Healthcare Revenue Cycle Management

What is HCA Healthcare doing in revenue cycle that’s driving 12% margins in a 2% industry? 📈 HCA - the 2nd largest health system in the country - just reported a 12% operating margin. 📉 Meanwhile - most hospitals are fighting to breakeven. On their latest earnings call, HCA didn’t claim they “solved” denials or removed payer pressures. In fact - they called out elevated denials and underpayments, especially with MA plans. In other words - HCA is not immune to the same pressures everyone else is facing. 👉 So what is HCA doing differently? 👈 🎯 They’ve turned rev cycle into a strategic driver of financial performance. Here’s CFO Mike Marks on their latest earnings call: “As you know, we've been working really hard over the last several years to strengthen our revenue cycle. We've added resources, technologies, and a lot of capabilities around dispute resolution to really go after the root cause of the denials. That work has continued to pay dividends.” I found 5 things HCA is doing, that might also help you increase margins: 1️⃣ Advanced denial management + dispute workflows Not just appealing more - but systematizing how to identify, prioritize, and resolve payer issues at scale 2️⃣ Deeper payer integration/connectivity Reducing manual touchpoints, accelerating issue resolution, and tightening the feedback loop between billing and payers 3️⃣ Advanced analytics on payer performance Using technology to more easily identify underpayment trends, denial patterns, and contract leakage in near real time 4️⃣ Relentless focus on cash realization We all know Cash is King - incentivize teams accordingly 5️⃣ Consistent investment in revenue cycle as a strategic function Not episodic fixes, but meaningful sustained multi-year infrastructure build For CFOs and revenue cycle leaders, the takeaway is clear: Revenue cycle isn’t just about managing downside. It’s one of the few remaining levers to actively defend - and expand - margin. *️⃣ Invest accordingly. *️⃣ What are you doing to protect margins right now: denial prevention, payer strategy, analytics, AI investments?

After a few candid conversations with health-system CFOs who collectively oversee billions in physician revenue, one theme rang loud and clear: revenue integrity only scales when clinicians can forget about billing. Here are the takeaways reshaping my roadmap: - Stop mopping—fix the pipe. Physician billing is high-volume, low-dollar. Every avoidable touch destroys margin. Accurate clinical context at the point of care is slashing denials before they happen. - Beware the DRG mirage. A $10 M coding lift can quietly blow up population-health costs if diagnosis creep inflates risk scores. Accuracy beats after-the-fact optimization every time. - 72-hour adjudication is coming. Medicare already pays 80 % of claims within seven days when the data are clean. Shared rails plus real-time records unlock a win–win for providers and payers. - Data as triage coach. Moving an ortho service from a 12:1 to 7:1 consult-to-surgery ratio freed OR time and lifted patient satisfaction, powered by feedback loops to PCPs. - Small practices = single-point-of-failure risk. One vacationing biller shouldn’t freeze cash flow. Submission logic must live in the platform, not in someone’s head. The future RCM stack won’t be a black box bolted onto the EMR. It will be a real-time, rules-aware copilot that flags payer changes before claims queue, adjudicates in hours, and lets clinicians focus on care, not CPT codes. Building toward that future now. If you’re experimenting in the same space, let’s chat. #HealthcareFinance #RevenueCycle #Automation #ValueBasedCare

Your registration team just cost you $13.5 million. And you're probably thanking them for being "efficient." Here's the uncomfortable truth: nearly 50% of all claim denials trace back to front-end issues like registration, eligibility, authorizations. Yet most revenue cycle leaders keep pouring money into back-end denial management instead of front-end prevention. The math is not good. If you process 10,000 claims monthly with a 15% denial rate, and half those denials come from front-end errors, that's 750 preventable denials every month. At $1,500 per claim, you're looking at $13.5 million in annual revenue leakage. From front-end failures alone. Most organizations treat patient access roles like entry-level data entry positions. They're not. Elite front-end professionals are revenue protection specialists who prevent problems before they cost you millions. Prevention cost: 10 minutes of elite patient access specialist time ($8-12 in labor) Correction cost: Denial investigation (45 minutes), documentation gathering (30 minutes), resubmission (15 minutes), follow-up (20 minutes) = 110 minutes of specialized labor ($75-100), plus delayed cash flow That's a 700-900% cost multiplier for being reactive instead of proactive. What do you think? Are we solving denial management when we should be solving denial prevention? #FrontEndExcellence #RevenueProtection #HealthcareStaffing #PatientAccess #RevenueCycleOptimization #NCInsights

