Health systems face an increasingly complex regulatory landscape with evolving rules on price transparency, prior authorization and Medicaid reimbursement, pushing revenue cycle teams to adapt swiftly to stay ahead of compliance requirements and safeguard the patient experience.
“At VCU Health we are largely focused on defining optimal standard work in [price transparency, prior authorization and Medicaid redetermination], and then pursuing relentless error-free execution of that standard work, to be best prepared for new and even more complex regulatory or competitive landscape changes,” Brett McMillan, vice president of revenue cycle for the Richmond-based health system, told Becker’s.
For example, VCU Health’s approach to price transparency begins with the vision that every patient — for every encounter — should receive an appropriate good faith estimate at the time of scheduling.
“We expect our schegistration and front-desk teams to have sufficient knowledge of insurance plans, coverage terms, services being quoted and the plethora of financial assistance options we make available to patients (e.g. Medicaid eligibility assistance, indigent care program, long-term interest free financing, grant programs, discount program, etc) and to answer basic questions the patient may have about that estimate or financial assistance options,” Mr. McMillan said. “More challenging estimates and questions are routed to managers and a team of subject matter experts on the financial counseling team to address.”
VCU Health is also enhancing its expertise in key service lines such as transplant, cancer and cardiology by establishing dedicated financial counseling teams that provide comprehensive financial guidance — from episodic care estimates to broader assistance throughout the entire clinical care journey.
“This all-in approach sets us up well for what we assume will be expansion of the current No Surprises Act requirements,” Mr. McMillan said.
Another example is VCU Health’s approach to prior authorizations.
“A number of new capabilities have come online in the marketplace recently that promise to streamline and automate the prior auth process, and we are taking advantage of a number of those,” he said. “But more fundamentally what we found is that the prior authorization work has historically been very fragmented at our organization, with much of this work historically residing outside of revenue cycle operations where priorities and focus on training and keeping up with payer changes has been inconsistent.”
To combat this, over the past 24 months, VCU Health has leveraged job titles, Epic usage data and denial root cause analysis to pinpoint exactly who is performing this work.
“We’ve been successful in moving most of this prior authorization work into a centralized prior authorization team within the revenue cycle.” Mr. McMillan said. “Having most of this work in a central unit allows for greater focus on standard work, cross training, quality assurance efforts, and provides the organization with a single place to address authorization-related questions or concerns regarding denial information or new clinical service setup, etc. In this way, our focus on the basics around organizational structure and standard work sets us up to be more successful with respect to injecting automation and AI into these processes in the future.”
Tampa, Fla.-based Moffitt Cancer Center’s revenue cycle team is also proactively preparing for regulatory changes by focusing on automation, collaboration and patient-centered strategies.
“Automation has been critical. We are investing in technology, specifically patient estimation tools to handle the growing volume of required tasks and ensure we can generate accurate and timely patient estimates,” Viviana Beland, senior director of Moffitt’s front end revenue cycle, told Becker’s. “While we have had success implementing self-pay price transparency, that represents a relatively low volume; our current focus is scaling these capabilities to manage broader services with less human intervention. We are also leveraging AI technology to accelerate authorization approval turnaround times.”
Moffitt leaders emphasize that education — both for providers and patients — is crucial.
Providing high-quality care and outcomes goes hand in hand with ensuring patients are financially informed, and Moffitt works closely with clinicians to underscore the importance of price transparency and their role in supporting patient financial readiness.
“From the moment of new patient registration, our financial clearance process helps set expectations and prepare patients for what is ahead. We have established a comprehensive support system that includes insurance navigators, financial counselors and robust patient assistance programs to bridge financial gaps,” Ms. Beland said. “Additionally, by offering multiple payment options based on patients’ ability to pay and incorporating various digital billing options, we aim to provide patients with the tools they need to manage their healthcare expenses effectively. This will enable them to make informed decisions about their care — all within the convenience of our patient portal.”
Moffitt’s revenue cycle team also collaborates with its payer strategies team, which works directly with insurers to align on clinical pathways, newly FDA-approver therapies and medical necessity guidelines. Additionally, Moffitt partners with other cancer centers through the Alliance of Dedicated Cancer Centers to share best practices and anticipate regulatory changes.
“We are also tightly connected to our government relations team, ensuring they understand the operational and financial challenges we face,” Ms. Beland said. “They play an active role in shaping potential legislative solutions and keeping us informed, so we can act swiftly when changes occur.”
