To beat payers at their own game, one CFO is looking to his revenue cycle to even the playing field.
The payer/provider relationship has been strained in 2023, to say the least. Between ever-changing payer requirements and frequent denials, providers often feel like they are in a no-win situation.
As more hospitals and health systems look to fight back, many are bringing in more AI and technology to streamline revenue cycle process and reduce burdens across the board.
Most hospitals and health systems have a workforce that was heavily strained and became burnt out during the pandemic, and Mazurkiewicz says they are still dealing with the aftereffects.
“One of the effects of that burnout has been in documentation,” he says. “Insurers have raised the bar on expectations of documentation and prior authorization and will not pay if those expectations are not met.”
Mazurkiewicz says payers have been ramping up initiatives to ensure what they’re paying for has all the clinical documentation they require and more, so payers are now auditing more claims, delaying more claims, and that’s delaying cash flow.
“In the past year we’ve seen a substantial increase in initial denials, primarily coming from Medicaid and Medicare Advantage managed care plans. That means our revenue cycle initiatives need to be more focused on denials management,” he says.
So how will McLaren be achieving this? By continuing to prioritize revenue cycle AI and technology.
“We’re using AI to help with claims processing and documentation of our care. These tools help ensure physicians are fully and accurately documenting why they recommend a certain course of treatment, and then assess whether a claim is likely to be denied based on each insurer’s rules,” Mazurkiewicz says.
He says that these revenue cycle tools even provide insights into the reasons why a claim may be denied, so they can make those corrections before a claim is even submitted.
“It’s making sure our documentation is as right as our diagnoses.”
On a more basic operational level, Mazurkiewicz says for 2024 he will also increase McLaren’s focus on collecting cash at the point of service, when appropriate, which will in turn reduce its billing costs.
Amanda Norris is the Associate Content Manager of Finance, Payer, Revenue Cycle, and Strategy for HealthLeaders.
As denials pile up and prior auths get more complicated, organizations are looking toward technology to fight back against payers.