For CEOs Who Keep Missing Forecasts, The System Is the Problem. Revenue management operates as a system of controls. When those controls weaken, forecasts distort, and cash flow becomes less reliable. Governance, not motivation, restores shape. ✅ Control One: Strategic Discipline Every quarter begins with a written revenue thesis. It defines value concentration, capacity allocation, and deal archetypes. Deviation from the thesis requires written justification, not interpretation. ✅ Control Two: Cadence Discipline The operating calendar is a production line. Reviews run on fixed intervals. Inputs: evidence tables, variance deltas, and correction plans. Outputs: committed forecast, documented risk, escalation actions. ✅ Control Three: Deal Discipline Each pursuit is treated as a commercial audit. Power, problem, and payback must be verifiable. A deal without evidence is not a deal; it is deferred optimism. ✅ Control Four: Machine Discipline Gen AI is deployed as a compliance layer. It inspects data integrity, detects variance acceleration, and ranks forecast credibility. It also records judgment overrides for post-quarter analysis. Machine oversight extends human reach; it does not absolve it. ✅ Control Five: Leadership Discipline Executives close the feedback loop. They act on variance, not emotion. They measure adherence to system rhythm as tightly as financial hygiene. Governed revenue produces three outcomes: 1️⃣ Forecast integrity ≥ 85 %. 2️⃣ Win-rate uplift 15–25 %. 3️⃣ Managerial bandwidth returned to forward work, not re-forecasting. Governance protects ambition. Without it, speed converts directly into noise. #GTM #Revenue #therevenuecircle #marketing #sales #saas #innovation #technology #CEO #CRO #unicorn #startup

The ISO 27001 Audit Question That Changes Everything When auditors arrive, many organisations rush to show policies, procedures, and templates. But here's the reality: Having documents does not mean you have an effective Information Security Management System (ISMS). A simple way to assess the maturity of your ISO 27001 implementation is to ask four questions for every control: 📌 Do we have a Policy? What are the rules and management expectations? 📌 Do we have a Procedure? How is the process supposed to work? 📌 Is it Implemented? Can we demonstrate that the control is operating in practice? 📌 Do we have Evidence? Can we prove it through records, logs, reports, approvals, reviews, and monitoring activities? Let's take Access Management as an example: ✅ Policy: Access Control Policy ✅ Procedure: User Access Provisioning & Deprovisioning Procedure ✅ Implementation: MFA, role-based access control, joiner-mover-leaver process, least privilege ✅ Evidence: Access requests, approval records, access reviews, MFA screenshots. The same approach applies across every major ISO 27001 domain: 🔹 Information Security Policy 🔹 Asset Management 🔹 Access Management 🔹 Vulnerability Management 🔹 Patch Management 🔹 Incident Management 🔹 Backup & Recovery 🔹 Business Continuity & Disaster Recovery 🔹 Supplier Security 🔹 Human Resource Security 🔹 Physical Security 🔹 Logging & Monitoring 🔹 Change Management 🔹 Document Control 🔹 Compliance Management 🔹 Internal Audit One of the most common audit findings is not the absence of controls, but the inability to provide sufficient evidence that those controls are consistently operating. Remember: 📄 Policy tells people what to do. ⚙️ Procedure explains how to do it. 🛠️ Implementation proves it is being done. 📊 Evidence demonstrates that it was done. That is the difference between a documented ISMS and an effective ISMS. If an auditor asked for evidence of your controls today, which area would be the easiest to demonstrate and which would be the most challenging? image from MoS #ISO27001 #InformationSecurity #CyberSecurity #ISMS #GRC

