Below, I've asked Chat GPT to draft an RFP approach for revenue management services. This is not an area I work in, and I'm only offering it as a "look and see" for what it might produce. (I'm in no way vouching for the report, but it's still interesting. I suspect one could find articles on Google with titles like, "Things to consider when soliciting revenue cycle management.")
|Chat GPT 4's quirky Dalle-3 figures|
We are running a medium-size clinical laboratory. We derive about 75% of our revenue from conventional testing (clinical chemistry, etc) and about 25% from genomic testing (primarily cancer tests like EGFR, etc).
We have diverse payers (Medicare, Medicare Advantage, commercial plans and Medicaid) and we are convinced our revenue capture and receivable days are not at the industry standard (too many denied claims and appeals and too many under paid out of network claims). We need good help with revenue cycle management in the clinical laboratory space.
How would we design a survey or request for proposals that is granular enough to assure we hire a high quality vender who really is impactful, and not waste money on weak support services?
Designing a comprehensive Request for Proposals (RFP) for revenue cycle management in the clinical laboratory space requires a combination of clear objectives, detailed requirements, and structured evaluation criteria. Here's a step-by-step guide on how you can structure your RFP:
- Background: Briefly describe your laboratory, its size, specialties, and the revenue distribution between conventional and genomic testing.
- Objective: Clearly mention that you are seeking a vendor for revenue cycle management with expertise in the clinical laboratory space.
2. Scope of Work
- Revenue Cycle Analysis: Vendors should be able to provide an analysis of your current revenue cycle, identifying gaps and areas of improvement.
- Claim Management: Emphasize the need for efficient handling of denied claims, appeals, and underpaid out-of-network claims.
- Payer Relations: Describe your diverse payer mix and express the need for effective communication and negotiation with these payers.
- Reporting and Metrics: Highlight the importance of regular reporting on key metrics like Days in Accounts Receivable (DAR), Collection Rate, Denial Rate, etc.
3. Detailed Requirements
- Experience: Ask vendors to provide evidence of their experience in the clinical laboratory space. This could include case studies, references, or success stories.
- Integration: Your chosen vendor should seamlessly integrate with your existing systems. Ask about their experience with integration, especially with any specific systems you use.
- Training: Inquire about the training they provide to your staff during the transition phase.
- Customer Support: Understand their support structure – is it 24/7? What's the average response time?
4. Evaluation Criteria
- Relevant Experience: Give higher weightage to vendors with significant experience in the clinical laboratory space.
- Proposed Solution: Evaluate the comprehensiveness and feasibility of the proposed solution.
- Cost: While cost is essential, it shouldn't be the sole deciding factor. Consider the value the vendor brings in.
References: Reach out to the references provided and gauge the vendor's effectiveness and customer service.
5. Proposal Submission Guidelines
- Proposal Structure: Define the structure you want the proposals to follow. This could include sections like Executive Summary, Proposed Solution, Case Studies, Cost Breakdown, etc.
- Submission Deadline: Clearly mention the last date for proposal submission.
- Contact Information: Provide a point of contact for vendors to reach out in case of queries.
6. Questions for Vendors
- Can you provide a detailed breakdown of how you've improved revenue cycle metrics for other clinical laboratories?
- How do you handle denied claims and appeals? What's your success rate?
- How do you ensure compliance with regulations and payer-specific requirements?
- Describe a scenario where you faced challenges with a client similar to us and how you overcame them.
7. Terms and Conditions
Clearly mention any contractual terms, payment terms, confidentiality agreements, etc.
8. Conclusion and Next Steps
Thank your vendors for their interest and specify the next steps in the selection process, such as interviews, presentations, or site visits.
Remember, the goal of this RFP is not just to find the most affordable vendor but to select a partner who understands your unique challenges and can provide tangible solutions to improve your revenue cycle management.
At what point should I get my attorney (external counsel) involved. At RFP generation now? Or later when we are actually contracting.
