The RCM Maturity Framework, Part Two: The Four Stages of Maturity

EDITOR’S NOTE:

Matt Bridge continues his three-part series on how to achieve a high-performing revenue cycle for your facility. Bridge reports that you need an understanding as to where your organization falls on the RCM Maturity Framework. Here is Part Two in this exclusive series for ICD10monitor.

The RCM Maturity Framework, introduced in the first edition of this three-part series, is a powerful diagnostic tool in the quest to optimize and digitally transform revenue cycle performance. It serves as the basis for a practical approach to transforming revenue cycle management (RCM) to help future-proof operations through a hybrid model of in-house management, global services, advanced technologies, and actionable analytics.

Four stages make up the Maturity Framework: Emerging, Foundational, Advanced, and High-Performing. Where an organization falls within those stages is determined by its level of maturity across three pillars: service delivery, technology and interoperability, and analytics.

Knowing one’s organization’s status within each pillar – and therefore its stage of maturity within the Framework – allows finance and revenue cycle leaders to determine where they stand in comparison to other, similar institutions. It also allows them to benchmark their current maturation level, identify the steps needed to accelerate the maturation process and gain insights from high-performing organizations.

The RCM Framework allows leaders to create a customized roadmap for navigating their organization’s unique journey toward operational maturity and enhanced RCM by answering questions such as the following:

• What level of RCM maturity has your organization achieved? 
• Are you aware of how high-performing organizations are achieving advanced maturity?
• Do you know what’s needed to accelerate the maturation of your organization’s RCM?
• Have you determined the intended destination for your journey? 
• Does your team have the necessary skills and experience to take your revenue cycle operations to the next level?

Knowing the organization’s stage of maturity and where it falls short within each pillar provides the directional clues needed to continue advancing toward operational goals.

Emerging Stage

An Emerging stage organization is best thought of as one that has historically relied solely on private pay reimbursement models (e.g., retail healthcare), or that has grown rapidly through mergers and acquisitions (M&A) or other means, and is therefore saddled with disparate systems, processes, and delivery models. Its service delivery is all in-house, and its technology is incompatible with interoperability. Emerging organizations share several common characteristics:

• Service delivery: The model is fragmented, decentralized, and 100-percent in-house, and analytics are best described as ad hoc and spreadsheet-based.
• Technology and interoperability: There is minimal system integration between the electronic medical record (EMR), practice management (PM), and RCM technologies. Limited automation of core processes requires manual intervention for more than 80 percent of the work. Intelligent automation is nonexistent.
• Analytics: There is no unified analytics strategy, and key performance indicators (KPIs) are manually tracked. Because of this, benchmarks are missing in more than 80 percent of reporting. Furthermore, data integrity challenges are widespread, which negatively impacts technology adoption and insights.

Foundational Stage

Foundational organizations have started on their digital transformation journey, but still have a long way to go to achieve full maturation. There is some degree of staff augmentation, technology is standardized across the enterprise or locations, and analytics, while automated, are still primarily on spreadsheets. Common characteristics across the pillars are:

• Service delivery: There is a limited degree of centralization, but no scalable foundation. Less than 20 percent of work delivery is completed by staff augmentation vendors.
• Technology and interoperability: Process automation allows for some exception-based processing, and automated eligibility is used for more than 80 percent of eligible visits. Leading technology vendors are utilized, but there are opportunities for optimization. Finally, intelligent automation has not matured beyond the proof-of-concept stage.
• Analytics: There is either no centralized analytics team, or the existing team supports less than 50 percent of the organization, resulting in business unit-owned reporting. Local leaders apply benchmarks to increase insights in reporting. However, data integrity is inconsistent across business units, and there is limited visibility into the performance of global service vendors.

Advanced Stage

Organizations that have reached the Advanced stage of maturity are more technologically matured and innovative, with the ability to direct large cash outlays toward necessary investments like technology. Service delivery is best described as complementary, the organization is tech-enabled, and analytics are automated. Shared characteristics include:

• Service delivery: Complementary global services vendors strategically support operations and comprise up to 50 percent of the required effort. Centralization of like services for in-house populations is prevalent across business units.
• Technology and interoperability: There is an integrated enterprise-wide technology infrastructure, and exception-based processing has been heavily adopted to significantly reduce reliance on manual efforts. For example, prior authorization is automated for more than half of all eligible visits, and/or computer-assisted coding (CAC) is used for 100 percent of acute charts. Other examples include claim status inquiries that are automated for more than 75 percent of eligible portal follow-up; omnichannel patient payment solutions in place for all patient collections; and/or intelligent automation pilots.
• Analytics: A consolidated organization-wide business intelligence platform is in place. Benchmarking utilizing applicable industry standards exists for more than 75 percent of all reporting, and metrics have been defined and adopted across the system. There are minimal data integrity issues and strong visibility into global service partners.

High-Performing Stage (Full Maturity)

High-Performing organizations are among the 5-10 percent that have reached full maturity. They are cutting-edge, heavily driven by automation and autonomous coding, and receive optimal return on investment (ROI) for their use of global partners. Their service delivery is strategically integrated, technology is automation-forward, and analytics are integrated and insightful. Common characteristics include:

• Service delivery: Global partnerships are strategically leveraged to maximize ROI and limit reliance on in-house staff. Vendors assist with more than half of the work effort, the delivery model is scalable, and there is a high degree of centralization.
• Technology and interoperability: Systems are highly configured, optimized, and aligned with the operating model across all locations. Computer-assisted professional coding (CAPC)has been introduced for ambulatory services, while CAC-augmented autonomous coding is also in use. Innovative AI-based automation is prevalent across the organization, which is governed by Centers of Excellence (CoE) that track its impact.
• Analytics: Analytics are self-service and enterprise-wide, providing actionable insights across 100 percent of populations (in-house and outsourced). Comprehensive benchmarking is governed by Analytics CoE and applies to 100 percent of reported metrics. Predictive analytics exist in pockets, and a robust data literacy program is in place.

A deep understanding of where their organization falls within the RCM Framework – and where it falls short – empowers finance leaders to create a tailored roadmap to guide their organization toward operational maturity and a high-performing revenue cycle.

Part three of this series will provide real-world examples of one healthcare organization’s journey along the RCM Maturity Framework.