Improve Process Accuracy and ROI Using Process Street: A Medical Billing Brainstorm

In healthcare billing , precise execution is crucial, so organizations continually seek ways to enhance process accuracy and return on investment (ROI). It doesn’t matter if the role is internal to the healthcare practice or a Revenue Cycle Management (RCM) firm— structured workflows make all the difference. Whether it’s validating the coding or claims submission process is correct for the particular event or knowing how best to manage denials for a specific insurer, it’s vital to have the proper information at one’s fingertips.

This brainstorm explores how implementing Process Street can revolutionize workflow management for medical billing services with hundreds of interdependent processes. Organizations can reduce errors, enhance efficiency, and increase cash flow by standardizing operations and leveraging automation.

Understanding Medical Billing Process Challenges

Medical billing processes involve a series of interconnected steps—from patient registration, insurance verification, and pre-authorizations to claims submission, payment posting, and denial management. Each step, if mishandled, contributes to delays, inaccuracies, and financial losses. Examples include:

• Errors in medical coding during the *Charge Capture* phase can result in claims rejections downstream, adding manual rework, delayed cash flow, and frustration
• An incorrect pre-authorization process because the insurance company changed its rules, adding more delay to reimbursement
• Collections (particularly recouping revenue when a claim is denied)
• AR (streamlining what happens when a claim is sitting in Accounts Receivable, how long it sits, what happens when it gets into the red, etc.)
• Training staff - especially clinicians, let alone front desk admin staff - on changes to Medicare/Medicaid codes and the clinical requirements for using some and not others
• Integration between the different systems (the EMRs don't always align with the patient portal, for instance)
• The impact of a value-based care model on reimbursement and the constant shift towards a more outcome-based reimbursement system
• The future impact on the industry because of the incoming administration's focus on changing the Affordable Care Act (not to mention future administrations past this one as these rules by their very nature change, and it means the current system is always in jeopardy of needing to be rebuilt)

In this article, my theoretical RCM firm faces inefficiencies stemming from the hundreds of semi-standardized workflows typical in this environment. Many processes share similar core steps but diverge enough to create inconsistencies. These variations increase operational costs by increasing the number of Standard Operating Procedures (SOPs) to develop and keep up to date and challenge compliance with ever-changing billing processes and regulations. Let’s look at how one might generate Revenue Cycle Management Process Improvement

Streamlining Workflows with Process Street

Process Street can serve as the foundation for redesigning the organization’s approach to workflow management. By centralizing documentation and employing checklist-driven SOPs, the organization can ensure consistency and compliance across all claim’s lifecycle stages.

For instance, during the Claims Submission phase, Process Street workflows provide the SOPs in pre-built templates to confirm that all necessary documentation, such as insurance authorizations and coding validations, are done with the exact process needed by the particular hospital or clinic. And we all know that getting through the correct steps perfectly shortens the reimbursement process. There will be significant opportunities to automate the management of the ever-increasing and ever-changing SOPs.

Given this, it’s vital that we go through the standard discovery process to validate the different types of data contained in the SOPs. We want to thoroughly understand their individualities along with commonalities so we can build them in the most efficient manner. I typically argue one should use Improvizations’ “Here to There” approach.

Discovery

We like to describe our discovery method as a process to get from "HERE to THERE." And our approach is simple:

1. Analyze, vet, and gain a solid understanding of the business rules, policies, and procedures, and add to that deep and broad conversations with as many on your team as we can
2. Analyze and understand existing applications, systems (manual and software driven), current integrations, plans, and actual usage of your existing toolset

These two items combined provide us all with a clear understanding of "HERE." We find there is often a gap between perception and reality, and this process helps to close that gap. This is an important step because if we don't have clarity of the current reality, it's much harder to get to your goals.

So what are is your Current Situation & and what are the primary Challenges you seek to overcome?

And what is your Desired Future Situation & Solutions you think need implementing? This is your "THERE."

Now we can create a plan to get you quickly and efficiently to your desired state.

