Let's Get Digital: How 2 RCM Leaders Are Tapping Tech to Improve Patient Access

All eyes on prior authorization and scheduling.

RCM leaders are losing patience with barriers to patient access. 

When it comes to complex, expensive procedures, "medical necessity from a payer perspective is not always in alignment with what the physician necessarily says," says Shana Tate, chief revenue officer at Ballad Health, a 20-hospital system serving four states in the Appalachian Highlands (Tennessee, Virginia, North Carolina, and Kentucky).

It "creates a lot of angst" for everyone involved. Often, "the patient really doesn't know what's going on until they get a denial and then they're confused," Tate explains. And that's a good-case scenario. When surgery needs to be rescheduled to accommodate an ongoing appeals process, the patient may need to upend their plans, such as a work leave or travel arrangements for any family coming into town to help with recovery. For their part, the provider is left with the arduous tasks of fighting the initial denial and smoothing a disrupted schedule, both of which take up "a lot of resources and time," Tate says.

It's why she's focused on optimizing her team's front-end operation, augmenting their capabilities with technology intended to streamline core aspects of patient access, including prior authorizations and scheduling. "We're really, really pushing our organization forward into the digital," she explains. The goal is to make things faster and more accessible.

But they simply cannot do it alone.

"We have to do that with the payers by our side," Tate says. They've seen some important alignment on this front: Days before a December 31, 2024, deadline, Ballad Health reached an agreement with Cigna to ensure continuing in-network access for all of their hospitals, facilities and physicians, the organization said in a December 19 press release. As part of the renewed partnership, four hospitals in the system are gaining new in-network status with the insurer's marketplace exchange product.

Ahead are some more ways RCM leaders are improving payer and administrative processes to expand patient access. 

Smoothing prior authorization

Ballad Health has long partnered with a software vendor on electronic payer communications to fuel faster prior authorization approvals. Now, they're piloting EMR-based data exchange with one of their primary insurers to make the experience even "more seamless for the patient," Tate says. The results so far have been promising, even as her team continues to work out the kinks that come with new tech. "There's a lot of encryption, there's a lot of security that we have to get through," she notes.

Tate is not alone in pursuing tech-enabled prior auth solutions.

MemorialCare Health System, a four-hospital organization serving California's Orange and Los Angeles counties, has adopted robotic process automation (RPA) that allows "us to notify the health plans of hospital admissions, on average, within 14 minutes," Steve McNamara, vice president of revenue cycle, told HealthLeaders in an email. His team is also using the technology to identify any coverage alternatives to those presented at admission. Given the benefits they've seen from these early use cases, MemorialCare plans to explore additional RPA opportunities in 2025. 

Success on the payer front demands intervention prior to prior authorization. Ballad Health uses technology to verify a patient's insurance upfront to reduce stress for the person seeking care, who isn't always versed in the specifics of their coverage, and to ensure the system can collect on the services they provide. "So it's not just prior auth — it's also making sure that we have the appropriate insurance for the procedure" in the first place, Tate says.

Streamlining scheduling

Shoring up scheduling has been another big access initiative for both Ballad Health and MemorialCare. "We have invested in efforts to provide our patients with a high level of satisfaction with our scheduling and registration practices," McNamara says. 

"It's really important we make sure the patients can get in, and they're not on long wait lists," Tate says. Her team conducted analyses throughout 2024 to target the biggest backlog culprits.

 A key takeaway from the exercise? Get to the heart of what your patient population wants. "That's a big thing," Tate says. "If you don't really understand what the community is asking for, what they need, or what's going to make you successful, and you just throw spaghetti on the wall and hopefully something sticks, that's going to make your job much harder."

To truly understand "the different pockets" of Ballad Health's population, which spans rural and urban locations, Tate's team started prioritizing referral reports and other EMR outputs that offer valuable insight into the patient experience but were previously flying under the radar. It's helped them answer vital questions about leakage, such as: "Where were our patients going? Why are they going elsewhere? What do we need to do better?" Tate explains. "How do we make sure that we're reaching out to the entire population — not just one section of it?"

One solution: Introducing new avenues for patients to handle scheduling, payment, and other administrative aspects of their care. "If they want to call, they can. If they want to do it through technology, they can. If they want to text, we're working to make sure that they can," Tate says.

Despite the possibilities RCM leaders see for digital solutions and technology, there's still no replacement for good old-fashioned human-to-human support.

MemorialCare Health System has earned industry recognition for their concierge program, which, McNamara says, features "a team of trained individuals who identify patients in need of financial counseling to ensure they are aware of their out-of-pocket liabilities prior to the service date."