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Revenue Cycle Management RCM Model and Process

Revenue Cycle Management (RCM) Model

Conquering giant clients such as Epic, nThrive manages service models with only one medical bill. In the medical field, revenue cycle management (RCM) is important to simplify the management of health care providers, especially hospitals. The RCM process begins when the patient schedules an appointment and ends when the provider receives the fee. Any errors in the process may prevent the provider from charging in time or at all.

With the emergence of new third-party payment methods, the medical industry has shifted from traditional pay-per-service to quality-based, especially in the medical coding guidelines from ICD-9 to ICD-10, the management of medical bills has become more complex.

In order to free doctors from cumbersome bill management and focus on caring for patients, more and more providers are choosing to hand over their RCM work to companies that use proprietary technology platforms to handle this complex process, RCM the company.

RCM can provide outsourcing services such as patient pre-registration, appointment scheduling, medical billing, and coding. The outsourcing method is fully outsourced from end to end, and some outsourcing is also signed on a regular basis.

According to the 2019-2025 US Revenue Life Management (RLM) Market Size Report released by the US market research and consulting firm Grand View Research in January 2019, the US RCM market size is estimated to be US$10.98 billion in 2017, which is expected to be forecast. The compound annual growth rate during the period was 11.2%.

At present, the US RCM market is highly competitive with many participants, including:

  • 3M Health Information Systems (Salt Lake City)
  • Adreima (Downers Grove, Ill.)
  • Alls (Chicago)
  • Epic Systems Corporation
  • Cerner (Missouri)
  •  Change Healthcare (Nashville, Tennessee) and other giants.

The RCM company to be mentioned in this article, nThrive, is a newly formed merger company. It has not only entered into a partnership with Epic Systems Corporation and Cerner, but also has Adreima.

It is worth mentioning that nThrive not only provides regular RCM outsourcing services, but also provides business consulting, analysis and education training services to medical service providers with its powerful data analysis platform and expert team, which is different from peers. The advantage is.

Birth: three companies are one

Headquartered in Georgia, USA, nThrive is an analytics-driven, technically supported company that provides comprehensive revenue cycle management (RCM) outsourcing services to customers including hospitals and other healthcare providers. nThrive was born from three companies, its predecessor is MedAssets-Precyse.

In June 1999, MedAssets, one of nThrive's predecessors, was founded. MedAssets was originally a Group purchasing organization (GPO) that provides customers with a discount on medical supplies through large-scale orders. In 2007, MedAssets went public and expanded its line of business, including cost and clinical resource management, procurement, revenue cycle solutions, change management consulting, and data-driven analysis software. As of August 2014, MedAssets has grown to become the largest GPO in the United States.

In early 2016, private equity firm Pamplona Capital Management acquired MedAssets for $2.7 billion, and sold its drug procurement and consulting business to the VHA-UHC Alliance, one of the largest GPO participants in the medical field. MedAssets' revenue cycle management business is combined with the business of Precyse, a company acquired by Pamplona Capital Management in 2015.

MedAssets has powerful front-end systems such as patient access portals and good back-end systems such as charge trapping, claims rejection management and accounts receivable. Prior to the acquisition, MedAssets' CRM business performed well, managing more than $450 billion in patient revenues and serving more than 2,700 healthcare facilities. Precyse specializes in health information management, coding, case management, transcription, and clinical documentation improvement.

After the merger of the two companies, the new name is MedAssets-Precyse, and the company is positioned as a leader in end-to-end revenue cycle technology, outsourcing services and education markets. 

To ensure a smooth transition and continuous development of the two companies in key areas, Pamplona Capital Management invited J. Joel Hackney to serve as CEO of MedAssets-Precyse, hoping to use the power of Hackney to help the company continue to move forward.

Hackney has more than 20 years of executive experience and has held leadership positions at General Electric, Nortel Networks in Montreal, Canada, Avaya, California, and AVINTIV, North Carolina, with deep expertise in driving business transformation and profitable growth. Knowledge.

