Frank Forte
Healthcare ecosystem collaboration is key to a healthy revenue cycle
March 31, 2025
By Frank Forte
After decades of reluctant adoption, the healthcare industry has embraced a dramatic technological transformation over the past 15 years. In 2008, a mere 9% of hospitals and 17% of office-based physicians were using electronic health records (EHR) systems. By 2021, those numbers had skyrocketed to 96% and 78%, respectively.
This digital revolution has streamlined many facets of healthcare delivery and billing. Yet formidable challenges remain, particularly in the revenue cycle, which has become increasingly complex. As EHR systems have become nearly ubiquitous and interoperability initiatives gain momentum, some healthcare providers may believe their revenue cycle challenges are solved. But the reality is more nuanced, especially regarding complex claims and denials management.
While EHR systems easily manage routine tasks and standard commercial claims processing, they often struggle to navigate scenarios that involve multiple payers, intricate coding requirements, varying reimbursement rules, and increasing denial rates. These challenges are compounded when dealing with specialized claims outside typical commercial insurance processing, such as for military payers.
The scope of these challenges is considerable. For example, roughly 60% of workers' compensation claims are being initially sent to the wrong insurers, causing significant processing delays and increased administrative costs. Veterans Administration (VA) claims face similar complications, with about 13% being denied based on various technical issues, including timely filing violations, coding errors, authorization problems, carrier selection mistakes, and eligibility verification failures. Perhaps most alarming is that between 25% and 33% of out-of-state Medicaid claims are never filed due to enrollment complications. Financially vulnerable Americans deserve better.
These statistics reflect a deeper problem: The growing complexity of healthcare billing and reimbursement has overwhelmed the capabilities of standard systems and processes. Each specialized claim type has its rules, requirements, and potential pitfalls. Providers require special expertise in handling such claims to manage the revenue cycle more reliably and efficiently.
Specialized expertise enables collaboration
For claims processing to work and serve all stakeholders, collaboration across the healthcare ecosystem is essential to success. The complexity of modern healthcare revenue cycle management demands a multifaceted approach that draws on the strengths of various stakeholders, including hospitals, payers, third-party administrators, and specialized service providers.
At the heart of successful collaboration is specialized expertise. Unfortunately, most health systems lack such expertise. Efficiently processing complex claims and managing the growing volume of denials requires a deep knowledge of specific payer guidelines, state regulations, and documentation requirements that is beyond the ability of virtually any health system to realistically maintain, especially in the face of ongoing staffing shortages.
Since complex claims typically account for 5% or less of a hospital’s gross patient revenue, building and retaining specialized staff is challenging and expensive. Yet that 5% may account for millions in reimbursements. Hence, by forming strategic partnerships with specialized service providers, healthcare organizations can access the specific expertise needed for different claim types and denials while focusing on their core competencies.
Technology integration is another pillar of effective collaboration. EHR systems benefit from effectively interfacing with various specialized systems and tools. This results in connecting systems and constructing intelligent workflows that improve efficiency and accuracy across the revenue cycle.
Collaboration also delivers significant value in enabling regulatory compliance. Different payer groups have unique rules and regulations necessitating specific knowledge and attention to detail. Collaborative partnerships allow organizations to share knowledge and best practices to ensure compliance and reduce denials across all claim types.
The power of data sharing
How partnerships are structured and maintained impacts healthcare ecosystem collaboration. Effective data sharing and interoperability require secure and efficient clinical data exchange and administrative and financial information for proper claims processing. This enables all stakeholders to make informed decisions and take appropriate actions promptly.
Communication proves equally vital to partnership success. Organizations must establish and maintain clear channels for regular dialogue between all parties. Ongoing communication helps prevent misunderstandings, expedites problem resolution, and ensures all stakeholders remain aligned on goals and challenges. Regular check-ins and status updates keep projects on track and allow quick adaptation when issues arise.
Process standardization is another key component of successful partnerships, though it requires careful balance. Partners should work together to standardize processes while remaining flexible enough to handle unique situations and complex cases requiring special attention.
Finally, effective collaboration involves comprehensive performance monitoring. By regularly tracking and reporting key metrics, organizations can identify areas for improvement and ensure all partners are consistently meeting shared expectations. This data-driven approach supports the continuous improvement of collaborative efforts and demonstrates the value of partnerships to all stakeholders.
Conclusion
As healthcare continues to evolve, the importance of ecosystem collaboration will only grow. Though technologies like artificial intelligence and machine learning will create new opportunities for automation and efficiency, even closer cooperation between stakeholders is necessary for successful collaboration.
No organization can excel at everything. But by fostering partnerships that leverage each participant's strengths, healthcare organizations can build more efficient, effective revenue cycle operations that benefit all stakeholders – most importantly, the patients they serve.