📘 What is an Audit? An audit is a systematic process of examining, verifying, and evaluating information, systems, or activities to ensure they are accurate, reliable, and compliant with rules, standards, or laws. Think of it as a health check for an organisation’s finances, operations, safety, or processes. ⸻ 🔍 Purpose of an Audit Audits are done to: • Ensure accuracy of information (financial or operational) • Check compliance with regulations, laws, and policies • Identify risks and weaknesses • Improve processes and controls • Increase transparency and trust ⸻ 🧩 Types of Audits 1. Financial Audit • Reviews financial statements • Ensures numbers are correct and follow accounting standards 2. Internal Audit • Conducted by the company itself • Checks internal processes, risks, and controls 3. External Audit • Performed by independent auditors • Ensures unbiased verification 4. Compliance Audit • Checks adherence to legal, regulatory, and policy requirements 5. Operational Audit • Reviews efficiency and effectiveness of operations • Suggests improvements 6. EHS Audit (Environment, Health & Safety) • Checks workplace risks, safety controls, legal compliance • Identifies hazards and ensures safe working conditions ⸻ 🛠 The Audit Process (Simple Steps) 1. Planning Define scope, objectives, and areas to check. 2. Understanding the Process Gather information, understand workflows and risks. 3. Collecting Evidence Inspect documents, talk to staff, observe activities. 4. Testing & Verification Check accuracy, compliance, and controls. 5. Documenting Findings Note observations, gaps, and evidence. 6. Reporting Provide a clear report with strengths, weaknesses, and recommendations. 7. Follow-up Ensure corrective actions are implemented. ⸻ 🎯 Why Audits Matter Audits help organisations: • Build trust with stakeholders • Prevent fraud and errors • Strengthen internal controls • Improve efficiency and performance • Ensure safety and legal compliance

Deep Dive: The 5 Core Stages of the Audit Process and What They Really Involve. Following up on yesterday’s overview of the audit lifecycle, today I’m breaking down each phase of the process to provide clarity on the value each stage delivers particularly from a consulting perspective. 1️⃣ Planning – Setting the Foundation for a Successful Audit At this stage, the auditor and often a consulting partner gains a deep understanding of the business, industry dynamics, and internal structures. ✔️ Objectives: Define scope, identify key stakeholders, and establish timelines. ✔️ Consulting Insight: Help clients align their documentation and processes to reduce friction before fieldwork begins. 2️⃣ Risk Assessment – Focusing on What Matters Most This phase identifies where the greatest risks of material misstatement lie—whether due to fraud, error, or control gaps. ✔️ Objectives: Conduct risk analysis, review previous audit findings, and pinpoint high-risk areas. ✔️ Consulting Insight: Facilitate enterprise risk mapping, help teams prioritize audit readiness in critical areas. 3️⃣ Internal Controls Evaluation – The Health Check of Governance Auditors assess whether the company’s control environment is operating effectively to prevent or detect misstatements. ✔️ Objectives: Evaluate and test control processes related to finance, operations, and compliance. ✔️ Consulting Insight: Recommend improvements, automate manual controls, and close procedural gaps—turning audit findings into transformation opportunities. 4️⃣ Substantive Testing – Evidence-Based Assurance Detailed testing is carried out on transactions and balances to ensure financial data is accurate and complete. ✔️ Objectives: Use sampling and analytical techniques to test the validity of financial records. ✔️ Consulting Insight: Assist with data prep, improve reporting structures, and guide remediation on exceptions identified during testing. 5️⃣ Audit Reporting – Beyond Compliance The audit report is more than an opinion it’s a roadmap for improvement. ✔️ Objectives: Issue the final opinion and management letter, summarize control findings, and provide an audit conclusion. ✔️ Consulting Insight: Translate findings into actionable strategies, support communication with boards, and help implement control enhancements post-audit. The audit process isn’t just a compliance function it’s a strategic opportunity for operational insight. And as consultants, we play a crucial role in making that transition happen. Which phase do you find clients struggle with most? Or where have you seen the most opportunity for transformation? #Audit #Consulting #FinanceAdvisory #Governance #InternalControls #BusinessRisk #AuditReadiness #StrategicFinance #OperationalExcellence #LinkedInConsulting