In early June 2016, MedAssets-Precyse acquired the medical analysis and consulting company Equation. Equation's cloud-based intelligent analytics platform DataRiverTM turns medical data into actionable advice. 

After the acquisition, Equation's technical and data analysis capabilities enhance the capabilities of MedAssets-Precyse's existing analytics platform.

MedAssets-Precyse acquired Equation for less than a month, that is, at the end of June of the same year, MedAssets-Precyse was renamed nThrive, and the new company was born.

Combined with the business of companies such as MedAssets, Precyse and Equation, the new company nThrive focuses on revenue cycle management, providing products such as software, management services, business consulting and analytics solutions.

Chris Skiffington, president of nThrive's solution, said there was no significant overlap between the three companies' products. MedAssets has reliable revenue cycle management software, including front-end software for patient registration, mid-range chargemaster (management) components for managing pricing, and back-end products focused on claims and collection processes. 

The company also provides revenue cycle consulting and management services. Precyse specializes in health information management and the translation of clinical documents into medical bills. Equation fills the final gap in the analysis of revenue cycle management.

Strategic expansion: working with giants to acquire top players

The newly synthesized nThrive integrates the advantages of the three companies, but does not stop there, but chooses to continue to expand its strength.
A strategic acquisition of top players and collaboration with industry giants has become an important means for nThrive to enhance its business scope and market reach and achieve rapid expansion.

Patient registration and insurance qualification are the first steps in the revenue cycle management process. To help administrators quickly validate a patient's insurance eligibility in a provider's Patient Accounting System (PAS) and obtain patient benefit information, nThrive partnered with EHR giant Epic to create a Patient Access Suite. A combination of additional modules.

"By working with Epic, users no longer need to access external insurance verification procedures and re-enter personal and insurance information, and the required information is automatically integrated when the eligibility request is initiated," said Jit Sivalogan, director of product management at nThrive Patient Access Solutions.

Claim processing is a key factor in the revenue cycle process that affects the speed of payment. To alleviate the complexity of claims processing and reduce the probability of refusing claims, nThrive also worked with Epic and CernerTM to create a compatible claims coordination system to increase the likelihood of identifying and resolving problems during the claims process.

In addition, nThrive has acquired two companies that are leaders in their respective fields: Adreima and e4e Healthcare services.

Finding the right health insurance plan

In November 2016, nThrive acquired Adreima, a clinical integrated income cycle service provider based in Illinois. Adreima provides a patient-centric clinical integrated income cycle service that helps patients find the right health insurance plan and fulfill their financial obligations while working with healthcare providers to optimize revenue cycle functionality.

“Adreima provides nThrive's portfolio with new strategic capabilities, including patient insurance eligibility determination and registration services, which enhance the ability of healthcare providers to identify appropriate insurance plans to help them better care and help patients.” The company said in the acquisition statement.

In April 2017, nThrive acquired e4e Healthcare Services, a US-based Indian and Indian healthcare company. With over 20 years of experience in medical business process outsourcing, service providers and payers, e4e also offers value-added solutions for software, technology, service desks and analytics.

After the acquisition, e4e's doctor billing and coding solutions became an integral part of nThrive's outpatient products, enriching nThrive's product portfolio from patient to payment. At the same time, the acquisition of e4e has also enhanced the influence of nThrive on a global scale, especially in the Indian market.

Full industry chain CRM services: regular services + analysis, education and consulting

Mergers, acquisitions, cooperation. The nThrive, which has been merged for less than three years, has been recruiting a large number of talents, technologies and products, thus forming a set of front-end, mid-end and back-end covering the income cycle management, and even included Full-industry chain CRM services such as analysis, consulting and education after the end of the income cycle process.
Revenue Cycle Management Chart

The complete set of RCM services provided by nThrive (screenshot from nThrive official website)

This industry chain allows patients to concentrate on their visits, doctors focus on the consultation, and medical service providers turn into a sustainable, high-performance engine. 

