Assessment of the US Revenue Cycle Management Market, Forecast to 2022

  • ID: 4434995
  • Report
  • Region: United States
  • 123 Pages
  • Frost & Sullivan
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Revenue cycle management (RCM) refers to myriad administrative and clinical functions around the capture, management, and collection of patient service revenue. The RCM process starts with admission (patient access) and continues through to accounts receivable (payment and collections). A variety of RCM solutions (e.g., IT applications and services) are deployed to help healthcare providers perform different functions.

The objective of this research service is to present a comprehensive analysis of the US RCM market with respect to trends, revenue growth potential, and the dynamics at play for RCM information technology (IT) and services deployed by hospitals and physician practices through 2022.

Additionally, the report will:

  • Analyze market forces impacting adoption of RCM IT and service solutions among hospitals and physician practices
  • Evaluate existing and emerging regulatory objectives centered on providers’ financial risk management initiatives
  • Highlight best practices in the areas of design and deployment of an integrated financial workflow that supports value-based care
  • Assess the outlook of outsourced or shared service-based RCM operating models
  • Identify 5 major growth opportunity areas related to RCM
  • Estimate the revenue potential of the total US RCM market (software applications and services), and include breakdowns by hospitals and physician practices, from 2016 to 2022
  • Shortlist vendors that propose best-in-class solutions for hospitals and tphysician practices

This study is segmented into major functional segments of RCM:

  • Patient access
  • Registration and charge capture
  • Billing and collection

In terms of end-user adoption, this study classifies the buyer market in two broad provider categories:

  • Hospitals
  • Physician practices

The market projection ($ value) is stratified based on the following overarching RCM product segments:

  • IT (software applications)
  • Services

Market Background

The shift in population demographics coupled with the rise of risk or value-based reimbursement models is driving the need for better prediction and management of revenue cycles, especially for high and at-risk patient populations. The prevalence of legacy RCM IT systems, which do not optimally support the goal of building a broader but coordinated and enterprise-wide financial ecosystem, is restricting providers from achieving the desired results around healthcare cost and collection. Most US-based providers still grapple with low operating margins, resulting from poor accounts receivable (A/R) performance and high average denial volumes. Many health systems attribute this inefficiency to their suboptimal knowledge and implementation of value-based RCM pathways that require significant investments in RCM IT. The need for efficient claims processing, which in turn results in optimized collection of risk-based revenue, supports adoption of value-based financial management solutions. Most providers that embrace alternative payment models acknowledge the need to deploy progressive scheduling, billing, and analytics technology modules capable of digitizing the entire RCM ecosystem. This view results from the growing adoption of payer contracts with specific provisions for efficient claims management, in addition to the need for integrating new capabilities that will meet the increasing financial responsibility of patients with coinsurance and large deductibles. Overall, the top unmet market needs driving adoption of next-generation RCM solutions among health systems in US are:

  • Comprehensive regulatory compliance and financial risk mitigation
  • The ability to collaborate with payers to customize revenue cycle workflows
  • Elimination of preventable operational expenses, attributed to claims processing
  • Automated identification of hidden patterns and root causes of claim denial
  • Optimized collection of payments, rebates, and incentives for patient services
  • Real-time reporting of financial and operational performance at an enterprise level

As a result, new growth opportunities involving external RCM solutions have gained precedence among many hospitals and physician practices. Most of them are willing to invest in advanced RCM capabilities that can streamline financial performance cost effectively by paving the way for seamless payer-provider communications pertaining to financial risk management.

These end users are likely to prioritize procurement of RCM solutions from external IT vendors based on implementation evidence and cost/benefit benchmarks. Hence, going forward, they are expected to rely on RCM vendors with proven expertise in optimizing financial performance through comprehensive patient access, error-free claims preparation, automated billing workflows, and robust RCM analytics. Vendors with solutions that can complement providers’ incumbent value-based payment arrangements and RCM IT ecosystems are expected to thrive in this market.

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1. Executive Summary
Key Findings-Study Highlights
Scope and Segmentation
Market Engineering Measurements
CEO’s Perspective
Key Companies to Watch
Executive Summary-3 Big Predictions

2. Market Overview
Market Definition
Market Background
Introduction to MACRA-Significant Changes to Provider Reimbursement Processes
Comparison of the 3 Payment Pathways Under MACRA
MACRA’s Final Rule-Implementation Timeline and Payment Adjustment Metrics
MACRA Final Rule for Reporting Year 2018-5 Key Takeaways

3. Introduction to RCM
US RCM Ecosystem-Key Product Applications
End-User and Product Segmentation of RCM
Key Market Elements Driving the US RCM Industry
End User-Specific Market Drivers
Physician Workflow
Why is it Important to Understand Trends in RCM?
Staffing Challenges Related to Medical Billing and Coding
Key Business Challenges
Drivers of Replacing RCM Platforms or Adding Value-added Capabilities
State of Digitization and Its Impact on Providers’ RCM Expense

4. Hospital RCM Market Analysis
Adoption of Essential RCM Components
Adoption of Next-Gen RCM Components
Replacement Rate vs. Pure Upgrade

5. Physician Practice RCM Market Analysis
Key Pain Points
Benefits of Physician Practice Management Solution
Considerations to Ensure Optimal Results from Practice Management Systems
Evolution of Practice Management Systems
Replacement Rate vs. First-Time Purchase Including Add-ons
KPIs for Hospitals

6. Value-Based RCM Ecosystem
Value-Based RCM-How the Ecosystem Should be Conceptualized

7. Outsourced RCM Services
Introduction to Outsourced RCM Services-Assessment of Market Forces
Outlook for Outsourced RCM Services-A Wide Array of Business Models are at Play
Key Considerations for RCM Outsourcing
Assessment of Best Practices-Outsourced RCM Services

8. Forecasts and Trends-Total RCM Market
Market Engineering Measurements
Forecast Methodology and Assumptions
Revenue Forecast
Percent Revenue Forecast by End-User Segment
Revenue Forecast by End-User Segment
Revenue Forecast Discussion

9. Forecasts and Trends-Hospital RCM Market
Market Engineering Measurements
Revenue Forecast
Revenue Forecast Discussion
Revenue Forecast by Offering
Revenue Forecast by Offering Discussion

10. Forecasts and Trends-Physician Practice RCM Market
Market Engineering Measurements
Revenue Forecast
Revenue Forecast Discussion
Revenue Forecast by Offering
Revenue Forecast Discussion-Software Applications
Revenue Forecast Discussion-Services

11. Penetration Analysis-Total RCM Market
Penetration Analysis-Hospitals
Penetration Analysis-Physician Practices

12. Vendor Landscape Assessment-Total RCM Market
Competitive Market Forces
Vendor Market Share-Total RCM Market
Vendor Trends
How Vendors Mitigate Financial Risk via Value-based RCM Solutions
Market Gaps in the United States

13. Competitive Market Structure
Competitive Environment
Healthcare RCM M&A-How 2016 Fared Against 2015
Notable M&As

14. Vendor Segmentation and Profiles
Vendor Segmentation-Software Application Providers
Vendor Segmentation-Service Providers

15. Growth Opportunity Assessment
5 Major Growth Opportunities
Strategic Imperatives for Success and Growth

16. Future Perspectives
The Last Word-3 Big Predictions
The Last Word-Discussion
Legal Disclaimer

17. Appendix
Market Engineering Methodology
Vendor Segmentation Capability Definitions

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