I enrolled at a rate of 97.3% for over 7 years… Here's how... It took 15 years of leading Sites and CRO’s to figure it out… Oh the pain...Cue the violin. So, we realised that there are a number of key aspects of a condition and the patients healthcare setting that help us find, connect with, enroll, and retain patient volunteers for studies. We call these factors - "𝗜𝗻𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻 𝗔𝘁𝘁𝗿𝗶𝗯𝘂𝘁𝗲𝘀". This idea brings together research and healthcare elements to determine which strategies, tools and techniques will be most effective for enrolling patients across various diseases and treatments. 𝗦𝗼 𝘄𝗵𝗮𝘁 𝗰𝗮𝗻 𝘆𝗼𝘂 𝗱𝗼? Here’s a quick overview of the Indication Attributes for Enrollment and some considerations for you to use. 𝗜𝗺𝗽𝗿𝗼𝘃𝗲 𝗨𝗻𝗱𝗲𝗿𝘀𝘁𝗮𝗻𝗱𝗶𝗻𝗴 𝗼𝗳 𝘁𝗵𝗲 𝗖𝗼𝗻𝗱𝗶𝘁𝗶𝗼𝗻: • Clarify how research and healthcare work together to better connect the two. • Push for earlier studies, even when diseases are not well understood. • Actively identify and engage patients, even if the condition doesn’t have a treatment yet. • Ensure routine testing and complete diagnosis documentation for accurate patient identification. 𝗧𝗮𝗸𝗲 𝗖𝗼𝗻𝘁𝗿𝗼𝗹 𝗼𝗳 𝘁𝗵𝗲 𝗖𝗼𝗻𝗱𝗶𝘁𝗶𝗼𝗻’𝘀 𝗖𝗵𝗮𝗿𝗮𝗰𝘁𝗲𝗿𝗶𝘀𝘁𝗶𝗰𝘀: • Design your enrollment process based on the specifics of each condition. • Choose whether to take a proactive or passive approach to enrollment, depending on the disease. • Adjust team sizes as needed to scale up enrollment efforts. • Focus on reviewing biopsy and test results to quickly identify potential patients. • Apply targeted strategies to streamline patient enrollment. 𝗙𝗼𝗰𝘂𝘀 𝗼𝗻 𝘁𝗵𝗲 𝗣𝗮𝘁𝗶𝗲𝗻𝘁’𝘀 𝗙𝘂𝗹𝗹 𝗣𝗿𝗼𝗳𝗶𝗹𝗲: • Build personalized enrollment strategies that connect with patients on an individual level. • Look beyond medical data—consider the patient's life, motivations, and decisions. • Factor in psychological and lifestyle elements that may affect participation. • Include advertising as part of a broader strategy to engage and retain patients. • Involve marketing teams to ensure patient-focused messaging reaches the right audience. 𝗖𝗿𝗲𝗮𝘁𝗲 𝗮 𝗦𝗺𝗮𝗿𝘁𝗲𝗿 𝗛𝗲𝗮𝗹𝘁𝗵𝗰𝗮𝗿𝗲 𝗦𝗲𝘁𝘁𝗶𝗻𝗴 𝗳𝗼𝗿 𝗘𝗻𝗿𝗼𝗹𝗹𝗺𝗲𝗻𝘁: • Simplify logistics and management systems to improve the enrollment process. • Select sites strategically, choosing those with strong referral networks. • Build positive, trusting relationships between sponsors and trial sites. • Reevaluate how sponsors and sites interact to cut costs and increase efficiency. • Invest in proactive enrollment systems now to avoid costly delays later. 𝗣.𝗦. The key to successful patient enrollment lies in understanding the condition, tailoring your approach, prioritizing patient engagement, and building strong site relationships. What strategies do you think should be prioritized? Let us know! 👇

