Highmark Health & AHN's Grand Vision for AI-Driven RCM

The integrated health system has a grand vision to use conversational AI as an 'added member of the care team' to improve revenue cycle management operations.

Highmark Health and its 14-hospital system, Allegheny Health Network (AHN), are partnering with Abridge to embed generative AI into clinical workflows, with a goal to reduce administrative burden and inefficiency.

By leveraging its position as an integrated healthcare organization, Highmark hopes to establish a scalable platform that can serve as "living laboratory" that tests the potential for AI in healthcare.

Initially, the partnership will deploy an AI-powered ambient listening technology, which will eventually become available to all of AHN's approximately 3,000 clinicians. The platform is designed to listen to clinician-patient conversations and, from that "golden record," automatically draft the documentation required for prior authorizations.

Fixing Prior Auth at the Point of Care

The objective is to move the PA process from a reactive administrative task to a proactive, real-time function occurring at the point of care.

"As an integrated payer-provider, we see so much of the back and forth between payer and provider that isn't laddering up to our ultimate goal of improving health," said Richard Clarke, Chief Analytics Officer at Highmark Health. "Getting rid of that non-value added back and forth gives us more time – more of an impact – to reinvest in health."

For AHN, the appeal is twofold. First, there is the immediate reduction of documentation burden for clinicians, a key factor in physician satisfaction. Second, there is the potential to scale AI technologies across multiple facets of clinical care.

"That's the fascinating thing with this technology: It's very intuitive," said Mark Sevco, AHN's President and CEO. "The speed of AI and the next frontier products from these organizations is going to be a game-changer and we want to be part of that."

The technology acts as an "AI consultant" in the room, according to Clarke, helping clinicians meet documentation requirements in the moment. This approach, he said, essentially allows the health system to take its existing gold carding program to the next level by allowing AI to validate that policy requirements are met during patient encounters.

The 'Living Laboratory‘ Advantage

Executives say the integrated relationship between Highmark Health and AHN enables the strategy in ways that might not be possible in other payer-provider relationships. This structure allows the organizations to create a sort of "living laboratory." to work out implementation challenges in an aligned and transparent manner, according to Clarke.

"Conceptually super simple, tactically really challenging," he said, noting that the primary challenge will be scaling the solution beyond an initial handful of procedures. The complexity stems from "long and complex" medical policies that vary by group and client.

In the partnership between Highmark Health and AHN, the payer side of the business will roll out the solution to its other provider partners.

A Foundation for Value-Based Care

While automating prior authorization is the immediate focus, Clarke emphasized that the "golden record" created during the encounter is a foundation for broader value-based care goals.

The partnership aims to use the AI to share "scaled insights, not just information," according to Clarke. This includes prompting clinicians in real-time about potential quality gaps or alerting them that their patient is eligible for specific digital health benefits or programs funded by the health plan.

"We've been focusing a lot on our rollout to make sure that all these tools are seen as an added member to the care team," Clarke said. "I want them to say, 'AI is part of my care team. It is not like an adversary. It is actually adding value.'"