The following provides nThrive with full industry chain services:

Patient Access Solution (front end): This program is designed to improve the patient's experience in the visit process.
nThrive provides collection services from insurance qualification verification to various materials, including the collection of point-of-service (POS) and prevention of patient registration errors, resulting in insurance institutions refusing to pay.

Mid-term revenue cycle solution (mid-end):

The chargemaster safety net provides services such as medical line item updates, compliance and arguable pricing, and prevents providers from leaking charges, overcharging, and generating incorrect codes.

Patient Financial Solutions (Back End): 

The back end of the revenue cycle is a key part of the health care provider's generating and driving development.
nThrive optimizes the processing of patient claims by managing claims, contracts and bill collection, reducing underpayments and shortening The number of days of accounts receivable and the cost of collections are reduced, accelerating cash flow, thereby helping health care providers to earn more.

Value-Based Care Solutions (Back End): 

Helps healthcare providers identify factors that influence cost, quality, and care decisions, and helps healthcare providers solve problems from a variety of perspectives through consulting services, on-demand education, and analytical tools.

Healthcare Consulting Services:

 nThrive's expert advisory team provides full guidance to help healthcare providers find financial and operational issues that affect them, and provides solutions that increase revenue, reduce costs, and improve patient and employee satisfaction. A high-performance, patient-centric income cycle.
Revenue Cycle Management for Clients

Healthcare Analysis Services:

nThrive integrates and analyzes different data sets of healthcare providers within 30 days through a streamlined data ingestion process, helping healthcare providers find work areas that need improvement, making data-driven medical decisions, quantifying doctors The value of improving the day-to-day operational efficiency of the organization and achieving growth targets.

Healthcare Education Services:

nThrive Education provides tailored online education, performance management and benchmarking solutions that enable healthcare providers to structure medical coders, health insurers, clinical document specialists, doctors and other staff A personalized training program that helps health care providers' teams improve their skills, endurance and competitiveness.

Today, nThrive attracts more than 1,350 hospitals and other healthcare organizations with its full range of CRM services, and has offices in multiple countries around the world, with more than 6,000 employees generating an average of $600 million in annual revenue.

Of course, as the entire medical sector pays attention to the application of electronic health records (EHRs), the transformation of value-based medical services and the continual rise in demand for curbing medical expenses, the RCM market has greater potential for development, such as nThrive and CRM. The future can be expected.

For the domestic markets, due to the different medical environments at home and abroad, the true CRM company has not yet appeared.

However, some platforms dedicated to improving the medical treatment process and experience are emerging in Asia, such as the doctor of fruit. 

The arterial network used to be the "high-end medical version of the Mei Tuan Review, how can the doctors of the fruit change the way of the middle-class medical treatment?
  The title of the doctor, the model of the fruit doctor was analyzed.

Dr. Yuguo has established a service network covering users, commercial medical institutions and insurance institutions, focusing on quasi-middle-income and above-income people, connecting high-end private medical institutions and insurance institutions, providing users with high-end private medical institution screening and doctor practice information.

Services such as enquiries and visit discounts help users make better medical decisions. 
The business model of the fruit doctor has many similarities with the “Meiuan Review”, which is mainly reflected in the medical information acquisition and medical experience evaluation.

Although the doctor of the fruit is slightly different from the CRM company in the strict sense, with the continuous introduction of the domestic medical reform policy and the continuous improvement of the commercial medical insurance system, Asia's medical industry will usher in a period of great change.

In the future, the CRM model will be implemented in Asia in a way that is consistent with the characteristics of Asia's medical environment.

Author's Bio

Doctor Shawna Reason, Virologist
Dr. Shawna Reason
Name: Shawna Reason

Education: MBBS, MD

Occupation: Medical Doctor / Virologist 

Specialization: Medical Science, Micro Biology / Virology, Natural Treatment

Experience: 15 Years as a Medical Practitioner

About Me

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