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What are the top 5 challenges in Specialty healthcare revenue cycle management?

RCM processes have been automated in many health systems and physician practices in the past decade, resulting in greater efficiencies and better patient experiences. Nevertheless, specialty healthcare providers still face significant challenges.

Ventra Health revenue cycle management is particularly challenging in the specialty environment. Oncology, rheumatology, gastroenterology, and ophthalmology are some of the medical disciplines that face administrative and financial challenges that negatively affect performance.

To implement an integrated RCM strategy that incorporates clinical decision-making and business operations, specialists must create prior procedural authorizations, manage advanced payment models, or synthesize the huge amounts of clinical information generated by sophisticated devices and software platforms.

Ensuring proper revenue capture

Medical billing relies heavily on charge entry. It involves a patient account charged the correct amount based on the medical codes and the fee schedule. The charge entry procedure determines a physician’s reimbursement for services rendered. In addition to this, cost accounting methodologies and financial benchmarking require the practice to get reimbursed effectively, so charge entry is crucial.

A specialty ecosystem involves many specialists participating in value-based care or bundled payment programs, making the charge entry process more complex. Complex diseases result from multiple systems that generate different types of information that can help diagnose & treat them. In the charge entry process to overcome issues, Healthcare organizations must move towards data interoperability.

Compliance Standards

Healthcare Information Portability and Accountability Act 1996 (HIPAA) must be integrated with your revenue cycle management system to prevent privacy breaches. You can be subject to heavy penalties and lose your medical practice if you violate health care fraud and abuse laws. Mandates under HIPAA –

  • Medical coding standardization
  • An annual compliance audit of the facility
  • Medical claims can be filed electronically
  • A foolproof workstation
  • Access to medical records is restricted and on a need-to-know basis
  • Online Coding Software and Software Access Protected by Password

You must protect protected health information (PHI) as a healthcare provider by charging honestly and following all HIPPA guidelines and protocols.

Reducing treatment delays by managing prior authorization

Prior authorization frustrates many specialists. It may seem opaque and time-consuming, but it is vital to control costs and ensure providers utilize evidence-based medical protocols.

It is the responsibility of the practices to ensure that every patient’s treatment plan adheres to the specifics of their insurance plan. Considering that prior authorization is not an approved process for all payers, specialty practices gain by adopting platforms that automate and customize workflows to cater to the unique requirements of each payer.

It allows providers to more effectively react to clinical declarations of treatment intent, acquire and archive supporting clinical documents, and quickly meet other payer-specific requirements to expedite approval of critical patient care.


Physicians and providers must be credentialed and authorized by the Payer’s network to provide patients covered by its plans. Obtaining credentialing validates a physician’s ability to deliver clinical care. Payers verify a physician’s education, license, and specialty accreditation. Payments may be delayed or refused by payers if physicians are not credentialed and enrolled with them, so they are negatively affected.

Those who work in specialty healthcare must ensure their credentials are appropriate for their skill set. Credentialed providers should provide up-to-date information on acquiring new specialty certifications. By leaving credentialing to external specialists, you can avoid reimbursement hiccups.

Monitoring payer contracts and drug pricing

In addition to CMS quarterly updates, commercial payors in the US also do so. Specialty medical care involves expensive, cutting-edge drugs and therapies, and even a small change can significantly affect a practice’s financial picture. Before deciding on a treatment plan for a patient, it is essential to be aware of such changes. An experienced billing company will ensure your RCM system is kept up to date.

When you deal with high volumes of patients, you can thus leverage their services for reduced workload and minimize any opportunity for revenue loss due to a lack of prior information.

Mehedi Hasan

Mehedi Hasan is an enthusiastic health blogger and the founder member of WOMS. He likes to share his thoughts to make people inspired about their fitness. He is an experienced writer and author on highly authoritative health blogs.

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