Should he / she review the responses (for whether they are legally clear or legally vague?)
Involving your attorney (external counsel) at various stages of the RFP process can be beneficial for multiple reasons. Here's a breakdown of when and why you might want to involve them:
RFP Generation: It can be beneficial to involve your attorney during the initial stages of drafting the RFP. They can:
- Ensure that the language used in the RFP is clear and unambiguous.
- Help draft the "Terms and Conditions" section to protect your interests.
- Ensure that there aren't any clauses that could unintentionally bind your lab legally.
- Advise on any regulatory or legal considerations specific to your industry or region.
Reviewing Responses: While primarily the evaluation of responses will be based on technical and financial criteria, having an attorney review them can be advantageous:
- They can identify any responses that contain legally vague or ambiguous statements.
- They can provide insights on any potential legal risks associated with a vendor's proposal.
- They can ensure that vendor responses align with the legal terms and conditions set out in the RFP.
Contracting Phase: This is the most critical stage where you'd want your attorney deeply involved. They will:
- Draft or review the contract to ensure that all terms are clear and protect your laboratory's interests.
- Negotiate terms with the selected vendor's legal team.
- Ensure that all regulatory and compliance requirements are met in the contract.
- Advise on potential risks and liabilities.
Post-Contractual Issues: If there are any disputes or issues that arise after the contract is signed, your attorney will be instrumental in providing guidance and representing your interests.
Recommendation: While it might seem like an additional cost, involving your attorney early on, especially during the RFP generation and response review phases, can preempt potential legal pitfalls. It's often more cost-effective to prevent issues at the outset than to resolve them later. Furthermore, having legally sound RFPs and contracts not only protects your laboratory but also instills confidence in potential vendors, as they see that you're thorough and professional in your approach.
Are there meaningfully different approaches to RCM for clinical chemistry vs genomics? If so, should I ask for specialized expertise in the two domains rather than just 1 generic domain?
Yes, there are distinct differences between revenue cycle management (RCM) for clinical chemistry and genomics, primarily driven by the nature of the tests, the technologies involved, reimbursement structures, and regulatory considerations. Here are some of the differences:
Nature of Tests:
- Clinical Chemistry: Involves standard tests that have been in use for many years, such as blood tests, urine tests, and others. These tests are widely accepted and understood by both medical professionals and payers.
- Genomics: Involves advanced genetic and molecular tests, which might be new, specialized, and not as widely accepted. These tests can be more complex, and their clinical utility might be questioned by some payers.
- Clinical Chemistry: Reimbursement codes and structures for these tests are well-established, with clear billing practices.
- Genomics: Given the novelty and complexity of some genomic tests, reimbursement can be more challenging. Some tests may not have established reimbursement codes, or payers may be hesitant to cover them without clear evidence of their clinical utility.
- Clinical Chemistry: These tests are generally less expensive.
- Genomics: Genomic tests can be significantly more expensive due to the advanced technologies and expertise required.
- Clinical Chemistry: Regulations are well-established.
- Genomics: The regulatory landscape for genomics is evolving, with new guidelines and considerations emerging as the field advances.
- Clinical Chemistry: Given the widespread acceptance and understanding of these tests, negotiations with payers are often straightforward.
- Genomics: Negotiations can be more challenging. Payers may require more evidence of a test's clinical utility or may not recognize the value of newer tests.
Given these differences, it's advisable to seek RCM vendors with specialized expertise in both domains.
While there's overlap in the fundamental principles of RCM, the nuances and challenges of each domain can significantly impact revenue capture, claim denials, and payer negotiations.
Recommendation: In your RFP, do specify that you are looking for vendors with expertise in both clinical chemistry and genomics RCM.
- Ask them to provide evidence of their experience in each domain, such as case studies, success rates in claim approvals, and expertise in negotiating with payers for both types of tests. This will ensure that you partner with a vendor who understands the unique challenges and opportunities in both areas.