Rangy new HIPAA reg proposals could ramp up cybersecurity expectations, investments, and dings for falling short. Make sure you're ready.
On January 6, HHS published a proposal to amend the HIPAA Security Rule, foretelling the most sweeping changes to HIPAA regulations in more than a decade. If enacted, the updates will "have a major impact on HIPAA-regulated entities operationally and financially, requiring a major investment in cybersecurity," The HIPAA Journal reports.
Key proposals include more stringent risk analysis, detection, and response measures, along with a range of protections including network segmentation, ePHI encryption, multi-factor authentication, and anti-malware protection.
Although the fate and timing of the final rule is murky under the new administration, comments are due on or before this Friday, March 7. "Extensive feedback is expected from HIPAA-regulated entities and healthcare industry stakeholders due to the number of new cybersecurity requirements," the journal reports.
Regardless of how it all shakes out, there's at least one measure that's worth getting a jump on now: Continuity planning in case of widespread disruption — a growing reality in today's volatile world, and one that takes myriad forms.
"If you don't have a good mitigation strategy today, you're dead in the water," says Ejay Birkmeyer, assistant vice president of revenue cycle operations at The University of Texas Medical Branch (UTMB), a four-hospital system based in Galveston, Texas. Aside from multiple hurricanes, the organization has braved freezes and other power-zapping disasters in recent years. "And of course, that's Mother Nature attacks. Now, you're talking about cyberattacks, which, on top of that, your continuity plan has to deal with."
More than a year after the Change Healthcare breach, UTMB, a then-client of the vendor, is still feeling the ripple effects as they finish digitizing thousands of payer files that they had to capture on paper in the aftermath.
Three weeks post-attack, Birkmeyer participated in a continuity planning session led by a former Department of Justice staffer. "We got to hear some inside things on planning, and there's a lot of 'what ifs,'" he says. "It goes down a rabbit hole."
The system's resulting 250-page plan touches on everything from civil unrest to natural disasters to other more and less likely disturbances. Ahead, he shares his biggest takeaways from the exercise.
Opt for vendor interoperability
Over his more than two decades in healthcare, Birkmeyer says he's seen a seismic shift in the industry's relationship to technology — from lagging to leading on many fronts. Now, "some of the healthcare IT is on the cutting edge because we're introducing AI into it," he says. "A lot of the things that didn't exist before now exist, and we're trying to take advantage of them early."
Interoperability is crucial to ensuring a standardized, sustainable approach, and many vendors are taking their cues from "Congress and governmental [agencies] stepping in to try to make it better," he says. Major players like Oracle Health and Epic Systems are "very big" on the practice, which allows them to share data across their own and other platforms, he explains. "Because the more information you have, the better medical decisions you can make on patients."
When it comes to vetting potential vendors and tech partners, it helps to have a designated staff member keeping tabs on the regulatory landscape, including new proposals coming down the pike, says Birkmeyer, whose team monitors briefings from HFMA and federal agencies, including CMS, HHS, and the Cybersecurity and Infrastructure Security Agency (CISA, formerly US-CERT and ICS-CERT).
UTMB's chief information security officer looks specifically for a prospective cloud service provider's compliance with the Federal Risk and Authorization Management Program (FedRAMP) and Texas-specific TX-RAMP protocols for state and government institutions.
Requirements could get even stricter in the final cyber rule, Birkmeyer predicts, in terms of what's considered secure transmission and storage of PHI and financial information. "And some people will meet that, and some people may not."
No matter how sophisticated your tech partners are, none should be your end-all, be-all on any specific function. And that's where Birkmeyer's single biggest piece of continuity planning advice comes in: Resolve single points of failure. For UTMB, Change Healthcare was that Achilles heel when it came to claims management. Now, they have a backup vendor on retainer in case their primary solution is hit.
Tap into tech for recovery
Birkmeyer's team has had to manually post or convert paper files to an electronic format for documentation affected by payer downtime following the Change Healthcare breach, including roughly 250 explanations of benefits (EOB). "We did a lot of them by hand, but when you're talking about [a] thousand patients on the EOB, you really can't do that by hand very quickly," he says. "We've had to weigh cost of converting versus cost of paying overtime versus time it takes, or do we need extra resources?"
