Healthcare Revenue Cycle Solutions


Healthcare Revenue Cycle Solutions

It is imperative for today’s healthcare providers to maximise the revenue received for the services they provide. Protiviti helps organisations enhance revenues and margins by improving strategy, processes and system controls. Our approach is designed to improve net revenue and/or sustainable cash, accelerate cash flow, enhance overall revenue cycle performance, and prepare for future acquisitions or joint ventures.

A great way to get started is to perform a comprehensive yet targeted Revenue Cycle Diagnostic to evaluate the overall health of the revenue cycle. Our approach is designed in a way that allows management and other stakeholders to gain a clear understanding of the business in order to identify, source and measure risk at both the entity and process levels.


Patient satisfaction and optimal reimbursement hinge on the efficiency and effectiveness of initial patient touch points, including patient data collection, pre-registration, insurance verification, up-front collections and payer notification. Our design and implementation teams work with management to develop a roadmap for a healthy revenue cycle that mirrors the goals of the organisation and helps validate that patient access and utilisation review processes optimise overall revenue cycle performance and increase patient satisfaction.


Financial success for many healthcare organisations depends directly on capturing and charging accurately for eligible services rendered and supplies used. Failures or delays in the charge capture process jeopardise revenues and patient satisfaction, as well as regulatory compliance. Our charge capture services help organisations quantify and identify root causes of inaccurate charging and resolve them permanently. In addition, we have extensive knowledge of and experience with third-party tools that can be used to automate the identification of missing charges. Our approach considers both revenue optimisation and patient care to help organisations achieve sustainable improvements and long-term results.


An organisation’s CDM and the process for maintaining the CDM must be well-designed and controlled. We routinely review CDM structure/integrity, access, charge methodology and utilisation of service items, and evaluate the infrastructure housing the CDM as well as any overrides from other systems, such as pharmacy, materials management, lab or surgery. In addition to analysing the current CDM process, we can assist in building out a price optimisation model to help organisations understand the potential impact to its revenue and patient volume based on CDM changes.


The critical role of HIM in both clinical and financial areas is rapidly changing in today’s environment, with new government regulations, increased use of technology, the ever-growing need for information governance, and the shift from fee-for-service to value-based delivery and payment systems. We partner with process owners by performing chart audits and isolating opportunities for improvement in documentation and coding.


An accurate and streamlined billing process is essential to ensuring timely payment, which is why billing departments continuously work to improve both their quality assurance capabilities and their ability to process claims quickly. We can help you determine where you stack up against other billing departments and ultimately help identify and employ the billing practises that will work best for your department. The key is to ensure you have the right monitoring and quality assurance controls in place to detect inaccuracies and pending deadlines.


We will help you understand the financial impact of denials on your organisation, analyse and determine the root causes of denials experienced, devise strategies to minimise denials and enhance operational performance, and assist you in implementing these strategies. We offer a holistic business process approach to diagnosing and addressing denials and their consequences for your organisation’s revenue operations, in addition to performing data analytics to ensure your system is capturing denials completely and accurately. We can also create customised reporting to help the organisation isolate, root cause and remediate process deficiencies causing denials.


Often, underpayments are as significant a problem as denials, especially when a contract management system is not used to ensure actual reimbursement equals expected reimbursement. On the opposite end of the spectrum, it is imperative to identify and refund overpayments in a timely manner, as there can be financial and regulatory repercussions if payer requirements aren’t met. Systematically monitoring and resolving payment variances can have a significant impact on a healthcare organisation’s bottom line and provide the basis for enhancing integration and communication between departments. We help organisations assess the effectiveness of their current payment variance process and identify remediation strategies where the process falls short. In addition, we help determine whether an automated solution would be value added.


MBS is a service line that Protiviti has developed to share the workload and burden with our clients in order to support revenue cycle processes. Tenure, talent, backlog support and growth are challenges in most revenue cycle processes. We are able to step in and manage all or specific operations within the CBO, including billing and collections, contract management, authorisation and insurance verification, call centers, CDM creation/maintenance, new provider/business office integration, reporting/monitoring, credentialing, and more. In addition, we can provide interim support for key revenue cycle positions, including VPs/directors, coders, coding auditors, billers, collectors and cash posters, among many others.