About the author: Frank Forte is CEO of EnableComp.
After decades of reluctant adoption, the healthcare industry has embraced a dramatic technological transformation over the past 15 years. In 2008, a mere 9% of hospitals and 17% of office-based physicians were using electronic health records (EHR) systems. By 2021, those numbers had skyrocketed to 96% and 78%, respectively.
This digital revolution has streamlined many facets of healthcare delivery and billing. Yet formidable challenges remain, particularly in the revenue cycle, which has become increasingly complex. As EHR systems have become nearly ubiquitous and interoperability initiatives gain momentum, some healthcare providers may believe their revenue cycle challenges are solved. But the reality is more nuanced, especially regarding complex claims and denials management.
While EHR systems easily manage routine tasks and standard commercial claims processing, they often struggle to navigate scenarios that involve multiple payers, intricate coding requirements, varying reimbursement rules, and increasing denial rates. These challenges are compounded when dealing with specialized claims outside typical commercial insurance processing, such as for military payers.
The scope of these challenges is considerable. For example, roughly 60% of workers' compensation claims are being initially sent to the wrong insurers, causing significant processing delays and increased administrative costs. Veterans Administration (VA) claims face similar complications, with about 13% being denied based on various technical issues, including timely filing violations, coding errors, authorization problems, carrier selection mistakes, and eligibility verification failures. Perhaps most alarming is that between 25% and 33% of out-of-state Medicaid claims are never filed due to enrollment complications. Financially vulnerable Americans deserve better.
These statistics reflect a deeper problem: The growing complexity of healthcare billing and reimbursement has overwhelmed the capabilities of standard systems and processes. Each specialized claim type has its rules, requirements, and potential pitfalls. Providers require special expertise in handling such claims to manage the revenue cycle more reliably and efficiently.
Specialized expertise enables collaboration
For claims processing to work and serve all stakeholders, collaboration across the healthcare ecosystem is essential to success. The complexity of modern healthcare revenue cycle management demands a multifaceted approach that draws on the strengths of various stakeholders, including hospitals, payers, third-party administrators, and specialized service providers.
At the heart of successful collaboration is specialized expertise. Unfortunately, most health systems lack such expertise. Efficiently processing complex claims and managing the growing volume of denials requires a deep knowledge of specific payer guidelines, state regulations, and documentation requirements that is beyond the ability of virtually any health system to realistically maintain, especially in the face of ongoing staffing shortages.
Since complex claims typically account for 5% or less of a hospital’s gross patient revenue, building and retaining specialized staff is challenging and expensive. Yet that 5% may account for millions in reimbursements. Hence, by forming strategic partnerships with specialized service providers, healthcare organizations can access the specific expertise needed for different claim types and denials while focusing on their core competencies.
Technology integration is another pillar of effective collaboration. EHR systems benefit from effectively interfacing with various specialized systems and tools. This results in connecting systems and constructing intelligent workflows that improve efficiency and accuracy across the revenue cycle.
Collaboration also delivers significant value in enabling regulatory compliance. Different payer groups have unique rules and regulations necessitating specific knowledge and attention to detail. Collaborative partnerships allow organizations to share knowledge and best practices to ensure compliance and reduce denials across all claim types.
The power of data sharing
How partnerships are structured and maintained impacts healthcare ecosystem collaboration. Effective data sharing and interoperability require secure and efficient clinical data exchange and administrative and financial information for proper claims processing. This enables all stakeholders to make informed decisions and take appropriate actions promptly.
Communication proves equally vital to partnership success. Organizations must establish and maintain clear channels for regular dialogue between all parties. Ongoing communication helps prevent misunderstandings, expedites problem resolution, and ensures all stakeholders remain aligned on goals and challenges. Regular check-ins and status updates keep projects on track and allow quick adaptation when issues arise.
Process standardization is another key component of successful partnerships, though it requires careful balance. Partners should work together to standardize processes while remaining flexible enough to handle unique situations and complex cases requiring special attention.
Finally, effective collaboration involves comprehensive performance monitoring. By regularly tracking and reporting key metrics, organizations can identify areas for improvement and ensure all partners are consistently meeting shared expectations. This data-driven approach supports the continuous improvement of collaborative efforts and demonstrates the value of partnerships to all stakeholders.
Conclusion
As healthcare continues to evolve, the importance of ecosystem collaboration will only grow. Though technologies like artificial intelligence and machine learning will create new opportunities for automation and efficiency, even closer cooperation between stakeholders is necessary for successful collaboration.
No organization can excel at everything. But by fostering partnerships that leverage each participant's strengths, healthcare organizations can build more efficient, effective revenue cycle operations that benefit all stakeholders – most importantly, the patients they serve.
About the author: Frank Forte is CEO of EnableComp.