Finding solutions that overcome payer hurdles whilst maintaining regulatory compliance is a major concern for many practices. Solving RCM constraints positively impacts a medical practice’s financial stability and improves quality of care. With the following payer insights, physicians can reduce their major pain points and increase the financial stability of their practice. Here’s a closer look.
Roadblocks to Reimbursement
Healthcare payer challenges include rising costs along with constantly changing rules and regulations that can cause difficult prior authorizations and increase reimbursement denials. Negotiating favorable payer contract agreements, improving front desk operations to reduce denials, solving staffing shortages, and managing complex regulatory rules are instrumental when solving payer challenges.
Administrative Burdens and Billing Errors
Medical billing is a frustrating process. Because payers habitually work every angle to refuse a legitimate medical payment, the average practice estimates their manual claims denial rate at approximately 20%. Many of these claims are never resubmitted for payment. Physicians overwhelmingly agree that billing is their practice’s most time-consuming, and financially wasteful expenditure. Using a manual billing protocol includes employing expert medical coding professionals and claims processing ancillary administrative staff. Making sense from the convoluted data that insurance companies return in response to provider claims is an arduous task. It is more important than ever, particularly when using machine learning solutions, that submitted claims information be as accurate as possible. Be mindful when using templates and resist the convenience of copy paste of previous visit notes. Always provide specifics on any new or abnormal findings, include only relevant diagnostic codes, and make sure to include all required information when using Modifier 25 to reduce the risk of audits. Streamline and simplify your end-to-end process to effectively deploy data and utilize automation to close the feedback loop between claim submission and adjudication.
Telehealth Services
Reimbursement rules for telemedicine services can be unclear and inconsistent. This creates physician uncertainty in the value of adding remote services. Patients, however, are certain. They want telehealth, and in 2025, a practice without automated solutions is likely to struggle. Beware of platforms that lack interoperability between the electronic health record (EHR) systems, telehealth, and RCM operations that can hinder data sharing and slow payments for rendered care. Working with a whole practice healthcare software solutions partner solves this problem.
Regulatory Compliance and Revenue
Regulatory rules have become more complicated along with automated healthcare administrative solutions, creating new payer challenges. Physicians know that a poor audit can fiscally decimate their practice. Complete compliance amongst the enormity of CMS reimbursement regulations and payer contract terms is a non-negotiable when minimizing legal and financial risks. Manual submission of claims with new and often confusing regulations is yeoman’s work, as mistakes can lead to financial penalties and worse. Communication must be compliant, as a simple error can result in lawsuits, penalties, healthcare fraud accusations, removal of insurance privileges, and massive legal fees. Be aware that some states are focused on prosecuting these types of errors and impose treble damages on any provider who makes billing errors or utters a false claim.
Additionally, when working with practice notes, it’s important to verify AI-generated content, as it may occasionally produce incomplete records, generate duplicate content, or miss key elements needed for approval. Patients should also be informed of any ambient listening, and consent to the use of the scribe to avoid legal or ethical issues. Medical practices should always partner with software solutions designed specifically for healthcare practices that can demonstrate risk reduction, and accuracy in data translation.
Negotiating Rising Costs
In 2025, physicians are dealing with a 2.83% Medicare reimbursement cut, rising operational costs, and the need to adapt to evolving healthcare regulations. Operational costs are higher than ever, impacting both practice financial stability and patient care.
A thorough, legally sound, and informed approach can help practices ensure long-term profitability. Begin by understanding all contract terms and analyzing performance metrics. Do not underestimate your practice’s value, schedule regular contract reviews, build strong payer relationships, and use termination as a strategy tool. For improved contract terms and negotiation management, many physicians choose to outsource negotiations.
Fill in Staffing Gaps
When hiring, make sure you choose the right person for the right role. People enjoy doing jobs where they excel, and that can go a long way in employee retention. Promoting longevity of employment with valuable team members can avoid the disruption and cost of employee turnover. Beyond supporting a healthy work-life balance, checking in with your staff on a regular basis is imperative for employee retention. Does the employee feel they are situated in a role that is aligned with their skillset? Are they active and interested in the practice’s success? Employee reviews are a great time to have these conversations.
Use Available Technology to Automate Routine Tasks
Ease your staff’s burden and generate faster payments with automation. Manual processes can lead to errors and delays in payments, which is further burdening physicians and their staff. While this seems like a basic solution, real-time data visibility in healthcare billing remains highly elusive. This is because one of the biggest challenges in accurately submitting claims is the puzzle of checking the correct boxes. For a provider practice with more than one location and numerous providers, this means a constellation of rosters, rates, and schedules due to differing insurance providers and their moving target rules.
Improve Your Front Desk Operations
Making sense of the data that insurance companies send back in response to provider claims is difficult — at best. Streamline and simplify your end-to-end process to effectively deploy data and utilize automation to close the feedback loop between claim submission and claim adjudication. All submitted documentation should be as clean and as accurate as possible.
Proactive documentation, prior to patient check-in pays long term dividends. A practice’s front desk operations is the first line of defense against denials and incomplete payments. Take care to ensure your processes involve checking eligibility and coordination of benefits, verifying of primary care provider (PCP), and double-checking of data entry. Patient check-in using digital tablets can also speed these tasks, cutting administrative time while reducing typographical and other errors. Remember, the collection process begins before the appointment. Clean up your front desk operations. Squeaky clean, accurate information will reduce the burden of constant denials and lower operational costs.
Effortless RCM is Here
Revenue cycle automation platforms (RCM) were developed to aid healthcare providers by improving reimbursement speed and lowering claims denials by streamlining the end-to-end billing process. At Virtual OfficeWare Healthcare Solutions (VOW), we’ve simplified the overall claims process with our automated approach and firsthand experience managing healthcare data. Our whole practice, scalable, intelligent data models will simplify and synchronize your payer updates. You can depend on our reliable digital healthcare software solutions that easily validate, generate, and automatically submit the cleanest claims for fastest reimbursement. VOW clients enjoy simplified onboarding, and first-pass billing reimbursement rates upward of 94%. In recent years, over 96% have avoided quality reporting penalties—well above the national average of 63%. With real-time analytics and tailored, automated front desk solutions, our clients always have a finger on the pulse of their practice performance. VOW’s goal is to identify and eliminate administrative drag factors so that providers can invest more of their time, money, and energy into caring for their patients. Ready to hear the details? Contact our experienced billing support team to explore your options today and improve your revenue cycle tomorrow.