To help speed up the process, they've leaned on emergent EOB conversion tech from a current vendor that "made a lot of technological improvements" quickly following the breach to help systems get their documents back online, Birkmeyer says. Even though they're nearing the finish line, "it's taking a long time to get to an accuracy rate that we're comfortable with in posting some of those."
Go old school
Although there are a lot of shiny new objects in the revenue cycle marketplace, don't sleep on the older tech.
The proliferation of remote work at the COVID-19 pandemic's peak means many organizations are better equipped with strategies to support a distributed staff — such as laptops or mobile desktops for everyone — which also comes in handy when preparing for "a physical attack on a building or something of that nature," says Birkmeyer. At UTMB, "continuity planning now extends to plugging in somewhere else," such as at home and other hospital campuses. "We have worked on moving our secondary locations for servers off the island, even away from Houston," he adds.
When preparing for full network outages, think even older school. "As a society, we're trying to get away from paper, but [when] none of the digital streams are available, you have to have some marching orders somewhere," Birkmeyer says. He recommends keeping a printed copy of the continuity plan in a designated folder or notebook, along with a list of key phone numbers, such as those belonging to vendors.
Put heads together
Birkmeyer's team also compares notes with peers across and beyond the UT network, such as Ochsner Health and LCMC Health, two Louisiana-based systems that face hurricanes and other similar regional threats. "That information is invaluable between organizations, and it really does help with your own planning," he says.
Cultivate that same sense of camaraderie between departments within your organization, he advises. He sees cybersecurity as "a three-part deal" between financial, clinical, and IT teams. "So those people at the table can make some of the core decisions about your organization on how to secure data."
As health systems face razor-thin margins, executive upheaval, and sky-high expectations, some are calling on a burgeoning type of leader to helm the revenue cycle: the fleet-footed interim exec.
"The demand for interim revenue cycle executives is poised to grow significantly in 2025," wrote WittKieffer consultant Robert Springall in a recent LinkedIn post. "As healthcare systems navigate constant changes and challenges, interim revenue cycle leaders are essential in ensuring smooth operations and achieving financial success."
It's something Patrick McDermott, who's partnered with WittKieffer to land interim contracts, can attest firsthand.
Once a full-time health system exec, McDermott is on his fifth on-demand gig in five years, with stints at ProMedica, Scripps Health, and Lawrence General Hospital under his belt.
He knows he's in good company.
"The turnover rate among the revenue cycle VP and the CFO really jumped up" in the past few years, McDermott says. Culprits include ever-tight margins and return-to-work mandates that are driving some senior leaders to retire early or leave for more flexible roles, such as remote or interim ones.
But the gig is not for the faint of heart.
McDermott has come up against a culture in need of total rehabilitation, plus two cyberattacks: the nationwide Change Healthcare attack that would have drained the organization he was partnering with, which relied on state Medicaid, of their operating income within two weeks without swift intervention, plus a more targeted breach that took another system's EHR down for 30 days, sending the revenue cycle into a spiral.
"We had to completely rebuild the accounts receivable [in] a blitz sprint formation," McDermott recalls. "If you don't do it quickly, then you can be set up for denials and bad debt and bad customer service."
Ahead, he shares how rev cycle execs and teams can ensure success when entering the high-octane world of interim leadership.
'Endless' possibilities for partnership
To initiate an interim engagement, which can range in length from a few months to a year and change, prospective partners often work through an executive search and consulting firm like WittKieffer or the boutique Boca Raton, Florida–based Rudish Health, says McDermott. Once the two parties are matched, the leader is typically onboarded to the organization through their standard process for a vendor or supplier. It all "plays like lightning speed," he explains, and therein lies the opportunity.
Interims can help systems thrive in times of transition, such as after an executive has departed, a crisis has emerged, or an exciting initiative has gotten off the ground but requires specialized expertise to succeed.
In such cases, an on-demand leader presents a cost-effective, quick-start alternative to a lengthy — and risky — search for full-time talent. "You can't just let an executive seat be empty for a month or three months because everything just comes to a halt," McDermott says.
And interim engagements aren't just for teams looking to fill gaps — organizations in many different circumstances can benefit.
"I think it's something that's going to be permanent in the industry," Adam Burns, principal of WittKieffer's interim leadership practice, recently told Newsweek. "Once [health systems] start to think about all the different ways they could use somebody — when you take the org chart out of it and just think about the lists of challenges and projects and opportunities they have — it's endless."