How the Food Industry Thinks About and Prioritizes Audits (A Train Analogy) 1. Internal Audit (Train Maintenance) Analogy: Like a vintage train being checked by its own crew. Example: A food manufacturing company performs internal audits to ensure compliance with internal SOPs and food safety standards like HACCP or ISO 22000. Purpose: Maintain operational efficiency, food safety, and continuous improvement. Focus Areas: - Equipment cleaning and calibration - Staff hygiene and training records - CCP monitoring and production process control 2. Customer Audit (Passenger Expectations) Analogy: Like modern cargo train inspections by clients ensuring the cargo's safety and punctuality. Example: A supermarket chain or bulk buyer audits the food supplier to ensure product safety, labeling compliance, and packaging standards. Purpose: Assure product consistency, food safety, and compliance with buyer expectations. Focus Areas: - Product specifications (e.g., allergen controls, labeling) - Shelf-life and packaging integrity - Adherence to customer requirements and delivery terms 3. Regulatory Audit (Government Inspection) Analogy: Like a high-speed train being inspected by government authorities for high safety and legal standards. Example: Food safety authorities (e.g., FDA, FSSAI, EFSA) conduct audits to ensure the facility complies with food laws and hygiene regulations. Purpose: Protect public health by enforcing food safety, hygiene, and traceability standards. Focus Areas: - Facility cleanliness and infrastructure - Documentation and traceability systems - Compliance with food safety laws and export regulations In the food industry, audits are essential tools used to ensure safety, quality, and compliance across the supply chain. These audits can be viewed through different lenses, each serving a unique purpose. Internal audits function as a proactive self-check mechanism. In the food industry, internal audits ensure daily operations align with safety standards like HACCP and ISO 22000. Customer audits verify that suppliers meet buyers' specific quality and delivery expectations. Regulatory audits, often by authorities like the FDA or FSSAI, ensure legal compliance and public health safety. Together, these audits strengthen food safety, build trust, and support responsible business practices. #FoodSafety #HACCP #ISO22000 #InternalAudit #CustomerAudit #RegulatoryAudit #QualityAssurance #GMP #Traceability #FDA #FSSAI #EFSA #FoodIndustry #AuditCompliance #SafeFood #FoodManufacturing #FoodStandards #PublicHealth

Denials have crossed the line from operational nuisance to structural margin risk, and most revenue cycle models have not yet adjusted to that reality. The latest Experian Health State of Claims report is out and it reinforces what many RCM leaders have long been experiencing firsthand. ❌ Denials are no longer a downstream problem to be worked after the fact. They are being created upstream through fragmented intake processes, declining data quality, and workflows that were never designed for today’s volume, complexity, or payer behavior. Key data signals RCM leaders should not ignore: 💡 41% of providers now report denial rates exceeding 10%. Double digit denial rates are now almost normal and too few are looking in the right places to drive it down. 💡 Missing or inaccurate data drives 50% of all denials. 💡 68% say claims submission is more difficult than it was a year ago. Claim submission is now the key role and critical technology point in the claim cycle. 💡 90% of denied claims still require manual human rework. Skill set matters more than ever. 💡 Only 14% are using AI in a way that materially reduces denials What stands out is not just the scale of the problem, but how consistently it drains time, labor, and cash flow across the entire revenue cycle. This is not a payer issue, and it is no longer a staffing problem that can be solved with incremental headcount. It is a design problem. What this means for revenue cycle leaders: ✅ Clean claims must be engineered at intake, not recovered after denial. If your EHR or billing platform are not helping to produce cleaner claims, it is working against you. This is as much about process as it is about technology. ✅ Fragmented front-end systems are now a direct financial liability. Payment recovery after claim submission is expensive and overturn rates only now say a preventable issue cost you more. ✅ Manual rework is becoming the single largest hidden cost in RCM. ✅ Denial prevention, not denial management, is the new performance benchmark. ✅ Technology must actively prevent errors, not just report on them More than half of organizations surveyed are now willing to replace their claims management platforms if the return is compelling. That signals a market that is no longer looking for optimization around the edges, but for structural change that leaves a noticeable impact. Standing still is no longer neutral. It is a measurable, recurring cost and it is increasingly visible in healthcare finance. I’ve said this for years… when your AR team is larger than the team responsible for getting it right at the front end, that imbalance is your first red flag. It’s a signal that rework has become the operating model. #healthcarefinance #revenecyclemanagement