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Revenue cycle management checklist: improve experience & profits

Published: January 28, 2025 by Experian Health

Revenue cycle management checklist improve experience & profits

As margins tighten, traditional revenue cycle management strategies are on shaky ground. Many healthcare providers are turning to automation and AI to simplify payments, prevent revenue loss and protect profits. This article breaks down some of the most common revenue cycle management (RCM) challenges facing healthcare leaders and offers a practical checklist to optimize patient access, collections and claims management, while building a resilient and patient-centered revenue cycle.

Common challenges in revenue cycle management

Revenue cycle management is how healthcare organizations handle the financial side of patient care, from patient billing to claims management. Healthcare providers rely on RCM to ensure they are properly paid, so they can keep the lights on, pay their staff and deliver quality patient care.

Are traditional RCM strategies still fit for purpose? Consider some of the current challenges:

  • Patients are responsible for a larger share of costs due to high-deductible health plans. How can providers help them understand their financial obligations and make it easier to pay without hurting their experience?
  • Minimizing claim denials is a daily focus, thanks to constantly changing policies and regulatory updates. How do revenue cycle teams keep up with payers?
  • Staffing shortages remain on the agenda. How can providers ease pressure on staff to maintain productivity and morale?
  • There’s also the question of how to turn mountains of data into actionable insights. How do teams interpret it correctly to identify bottlenecks and opportunities for improvement?

Automation and AI offer a way through. When implemented thoughtfully, these tools can speed up processes, reduce errors and clear operational roadblocks for a more resilient revenue cycle. The following revenue cycle management checklist includes some of the key questions to consider along the way.

Checklist for improving revenue cycle management

Automating patient access

  • Can patients book appointments online?
  • Does the online scheduler automate business rules to guide patients to the right provider?
  • Are patient identities verified at registration and point of service?

A healthy revenue cycle starts with efficient patient access. According to the State of Patient Access 2024, 60% of patients want more digital options for scheduling appointments, managing bills and communicating with providers. Providers who see improvements in patient access also credit automation, which speeds up intake and improves accuracy.

A good first step is to replace paper-based processes with online self-scheduling and self-service registration. These tools make life easier for patients, boosting satisfaction, retention and engagement. Behind the scenes, Experian Health’s new AI-powered tool, Patient Access Curator, helps providers get paid faster by verifying and updating patient information with a single click – accelerating registration and paving the way for faster reimbursement.

Register now: Exact Sciences and Trinity Health will share how Patient Access Curator is redefining patient access in this upcoming webinar.

Optimize patient collections with data and analytics

  • Are patient estimates provided upfront?
  • Are notice of care requirements being addressed?
  • Are patients offered appropriate financial plans and easy ways to pay?

With more financial responsibility resting on patients’ shoulders, patient collections are under the spotlight. The State of Patient Access report shows that upfront estimates and clarity about coverage are top priorities for patients, because when they know what they owe, they’re more likely to pay on time. Implementing tools to promote price transparency and easy payment methods should feature in any RCM checklist.

WithCoverage Discovery, healthcare organizations can run checks across the entire revenue cycle to find billable commercial and government coverage that may have been forgotten, to maximize the chance of reimbursement. Meanwhile, Patient Payment Estimates offers patients clear, accessible estimates of their financial responsibility before treatment, so that hose who need financial assistance can be directed automatically to payment plans and charity options.

Case study: How UCHealth secured $62M+ in insurance payments with Coverage Discovery®

Improve claims management to reduce denials

  • Are high-impact accounts prioritized?
  • Are remittances reconciled with payments received?
  • Does claims management software generate real-time insights and reports?

With 73% of healthcare leaders agreeing that denial increased in 2024, and 67% saying it takes longer to get reimbursed, claims management is a great use case for automation. ClaimSource®, ranked Best in KLAS in 2024 for claims management, automates the entire claims cycle in a single application. It integrates national and local payer edits with custom provider edits to verify that each claim is properly coded before submission. By focusing on high-priority accounts, providers can target resources in the most effective way to ensure a higher first-pass payment rate.

A major advantage for ClaimSource users is access to AI Advantage™. This tool utilizes AI to “learn” from an organization’s historical claims data and trends in payer behavior to predict the probability of denial. It also segments denials so staff can prioritize those that are most likely to be reimbursed, reducing the time and cost of manual appeals and rework.

Case study: After using AI Advantage for just six months, Schneck Medical Center reduced denials by an average of 4.6% each month, and cut rework time from 12 to 15 minutes per correction to under 5 minutes.

Benefits of implementing a revenue cycle management checklist

The key to choosing the right RCM tools and technologies is to build the strategy around what patients need most. A clear, transparent and compassionate billing experience is more manageable for patients and helps providers get paid faster. An RCM checklist helps teams stay focused on the tasks that matter.

Providers can build on the suggestions above by choosing the key performance indicators (KPIs) that align with their specific goals. Metrics like financial performance, billing efficiency and collections rates can be combined to guide resource allocation, drive improvements and speed up reimbursement. With a well-designed checklist informed by clear KPIs, revenue cycle leaders can keep their teams on track and take their organizations from “surviving” to “thriving.”

Learn more about how Experian Health’s revenue cycle management tools can help healthcare providers meet current challenges, improve the patient experience and increase cash flow.

