication misses as well. Although it’s frustrating to lose a payment because a staff member missed an email or didn’t check into the payer’s portal, these issues can be quickly rectified. Often it takes analytics to discover these oversights. 

Revealing data is helpful, but good healthcare intelligence tools go a step further. Some can segment A/R  based on various criteria, such as the age of the receivable, payer type, or account value. For instance, high-value accounts or those with long outstanding balances can be prioritized for follow-up. When an intelligence tool can generate a priority list automatically, leaders avoid the intense labor of putting that together manually. Staff can start their day ready to work accounts from top to bottom. 

Finally, the best healthcare revenue intelligence tools provide predictive analytics that can forecast future cash flows based on historical payment patterns and current trends. These insights provide CFOs and revenue cycle leaders with the data to make informed financial planning decisions, ensuring that the organization is prepared for upcoming financial needs. This “predictive analytics” feature streamlines resource allocation as well. (Read about the five styles of healthcare payer analytics here.)

Optimizing patient billing and collections with intelligence

By cross-referencing services rendered with billing codes and payer requirements, healthcare revenue intelligence limits billing errors. Accurate billing not only minimizes claim denials but also enhances transparency for patients, reducing confusion and improving their trust in your organization. 

Good analytics tools identify inefficiencies and bottlenecks in the billing process. Delays in bill generation or patient information errors make a bad impression on patients. By addressing issues raised, healthcare organizations improve billing accuracy and delivery.  

Beyond intercepting errors, healthcare analytics help you get to know your patients’ habits so you can tailor bills to their preferences. For example, analytics can identify patients who are likely to pay promptly and those who may need reminders or payment plans. By segmenting patients based on their payment histories, healthcare organizations can personalize collections, a step patients appreciate. 

As with A/R analytics, billing is communication-dependent. Some healthcare revenue intelligence tools analyze communications, bringing any misses to staff attention. 

Sometimes, despite several communications and reminders, patients just aren’t getting their payments in. In some cases, analytics can uncover the reasons behind outstanding patient balances. With this information, staff can reach out to patients and offer to establish a flexible payment plan, provide financial counseling, or explain billing statements. Reducing outstanding balances enhances cash flow and reduces the need for collections agencies.

Intelligent analysis fuels a robust healthcare revenue cycle

Today’s progressive providers depend on healthcare revenue intelligence to achieve maximum profitability. Without it, you risk making decisions blindly, and nobody respects that. Embracing revenue cycle analytics is not just about improving the bottom line—it's about creating a sustainable, patient-centric approach to healthcare delivery.

Deep knowledge and understanding of your contracts and payer mix via contract analytics ensures you have the ammunition to advocate for your organization. 

MD Clarity's RevFind assists practices, physician groups, and MSOs in managing and controlling payer contracts by digitizing and centralizing all agreements into one location. It renders the details of contract performance in clear charts and graphs that demonstrate what reimbursements for certain payers and CPT codes should be and what was actually received. This system meticulously reviews each actual payment against the stated terms of the contract, highlighting any discrepancies for staff to address with payers and correct improper reimbursements. Additionally, it compares your reimbursements with national benchmarks, including Medicare. RevFind not only provides essential insights for proactive negotiations but also identifies costly trends for significant revenue recovery. By pinpointing systemic root causes, it helps prevent future underpayments. Finally, RevFind reveals how each payer contract is performing, so you can gather the competitive intelligence you need to negotiate from a position of strength. 

Schedule a demo to see how RevFind sweeps in more of your earned net revenue.

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