As an example, systems with strong revenue cycle leadership intact can tap a short-term co-executive as a change agent.
"Someone once taught me, you should work on today's problems in the morning and work on future problems in the afternoon," McDermott says. Having two leaders lets you do both at once, with one focused on the "blocking and tackling" for personnel, initiative and vendor management, and technology improvement, and the other handling "acceleration and amplification," he explains.
Trust (is) the process
Given today's fraught staffing and security landscape, health systems should consider adding on-demand leadership to their crisis response plans, says McDermott. "[You] can't just be caught flat footed," he stresses. "You have to be ready for a cyberattack. You have to be ready for the key executive to leave the organization. You have to be ready."
He suggests having an executive recruiting firm on standby so an interim leader can be engaged swiftly during unexpected transitions.
For their part, interim leaders — and those vetting them — should prioritize "really good situational leadership skills and EQ," McDermott explains. "You can't just go in with a preconceived toolkit and just start doing things. In fact, it'll backfire on you if you do that."
To gain buy-in out the gate, it's vital to put people over processes. "If you put the results first, the machine first, then you'll never gain the trust," he says. "And once you want to start making changes and improvements, you will be resisted because you didn't put the time in to build the trust."
There are no shortcuts, but there's also not a lot of time to waste: Trust-building is "an important element of success in the first 30 days," McDermott says.
To put in the reps that get teams past skepticism, he follows these three principles:
Listen to understand (not prepare your reply)
Show appreciation and recognition
Create an inclusive culture
"Just like in regular revenue cycle management, there's a front, middle, back. You have to get everybody involved," he says. "Otherwise, people feel like they're excluded."
And finally, don't forget to honor who and what has come before you.
"You have to really respect and take some time to understand the history, vision, values," says McDermott. "Otherwise, culture will eat you for breakfast, lunch, and dinner."
New market reports project meteoric vendor growth in the coming decade. Execs should tread lightly to avoid being swept away in the hype.
RCM technology is booming.
The vendor market could reach anywhere from $343B to nearly $900B globally within the next decade, according to new projections from Straits Research and Coherent Market Insights. The outsourcing portion alone could achieve $170B by 2032, says HTF Market Intelligence (MI), which values it today at $90B globally.
"This market is expanding due to the increasing complexity of healthcare billing, a focus on reducing operational costs, and improving cash flow through specialized outsourcing partners," states the HTF MI report.
It's something HealthLeaders has been tracking for a while now: Nearly one-third (32%) of systems and hospitals surveyed by Kaufman Hall in 2023 were pursuing outsourced revenue cycle solutions, up from 27% in 2022.
But just because vendor partnerships are on the rise doesn't mean everyone should hop on the bandwagon, revenue cycle execs have told us. Ahead, they share how to set the stage for success.
Scope the state of play
Whether outsourcing revenue cycle management to a new vendor or external team, drivers often include the need for specialized expertise and uniform adherence to increasing regulations, analysts say. There's also the promise of scale and improved focus on core operations without major investments in infrastructure or staffing, Lynn Ansley, vice president of revenue cycle management, at Moffitt Cancer Center, previously told HealthLeaders.
The intersection of automated and outsourced solutions only stands to grow as nascent tech gains ground in healthcare. Whether it's robotic process automation (RPA), regular automation, or the "complete revolution that's coming in the next three to five years based on AI," Mercurio said these tools are "going to really change, I think, a lot — if not most — of the way we do things, especially in the rev cycle."
It's a prediction echoed by analysts, who say RCM software already contributes more market share than services. While web-based solutions make up the most market share today compared to cloud-based and on-premise counterparts, according to Straits, cloud adoption presents an opportunity in the coming years, say forecasters, who also point to RPA and patient-centric care as opportunities. McKesson and Cerner are among the most-cited companies to watch.
Weigh costs against cost savings
While it may be enticing to jump on the vendor train to cut costs, revenue cycle leaders must be crystal clear with their expectations and thoroughly examine what a prospective partner can do for their specific challenges. Making the wrong decision could lead to a loss of control, a dependency on insufficient partnerships, data security risks, and "wasted effort and time for both" parties, Ansley warned.
It's also important to consider the broader strategic implications of outsourcing, she said. This includes evaluating how it aligns with the organization's long-term goals, such as patient experience improvements, clinical outcomes, and operational efficiency. A time when outsourcing often does make sense is during a merger or acquisition, she noted, especially when a deal throws "two different rev cycles" into the mix.
