RCM by Care Settings
Your healthcare setting is not generic.
Your RCM should not be either.
Deploying a generic revenue production model into a healthcare setting with specific requirements creates systemic revenue leakages. Yet, a majority of in-house RCM departments and traditional vendors use uniform workflows for each care environment. This results in clinical-to-financial translation errors and a surge in denials that ultimately lead to a compromised bottom line.
AltuMED offers specialized RCM solutions for care settings to keep these problems at bay. Our custom revenue cycle workflows fully align with the clinical logic, payer behavior, and compliance requirements of your practice. We ensure that your RCM stays aligned with the services you provide.
Why Your Healthcare Setting Dictates Your Revenue Cycle
You cannot apply a uniform revenue cycle formula to disparate clinical environments and expect it to deliver. That’s because every care setting works on its own specific operational vectors. These vectors include:
An expert RCM partner like AltuMED prevents all this with specialized workflows. The combination of our strategic workforce and a Smart RCM Engine ensures that your care setting stays away from revenue cycle rabbit holes.
Customized RCM Services for Diverse Healthcare Facilities
An RCM partner that adapts to your clinical footprint is your strategic asset. AltuMED is built to be that partner. You can count on us for financial optimization of your healthcare setting. Here is how we fulfill the specific RCM requirements of six major care settings.
Physician Groups
Outpatient physician groups mainly deal with high volumes of low-cost claims. So, they naturally require RCM mechanisms that could automate coding for such claims. But the challenging part in it is that even a small systematic mistake in coding execution can compound into severe revenue leakage. At AltuMED, we prevent these errors by setting up:
- Smart automation of encounter-level logic and MDM documentation
- Mechanisms to check for and rectify modifier misapplication
- Workflows that adhere to "incident-to" billing protocols
Laboratory Networks
Like physician groups, lab networks also work in a high-volume, low-dollar environment. But the regulations they must follow are sometimes tougher. Examples of those regulations are the Clinical Laboratory Fee Schedule (CLFS) and stricter provider credentialing.
At AltuMED, we keep your laboratory setting fully compliant by deploying advance compliance frameworks. This ensures your practice never comes under the auditors' radar. The main aspects of these frameworks include:
- Regulatory fee schedule orchestration
- HCPCS alignment
- Molecular diagnostic algorithm automation
Hospitalist Groups
Hospitalist Groups get a major portion of their revenue through DRG-based reimbursements, which require complex documentation. The most specific challenge comes from POS 21 and POS 22 status identification and assignment. So, accuracy matters more than anything here. At AltuMED, we eliminate this confusion through:
- Automated capturing of medical necessity for admission and observation
- Accurate documentation of illnesses’ severity through our intelligent validation system
- Complete documentation of Complications and Comorbidities (CC/MCCs)
Specialty Clinics (Oncology, Cardiology, Pain Management)
Specialty clinics deal with high-cost therapeutics and specialized treatments that require complex procedural coding. And since their medical services are of critical nature, they are highly scrutinized for compliance.
To help these clinics streamline their revenue, AltuMED offers specialized RCM solutions, which include:
- Smart J-Code management to protect revenue from both administered and wasted units
- Prior authorization handling to prevent utilization-driven exceptions
- MIPS quality metrics embedding into daily RCM workflows
Ambulatory Surgery Centers (ASCs)
ACS revenue cycle management requires separating professional and facility claims. This means the surgeon bills the patient for treatment and the facility charges for resources like operating room, recovery bays, medical supplies, and support staff. AltuMED ensures documentation accuracy for these claims through immaculate capturing of the services provided by both.
- We implement Medicare ASC fee schedules and packaged service rules.
- We automated surgical sequencing logic (to avoid multiple procedure payment reductions and capture maximum facility fee).
- We adhere to stringent AAAHC accreditation standards.
Hospitals & Health Systems
Hospitals and health systems run on massive scales in order to provide disparate billable services without compromising the quality. This presents a tough challenge for revenue teams as they must bridge the financial environments of different departments to run smooth RCM operations.
AltuMED overcomes this challenge through effective synchronization of institutional UB-04 and professional CMS-1500 charge capture across all hospital departments. This setup relays the captured data directly to the main RCM Engine, which means minimal risk of discrepancies and resultant denials/underpayments.
We also keep your inpatient DRG and outpatient APC fully aligned through continuous maintenance of your Chargemaster (CDM) database.
Frequently Asked Questions (FAQs)
Find answers to common questions about Smart Workflow RCM and how it helps streamline revenue cycle operations.
Why is medical billing different for various healthcare settings?
Reimbursement frameworks differ based on the clinical environment’s specific overhead and cost infrastructure. Outpatient providers must know how to work with E/M CPT codes. Labs must adhere to the Clinical Laboratory Fee Schedule (CLFS). Hospitalists need to master inpatient DRG metrics. Every setting requires a specific RCM model, which generic billers cannot implement.
How does outsourcing RCM improve a hospitalist’s revenue?
Expert hospitalist RCM can accurately target documentation gaps that can lead to undercoded inpatient encounters. They can differentiate between POS 21 inpatient admissions and POS 22 observation status and document this comparison precisely. This helps prevent downstream denials while ensuring comorbidities are captured with their true diagnostic weight.
What role does automation play in facility-specific RCM?
Automation takes care of repetitive data transcription tasks that slow down the progression towards payouts. Its main tasks include front-end eligibility checks and billing rules application before claim submission. This increases the overall efficiency of baseline transaction volume handling. As a result, certified coders get a lot of their time freed up for resolving complex medical necessity and payer denials.
What is the difference between professional and institutional billing?
Professional billing involves claim submission for individual provider services using CPT and HCPCS codes. The claim form used here is CMS-1500. Institutional billing involves claim submission for facility expenses, equipment use, and room costs using the UB-04 form.
How quickly can an RCM partner improve clean claim rates?
Getting a reliable RCM partner on board doesn’t mean you will see improvements the next day. The initial performance lift is usually visible in 60 to 90 days. During this initial phase, the partner will calibrate its workflows with your facility’s operations. By the end of this period, you will see a noticeable reduction in first-pass errors. Micro optimizations will continue over 6 to 12 months.
What Our Clients Say
Align Your Revenue Cycle With Your Clinical Footprint
Your healthcare setting needs an RCM framework that adapts to your operations. AltuMED, with its 15 years of experience in the industry, guarantees precision with this integration. Our customized and compliant workflows are the best fit for all healthcare environments.
Ready to eliminate the administrative friction and insulate your net collections from systemic payer downcoding?