Payer-Provider Software: 5 Strategies for Smooth Sailing

Tech is all the talk this year, but to find a solution that walks the walk, RCM leaders must get savvier in their selection strategy.

For many revenue cycle leaders, 2025 is all about the tech.

Time and again, execs have said they're investing big in AI and advanced analytics to improve team efficiency, payer relations, and patient access.

But all too often, shiny new tools that promise to help are doing more harm than good.

"If you've been in the industry long enough, [you've seen] criteria sets in the market that have a tendency to create friction," says Debbie Schardt, DSL, MBA-HCA, RN, assistant vice president of revenue cycle and utilization management at MultiCare Health System, which has 14 acute care hospitals throughout Washington state.

It doesn't have to be this way.

Schardt's intentional partnership with an RCM and UM vendor helped MultiCare save more than $8 million last year in the realm of case review and payer relations.

"That's just one KPI of that," Schardt says. Patients — her team's "primary focus" — are happy thanks to appropriate billing and out-of-pocket payment statuses, and staff members are satisfied with all the time and energy saved. "I've had no turnover in nurses because of frustration with technology," she notes. "That goes a long way in employee engagement."

To see such returns, revenue cycle leaders must ground vendor partnerships in a strong strategy from the start. Ahead, Schardt shares her field-tested tips for success.

Assess the landscape

As is the case with many providers, MultiCare is seeing a rise in denials, fueled in part by payer process automation and algorithms that are "creating some friction," along with more back-end audits, Schardt says.

Additionally, payers sometimes cite utilization criteria sets to deny or downgrade payment without considering real-time clinical decision making. It's a practice used by private and government entities alike, says Schardt, who recently had Medicare and Medicaid auditors reduce payment for inpatient care to a level set for outpatient observation. Her team's approach in such situations is to appeal — up to two times — saying, "No, this is a complex medical decision, and these were all the reasons why this patient was in, and the criteria set does not allow for the judgment of the physician who was caring for the patient at the time," she explains.

Such a thorough appeal process, though vital to patient and provider outcomes, can be pricey.

"We have the expense of nurses and physicians to do peer-to-peers, and if [the denial] doesn't get overturned, or it happens retrospectively, then we have to appeal in letter writing, which takes months and months and months," Schardt explains. "In the meantime, the providers are providing services, and we're not being reimbursed accurately or timely."

Set the strategy

In technology adoption, strategy should lead the solution selection process. "When it comes to the provider-payer landscape, the focus is collaboration," Schardt says.

To help meet this objective, MultiCare today partners with Xsolis, whose AI-backed UM and revenue integrity software aims to smooth case review, denial management, and related provider-payer interaction.

"Before we were kind of hunting and pecking through Epic, wondering, ‘Are we capturing everything that is relevant to the situation?'" Schardt recalls. "The platform puts it all together for us and allows us to be more efficient and concise in presenting the information."

Vet for vision

Although Schardt "couldn't be happier" with the collaboration, she wasn't an easy sell. "If anybody put them through the ringer, was me, okay?" she laughs. "I think I made them do 20 demos for me, then my team, and then the executive team."

Measured consideration helped MultiCare adopt early and grow intentionally with their vendor. "We were the third client," Schardt recalls of their partnership beginning in 2016. It was a "wise risk," and well worth it. 

To get there, Schardt posed thoughtful questions during the RFP process, such as:

• How many clients do you have now?
• Where do you see yourself in five years?
• What's your financial stability look like?
• How are you going to grow? Maintain?
• Are we, as a provider organization, going to outgrow you?
• Are there other uses for your product we haven't discussed?
• What's the experience like to work with you? How do you manage customer relationships?

This last point can be make or break, says Schardt, who's worked on both the vendor and provider sides of the aisle. Look for a partner that demonstrates commitment to all their clients, regardless of size or stature; listens and implements feedback; and takes fixing problems seriously, she advises.

Look for win-wins

Prospective partners should have a clear value proposition for payers and providers. "Let's face it, the providers aren't the only ones who are being really held responsible to good stewardship and efficiencies," Schardt says. So anything that can help "eliminate the noise and focus" is a win-win.

Among payers that are collaborating with MultiCare in the Xsolis platform, Schardt's team has seen a significant dip in wrongful denials for clear-cut cases, including many involving observation status. Reducing such friction paves the way for discussions on true edge cases, she says. "It got us away from talking about criteria and actually having a conversation about the patient."

It's mutually beneficial. "They've noticed efficiencies, we've noticed efficiencies, the relationship is a little bit better because we're really talking about the gray-zone cases," Schardt explains. "Those are really where everybody should be focusing."

Spot the time savers

MultiCare uses their UM platform to pen concise appeals, lifting evidence directly from physician advisors' peer-to-peer review for nurses to quickly refine. "Don't send me a four-page appeal letter," says Schardt, recalling her days at a payer organization. "Send me a paragraph or two telling me exactly why it is that you think this should be paid in the way that you think it should be paid."

Such precision makes the appeal process more efficient, effective, ultimately beneficial to those who matter most: the patients. "If we don't do this," Schardt says, "their out-of-pocket expenses may be very high. We certainly don't want that for them."