Get real about ROI
An unflinching focus on real return is especially important where emergent tech is involved.
However, RCM execs may not have the budget or the time and resources to spend on new ideas that take too much time to develop value or don't have clear value to begin with.
Several exchange attendees said they follow a technology ROI threshold of 3:1, meaning a new product or program must produce in revenue three times what it cost to launch the project. No one touches anything with a 1:1 return, and a 2:1 return won't hold up against unexpected and additional costs, particularly at a time when so many systems and hospitals are skating on thin margins.
Evaluating ROI starts from the jump, Ansley said. When it comes to outsourcing arrangements, vetting teams should partner with their CFO to review a prospect's track record, technology capabilities, and security measures to ensure they align with the health system's needs, she advised. She's found system executives are becoming more critical in their vendor evaluations. They're asking for things like detailed proofs of concept, assurances or guarantees, and shorter contracts (e.g., three years) to back up ROI — or back out quickly if it isn't there.
Consider a piecemeal approach
One way to boost ROI is to get creative with current partnerships.
Instead of contracting with a single entity for wholesale RCM support, Mercurio partners with "individual vendors that might do pieces and parts" based on Mass General Brigham's goals, as well as cultural, financial, and operational needs.
It reflects a larger vision to maximize value from existing solutions, including those used to outsource operations. "Oftentimes, you buy one product, and you don't realize that there are other offerings that that company might have that would be really beneficial to implement," he explained. "So we want to really take a hard look at any of our existing partners if we're trying to do something new in a space or expand with a technology, because it's a lot easier to, you know, add a new statement of work than it is to bring someone new inhouse."
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."
Getting there will take smart tech investments and relentless focus on the patient experience, according to two new trend reports.
After years of margin pressure, workforce strife, and pandemic recovery, things are looking up for revenue cycle leaders, according to two new trend reports.
"2025 could mark a turnaround period for the health care sector, driven by innovation, resilience, and strategic growth," write the researchers of Deloitte's2025 US Health Care Outlook for large systems and plans.
Of the 80 C-suite executives the firm surveyed, 59% are optimistic about their prospects in 2025, up from 52% just a year ago. Additionally, 69% expect to see a rise in revenue, and 71% anticipate improved profitability.
To get there, RCM leaders must shift focus from stability to strategy, the researchers say. It's a sentiment echoed in a 2025 report from Kaufman Hall and parent company Vizient aptly titled Strategy is (Finally) Back in the Driver's Seat. Chief among investment priorities: greenlighting AI and advanced analytics projects to automate revenue cycle management, which nearly two-thirds of leaders say is a top goal over the next three years.
Balance growth with affordability and access
Growth and affordability are twin themes for 2025.
Nearly a third (65%) of executives surveyed by Deloitte say developing growth strategies is a top priority. In terms of patient experience, more than half (52.8%) of leaders polled by Kaufman Hall see access, throughput, and capacity as their top focus for 2025. Deloitte's report reinforces this finding, noting that 55% of system leaders say they need to improve consumer experience, engagement, and trust; 46% say affordability is a top industry consideration.
Of course, growing margins and profitability while containing costs and rebuilding trust is a balancing act. But it's one that's mutually beneficial. "A loyal patient generates more than three times the revenue of an uncommitted one," Kaufman Hall researchers write.
Some ways RCM leaders say they're finding success on affordability and access fronts include:
Get to the heart of what patients want, says Shana Tate, chief revenue officer at Ballad Health, a 20-hospital system serving four states in the Appalachian Highlands. "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," Tate previously told HealthLeaders.
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 explained. "How do we make sure that we're reaching out to the entire population — not just one section of it?"
Be transparent. As patients become responsible for more of their healthcare costs, systems are putting more emphasis on their financial experience as consumers. When adjusting its pricing structure, Illinois-based Carle Health is mindful of how it will impact their patient population financially. "I think price transparency is an obligation of the health system," Aron Klein, vice president finance operations and supply chain, previously told HealthLeaders. "Quite honestly, I think it's a benefit to our patients to make sure they're fully informed in advance of services."
Break out the white gloves. MemorialCare Health System, a four-hospital organization serving California's Orange and Los Angeles counties, has earned industry recognition for their concierge program. The service 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," Steve McNamara, vice president of revenue cycle, previously shared.