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Manual prior authorization workflows represent one of the most tedious and expensive aspects of the healthcare revenue cycle. However, despite access to automated prior authorization software, only 31% of providers use electronic prior authorizations, according to the Council for Affordable Quality Healthcare (CAQH). The CAQH predicts that providers who switch to automated prior authorization software could not only gain back valuable staff time, but also see significant cost savings. What is prior authorization and why is it important? In healthcare, prior authorizations are when providers and payers decide in advance if a patient's insurance plan will pay for a specific treatment. Prior authorizations are crucial to reimbursements and keeping revenue cycles on track. Providers that offer services without prior authorization are unlikely to receive reimbursement from the patient's insurer. This can result in unpaid medical bills, leaving billing teams chasing patient collections or writing off bad debt. During the prior authorization process, providers submit a rationale for a proposed treatment to the payer. The request is approved or denied based on certain criteria, including payer policies and medical necessity. The payer may reject a prior authorization request if the treatment or service isn't covered under the patient's insurance plan, if it's not considered medically necessary or if a more affordable alternative is available. Simple paperwork errors, like missed deadlines or incomplete documentation when submitting a prior authorization, may also result in a denial. Challenges of manual prior authorization processes Despite the importance of prior authorizations in the revenue cycle, tedious manual prior authorization processes present challenges for many healthcare providers. Some of the key obstacles providers face using manual prior authorization include: Heavy administrative burden Healthcare providers spend a significant amount of time starting, completing and revising prior authorization paperwork. An AMA survey found that 86% of physicians say prior authorization has increased healthcare resource usage. At the same time, additional AMA data reports that providers spend around 13 hours working on 39 prior authorizations each week, and nearly one-third of providers report that these prior authorization requests usually end up being denied. Changing payer policies Keeping up with multiple payers and ever-evolving payer policies adds strain on staff and ultimately results in prior authorization denials. Changes are often unannounced, making it hard for providers to stay on top of updates. As a result, prior authorization submissions aren’t always accurate and may be based on outdated rules. This can lead to instant rejection and wasted time correcting and resubmitting requests. Inefficient workflows Prior authorization requirements can be complicated, especially when providers are juggling different payers, standards and service lines. Coping with these complexities often puts strain on manual systems, especially when multiple staff and notetaking methods are involved. Staff members may each get different pieces of information from payer websites (or over the phone) and not have the ability to benefit from their shared knowledge efficiently. Navigating communication hurdles and rapid payer information changes can result in workflow inefficiencies that snowball quickly. How prior authorization software can improve efficiency Replacing manual prior authorizations processes with automated prior authorization software can help providers improve efficiency. Here are some key ways providers benefit from automated prior authorization solutions, like Experian Health's Authorizations. Reduces manual interventions: This solution limits guesswork, human errors, and misinterpretations by automating data originating from the EMRs. Automation saves staff time and energy and prevents frustration. Stays current with latest payer policies: The prior authorization system stays up-to-date with the latest regulations and payer requirements. Automatic updates provide staff with the most current information, eliminating the need for staff to visit multiple payer websites or cross-check data by hand. Provides real-time updates: Providers can promptly clear authorizations for service by proactively identifying authorization status as pending, denied or authorized. This allows physicians to make timely treatment plans and for patients to avoid disruptions in care. Reduces risk of denials: Through automation, electronic prior authorization software ensures the accuracy and completeness of submissions by automatically checking with payers and vendors to validate that the authorization is on file. Payers and providers also get a shared view of account information, reducing the need for prolonged discussions about the status of authorization and rework requests. Key features to look for in prior authorization software When implementing prior authorization software, look for a solution that offers a wide range of features to automate and streamline the prior authorization process. Experian Health's prior authorization solution, Authorizations, for instance, offers healthcare providers the following key features: Real-time knowledgebase: Access to up-to-date prior authorization requirements and criteria in the National Payer Rulesets Submissions support: Removes guesswork and directs users to the correct payer portal based on procedure Automated inquiries: Automates the prior authorization payer inquiry process Enhanced workflow: Dynamic work queues display status and guides users through next steps Postback: Allows users to easily send authorization status, number and validity dates to health information systems (HIS) and practice management systems (PMS) Image storage: Receives and securely stores payer responses in an integrated document imaging system Reconciliation: Provides insights into authorization variations and helps resolve them, so staff can take proactive steps to prevent denials and appeals Integration with electronic health records and billing systems: Why it matters Providers often choose a prior authorizations platform that seamlessly integrates with existing Electronic Health Records (EHR) and billing systems for maximum efficiency. Solutions like Experian Health's automated prior authorization management tool, Authorizations, easily adapt to existing processes. This eliminates the need for a complete workflow overhaul and minimizes the learning curve for staff. Embracing prior authorization software for a more efficient revenue cycle Revenue cycle leaders who implement prior authorization automation strategies could see significant savings – $494 million annually as an industry, according to CAQH data.  Claims and revenue management processes are often complex and outdated, costing healthcare organizations time and money. High denial rates and slow reimbursements can hurt cash flow and get in the way of financial stability. Automating prior authorization can reduce claim denials, speed up reimbursements and improve the bottom line. Learn more about how Experian Health's electronic prior authorization software, Authorizations, uses automation to achieve greater consistency and efficiency for healthcare organizations. Learn more Contact us

Published: July 30, 2025 by Experian Health

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