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U.S. Hospital Revenue Cycle Management

  • April 2013
  • -
  • Frost & Sullivan
  • -
  • 105 pages

Overview and Outlook, 2012-2017

Revenue cycle management (RCM) solutions are used to help healthcare providers to maximize the collection of payments from insurance companies and/or patients by rationalizing a number of complex processes that occur across the entire patient accounts pathway. A large number and variety of vendors serve the hospital RCM market. Many vendors offer both software applications and services, while others specialize in one or the other. Some vendors only address the hospital market and some sell products and/or services to hospitals as well as ambulatory providers.

Executive Summary

• Revenue cycle management (RCM) solutions are used to help healthcare providers maximize the collection of payments from insurance companies and/or patients by rationalizing a number of complex processes and steps that occur across the entire patient-accounts pathway.
• A number of different software applications are utilized to address specific tasks involved with managing the revenue cycle. RCM software applications are usually characterized in two segments—core, or platform, solutions, and point solutions, or “bolt-ons,” which provide added functionalities to core applications. In addition to information technology, a number of RCM services such as consulting and outsourcing are used by healthcare providers to provide additional capabilities across the RCM process.
• A large number and variety of vendors serve the hospital RCM market. Many vendors offer both software applications and services, while others specialize in one or the other. Some vendors only address the hospital market and some sell products and/or services to hospitals as well as ambulatory providers including physicians and other providers.
• Today, there are well over Xvendors serving the hospital RCM market in some capacity, and that number is expected to grow, particularly among vendors of point solutions and services, as hospitals increasingly focus on re-engineering RCM to meet growing challenges associated with healthcare reform.
• In recent years, RCM solutions have taken a backseat to clinical systems because of providers’ focus on adopting clinical solutions like electronic health records (EHRs) needed to meet Meaningful Use (MU). As the MU program matures, hospitals are expected to shift their focus to RCM in order to prepare for changes in reimbursement and patient demographics.
• Today, revenue cycle processes and workflows are receiving unprecedented attention in the market as hospitals realize they must take every measure to maximize revenue and address inefficiencies and shortfalls in getting paid fully and on a timely basis. Many hospitals will need to significantly re-engineer their entire RCM function, and most seek solutions that offer robust integration between clinical and financial systems.
• The current penetration of RCM solutions for the inpatient (hospital) environment varies by type of application. Software applications needed for the core functions of patient registration, scheduling, billing, coding, and claims processing are almost universally adopted in hospitals today (> X percent), while other RCM applications are less penetrated or significantly vary in penetration across various types of hospitals.
• In terms of services, estimates on the rate of utilization of managed services across the hospital market vary significantly, ranging from X percent to X percent. Very few hospitals outsource their entire RCM function (>X percent), but some do.
• Total revenue for the U.S. hospital RCM market is estimated at $X million for the base year, 2012. This figure includes revenue derived from application software and selected services. Computer hardware is excluded from this calculation.
• Total market revenue is expected to increase steadily year over year, reaching $X million in 2017, representing a X percent increase from 2012. The total market revenue CAGR for the 2012 to 2017 forecast period is Xpercent.
• The majority of the revenue for hospital RCM will come from replacements and/or updates of legacy systems, including the addition of new modules to enable more advanced capabilities required by healthcare reform. In addition, hospitals will increase their use of managed services and consultants to address internal staffing and skill shortages, provide niche services, and lower costs for some routine administrative functions.

CEO’s Perspective

1. The healthcare industry is in a state of dramatic transition and transformation that impacts every segment of the market.
2. Hospitals are increasingly struggling with financial constraints that threaten to grow worse with time.
3. Many currently installed RCM systems have clumsy and outmoded technology platforms that must be replaced.
4. Legacy vendors serving the hospital RCM market have failed to innovate, opening the door for new market entrants.
5. The distinction between applications and services will continue to blur as vendors add new capacities to address diverse and growing customer needs.

Definitions and Scope of Study

This Study Pertains to the Following Region:
• The United States
• Over the period:
- Base year—2012
- Forecast period—2013 to 2017

Products Included in Study
• Proprietary software applications that comprise core platform and point solutions used to manage various components of the patient revenue cycle process in non-federal short-term general and other special hospitals.
• Software applications encompassing a variety of technology approaches including installed client/server systems, Web-hosted solutions, and software as a service (SaaS) are included in the analysis.
• The study also covers consulting and outsourcing services that hospitals use in conjunction with various aspects of managing the patient revenue cycle.

Products Not Included in Study
• Software applications and related services used to manage the patient revenue cycle in ambulatory settings (physician offices), nursing homes, managed care organizations, long-term care facilities, or other non-hospital care settings.

Key Issues this Study will Address

• What does the hospital revenue cycle management (RCM) process entail, and what are the key products and solutions utilized?
• What drives the current need for hospitals to adopt new RCM technology solutions and related services?
• What is the current penetration of core platform solutions, and who are the leading vendors providing these solutions?
• What are some of the new functionalities that hospitals look for in next-generation RCM?
• What is the expected revenue for the total hospital RCM market and key market segments over the next five years?
• How will key macro trends impact the market over the next five years?

Table Of Contents

U.S. Hospital Revenue Cycle Management
Table Of Contents

1. Executive Summary
2. Study Scope and Research Methodology
3. Market Overview
4. Market Analysis
5. Hospital RCM Market
6. External Challenges: Drivers and Restraints
7. Competitive Market Structure
8. Competitor Profiles
9. Forecast and Trends
10. Demand Analysis
11. The Last Word (Conclusions and Implications)
12. Appendix

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