Get smart on tech investments
When it comes to advanced analytics and AI, 65% of health system leaders surveyed by Kaufman Hall called revenue cycle automation a leading focus over the next three years, making it second only to clinical decision support in terms of priority.
Top ways health systems are investing in tech, according to Deloitte, include bolstering core infrastructure (43%); prioritizing virtual health, digital tools, and alternative sites of care (33%); and investing in platforms for digital tools and services (30%).
"All technology and operational investments and implementation projects at health systems should help ensure equitable access, experience, and impact for all users," the Deloitte researchers write. "Understanding the needs and impacts of different populations from a technology or operational change and intentionally designing to meet those needs or mitigate those impacts can help ensure broader adoption."
It's easier said than done.
"Vendors that say they can do what we're looking for are a dime a dozen," Brian Ice, vice president of clinical revenue cycle for the Allegheny Health Network, previously told HealthLeaders. But actually finding one "that's a good fit for your organization, that integrates well with your electronic health record, that has the right price tag associated with it" is an elusive goal.
To sniff out potential snake oil, consider connecting with a peer organization already using a prospective solution to discuss how implementation went, Michael Mercurio, vice president of revenue cycle operations at Mass General Brigham, previously advised. "There's a very big difference between selling and installing," he noted.
Other ways RCM leaders are getting real ROI on their investments include:
Go robo. MemorialCare Health System has adopted robotic process automation (RPA) that allows their revenue cycle team to "notify the health plans of hospital admissions, on average, within 14 minutes," McNamara said. 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, they plan to explore additional RPA opportunities in 2025.
Remove friction. "We're all trying to remove touches from the claims process," Ice said. The key, he noted, is to have AI do the number-crunching and analysis and give RCM and finance executives the data they need to make those collaborations meaningful, whether it's in plotting the right pathway for patients to pay their bills or working with health plans to align care management with coverage.
Look for big numbers. Mass General Brigham's rev cycle team is automating more than 80% of their radiology-related coding activity with a commercial computer-assisted coding solution developed by the system's physician organization billing office.
"We've seen a reduction in denials and therefore a reduction in cost on the backend, which we've been able to pass on to our practices or reinvest in ourselves by redeploying staff to areas [that] need it," Mercurio said. When considering automation, he recommends starting with higher-volume service lines where notes typically follow a standard template or format, such as radiology or pathology. "There's significant volumes of those, so the machines can learn very well on past history and do a really good job predicting the future."
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."
New year. New role. Renewed resolve to improve payer relations, financial sustainability, and patient access.
Last month, Sherri Liebl was appointed vice president of revenue services for CentraCare, a 10-hospital health system headquartered in St. Cloud, Minnesota. Liebl, a 12-year veteran of the organization and previously its executive director of enterprise revenue operations, has a big audacious mandate for her new role, which reports directly to CFO Mike Blair: "Manage all of the various polarities that are coming at us in multiple avenues, and still remain flexible and viable enough so that we can continue to exist in the communities and provide the necessary care to our patients at an exceptional skill rate," she explains.
To do it, Liebl has assumed oversight of two departments — government reimbursement and payer contracting — while retaining the traditional RCM function she's long helmed.
It's a tall order.
"The first 90 days is really about structure — learning the additional two departments and looking at how we can position ourselves a little bit differently … so that we can be more flexible as regulations come down the pipeline and we need to shift and change," she explains.
Over the longer term, Liebl will focus on "creating strategies to mitigate payer challenges, reduce costs, improve CentraCare's financial sustainability, and reduce the cost of care for our patients and families," she said in a statement.
Liebl sat down with HealthLeaders to discuss the "more holistic" suite of revenue services she now leads, her priorities for 2025 and beyond, and the sometimes unlikely sources of inspiration that help guide her decision making in the face of ever-evolving regulatory and payer challenges. It's a playbook that fellow RCM leaders can take a page from as they blaze their own paths into the new year.
1.On building relationships
"One of my very first goals is to … settle into the relationships with some of the other senior leaders in the organization to understand: Where are some of their stress factors at, where are some of their concerns at, and how can not only myself, but also my teams help them maneuver and mitigate?" Liebl explains. "What I'm looking to do is to create those partnerships and also to provide some education into the work we do and the reason for that work."