Centralizing Documentation

The next step in optimizing medical billing, or for that matter just about any process, is to centralize documentation. Although one could just key in the existing process documentation into Process Street, we find value in analyzing the similarities and differences between the common workflows. We can develop a template path to lower maintenance costs and challenges from that work.

To create a singular template for the base processes and sub-templates for the differences across a particular type of workflow, establish a standard format. By establishing a standard format, teams can quickly adapt these templates for specific needs, ensuring consistency across similar workflows.

Utilizing Workflows and “Sub”-workflows

Process Street enables users to create templates called workflows for each process. We can develop layers of these checklists across a few different boundaries. I am considering a scenario where one base template for a common process, for example at the Client level, could exist. That workflow run could call the sub-workflows for related but different requirements and rely on other common workflows as needed. Think of a multi-hospital system where each hospital does billing somewhat differently. Process Street could have a primary workflow that all the hospitals and clinics use for the common procedures (base template), and then, depending on the location, a different sub-workflow would be called.

We create additional value because when, say, Medicare billing rules change, only one common component needs to be changed, and it will apply across all the hospitals and clinics' processes.

Got Automation?

For processes that deviate from the norm, Process Street's conditional logic feature allows users to customize workflow runs based on specific criteria. This flexibility enables the client to manage variations without creating separate workflows, making it easier to maintain accuracy and streamline operations. Of course, one would need to analyze the existing processes to find the commonalities and differences that make this functionality beneficial.

And where this functionality is insufficient, we can use an automation tool like Make, Zapier, or Microsoft’s Power Automate to handle just about any need. For example, using the multi-hospital system SOP framework, we could build modular components described above for each vertical component, (e.g., corporate standards), and horizontal components, (e.g., insurance company rules, individual hospital policies), in Process Street. At runtime, the user would choose the hospital from a Data Set connected dropdown, and Power Automate could act like an aggregator. Using some amount of conditional logic, it would run the workflows attached to the chosen hospital on the fly with all the proper components of the SOP! This makes it easy to manage and update each component without needing a ton of complicated backend work, so changes can be made quickly and hassle-free.

The Importance of Testing and Analytics

Any large process improvement project requires solid user adoption processes, testing, and measurement processes to validate the win. Process Street provides analytics and reporting features that allow the client to measure the efficacy of workflows. Of course, one can build the above processes for the project into Process Street itself. The team can identify improvement areas and assess the implemented workflows' overall ROI by tracking metrics such as task completion rates and the time taken to complete processes. In some cases, Process Street's metrics could eliminate the need for additional operations workflow management systems, further simplifying the organization's tech stack.

Training and Onboarding

To ensure successful implementation, we always plan for User Adoption. User adoption is achieved by developing sound change management, training, and communication processes and consistently executing them from the very beginning of the project through months afterward. By offering workshops and resources focusing on using the new procedures effectively, employees will feel more confident and empowered in managing the workflows and upholding the accuracy needed for success.

The Near Future

I can see a future where the fully implemented revenue cycle workflow management system has the following components:

• Fully documented standard operating procedures
• Easily updated SOPs as required by client, clinic, insurance, and government policies and rules
• All the organization’s related tech stack is integrated
• No duplicate effort and increased accuracy by the internal team
• The ability of the user to query the library of SOPs like ChatGPT to find answers based on the data in documentation, workflows, datasets, and more (more of a mid-term dream because as we all know AI isn’t quite trustworthy enough to maintain proper security of your data!)
• Everything that doesn't need a human is automated

Conclusion

Implementing easily used and managed workflows can streamline the organization’s approach to medical billing by standardizing processes, reducing manual interventions, and fostering a culture of accountability. By leveraging easily queried and followed SOPs, automation, and analytics, the organization can achieve significant cost savings and build a scalable framework for future success.

This brainstorm underscores embracing technology to overcome challenges in complex environments. Medical billing services can position themselves for long-term growth and excellence by investing in structured, adaptable workflows. We love having a strategic approach to process improvement and automation. If this resonates with you, please check us out at Process Services | Improvizations or book some time directly with me. I love to chat about process improvement, optimization, and automation.