She recalls a recent conversation with a leader who, in response to hearing that the RCM function implements solutions to abolish debt for patients, said, "I had no idea. I thought you were just calling the patients up and asking them for money."
To curb such misunderstandings, Liebl is educating her peers on how her departments can help them achieve their priorities and track toward a shared North Star: better serving patients.
2.On reducing costs
Liebl's priority areas for reducing costs for CentraCare, as well as its patients and partners, include:
Working smarter, not harder: A big part of Liebl's new role will involve finding cross-functional efficiencies. "Let's not touch a claim three or four times. Let's get it out the door once, bring it back in, and have it fully paid," she says. That means aligning practices, processes, and technologies across system locations — an expansive, ongoing effort that last year drove the transition to a single, enterprise-wide EMR vendor and now includes the procurement team creating standard products and negotiating contracts "so that we get the best pricing, and we don't have one-off buys."
Readying for regulatory changes: "Right now, we've been focusing a lot of attention on what's going through Congress," Liebl says. Her team is closely following movement on the telehealth front, which earlier this month brought a stopgap budget bill to extend key program waivers for 90 days. CentraCare has invested heavily in this space since the start of the pandemic, contracting a company to provide some of its urgent care services, and the fate of those offerings hangs in the balance. "So we're doing those financial analyses to say, 'okay, if we can't do these telehealth services the way we have been doing them for the last couple years, what's the financial impact to us, and to the patient? Do we have the access available to the patients to still get them in? And how is this going to affect us going forward? Because now this is going to be a bigger lift."
Reducing patient burden: That means strengthening care access by improving geometric length of stay and ensuring services are being sought and provided in the right setting. It also means alleviating patients' financial strain. "We might decide that one area we'll need to reduce costs in might not be favorable to our bottom line. But is there another area where we can actually bring in additional revenue to make up for that lost revenue?" Liebl asks. "We're trying to find all of those hidden treasures under the rocks that we can control and we can impact to change that cost structure for our patients."
3.On mitigating payer challenges
"Nothing is more concerning to a patient [than] when they get a notice from the payer that their authorization isn't covered," Liebl says. "So we are really into the quality aspect."
At the same time, CentraCare must receive the payment it needs to "continue to thrive as a health system, so that we can continue to be here for the patients that we serve, knowing our populations are extremely rural, [and] we are one of the largest rural-setting facilities in our in our state."
It's a balancing act, and Liebl's strategy reflects that.
She approaches challenges, such as arduous prior authorization requirements, as areas of mutual challenge and opportunity. "It's really looking at how we partner with our payers differently and in a more effective and efficient way," she explains. "To say, 'hey, we understand this is a burden for us. It must be a burden for you. How can we come to terms where it's beneficial for us, and really putting the patient at the center of the entire experience … so we can create those long-term partnerships that are favorable to all of us."
Aside from seeding a resolution strategy that's gaining early traction with payers, Liebl will continue the work started by CentraCare's CFO and CEO, who asked different organizational stakeholders to lead collaboration experiments with a specific insurance partner. "Then we're going to come back and look at the successes because ideally, what we would like to do is blueprint this out and say, 'this really worked well with this payer; now let's move on to the next big payer to see what we can do,'" Liebl explains.
4.On finding inspiration in unlikely places
When it comes to professional development as a healthcare finance leader, Liebl is a fan of the usual haunts: She reads the publications of HFMA and related industry groups, attends conferences, and participates in a woman's health leadership group.
She's also an avid reader and podcaster with three books going at any given time. "One is always very much so on leadership or something that I can relate back to work," she explains, but not always in the way you'd expect. "I find that there are a lot of tips and tricks that we should be trying in healthcare that come from other industries."
Two recent favorites from other disciplines:The Mindset Mentor podcast with Rob Dial ("It really does help you … formulate your brain a little bit differently") andThe Outlier: The Unfinished Presidency of Jimmy Carter by Kai Bird. "The Outlier was a non-leadership book, but there were so many things to be gained in there," Liebl says. "The relationship building that he did within his tenure to bring two countries together was quite amazing. And I feel we can use that same type of technique as far as building relationships because healthcare is about relationships. It really is."
5.On restoring trust
Speaking of relationships, some need repairing. "There are a lot of folks who don't trust healthcare any longer. There are a lot of folks who feel we're just out for the bottom dollar," says Liebl. For her part, she sees dollars as a means to an end.
"What I'm hoping to achieve in this position is to leave the financial state for CentraCare better than when I came into this role, and even when I came to work here," she explains. "[So we can] say, 'okay, we did something really great here, and we kept the patient at the center of all the work we were doing, and look: Now we can continue to serve them for the long haul.'"
In a year rife with denials and discord, RCM execs say these three tactics may help turn the tide.
Payer practices, which have gripped public consciousness for much of December, are also the leading revenue cycle stressor for healthcare providers, according to recent research from HFMA and Guidehouse.
Among more than 130 system financial executives surveyed, nearly nine in 10 (85.8%) cite health plan patterns like denials and underpayments as one of their top three challenges; more than half (51.5%) finger a related pain point: prior authorization.
It's something RCM leaders have said time and again.
"We're in a crisis," Shanda Richards, revenue cycle director of Central Peninsula Hospital in Alaska, previously told HealthLeaders. "We're delaying care because we can't get prior authorization."
The following tactics, sourced from RCM execs throughout a year rife with denials and discord, may help turn the tide as we roar toward 2025.
Watch the legislative landscape
In January, the Centers for Medicare and Medicaid Services finalized the Interoperability and Prior Authorization Rule, setting requirements to streamline the process for Medicare Advantage, the Children's Health Insurance Plan (CHIP), and Medicaid managed care plans, among others.
Provisions aim to increase data sharing and, in turn, reduce the administrative burden on providers, enabling them to spend more time delivering care. Payers must, for example, send prior authorization decisions within seven calendar days for standard requests and within 72 hours for expedited ones.
While the incoming administration's impact on these and other hot-button measures remains to be seen, state legislatures are likewise taking action to alleviate providers' prior authorization struggles. Nearly half of U.S. states have passed bills in the past two years to improve transparency over requirements, reduce care delays, and increase publicly reported data.
Talk the talk
Coming to the negotiating table prepared can make a huge difference, RCM execs say. It starts with regularly reviewing payer contracts, a task that 17% of providers admit to overlooking.
Other best practices, according to RCM and financial execs who participated in this year's HFMA conference, include:
Be transparent about challenges in managed care and look at ways to file litigation if necessary.
Consider creating a national payer scorecard to keep track of the reputations, strategies, and tactics of every payer your organization does business with.
Stay diligent and in constant communication. Reinforce the need for patient care and partnership over profits.
Scale solutions
When it comes to earmarking investments over the coming months, most HFMA-Guidehouse survey respondents (71.7%) are prioritizing RCM tech, including automation, AI, and machine learning.
Proponents say such a focus can help providers counter tech-fueled upticks in denials. As an example, an October report by the U.S. Senate Permanent Subcommittee on Investigations highlighted UnitedHealthcare's use of AI to deny claims and found that the insurer's prior authorization denial rate for post-acute care jumped from 10.9% in 2020 to 22.7% in 2022.
"Payers rely on technology solutions just like we do to manage processes on their side," Aron Klein, vice president of finance operations and supply chain at Carle Health, previously told HealthLeaders. "If something [happens] on their side, it takes time to resolve, which ultimately delays processing or receipt of payment on our side."
The Illinois-based system has seen a 22% increase in denials year over year. The top culprits, according to staff research, include payer policy changes and issues with interoperative CPT codes. Additionally, most denials have come with a request for more documentation or information, creating a mountain of administrative work, Klein said.
To address such sticking points, his team has implemented a solution featuring forms populated with information from the system's EHR to send to payers. The intervention saves specialists 10 minutes per request, which has taken the timeline for appealing prior authorization–related denials from 46 days to 36.5 days.
Revenue cycle staff and leaders meet monthly to monitor progress and denial trends, updating system leadership on their findings so that they and the operations teams can assist in resolving them.
"We are bringing technologies and a patient-centered approach to alleviating the complexities of managing the care authorization process," Jessica Godbey, the system's vice president of patient access services, said.
Amid a flurry of outsourcing activity, one rev cycle VP says RPA, AI, and other emergent tools are "making us all rethink" traditional cost-saving measures.
Whether outsourcing revenue cycle management to a new vendor or offshore team, cost is typically a driver, but "tech's making us all rethink that," says Michael Mercurio, vice president of revenue cycle operations at Mass General Brigham, a 12-hospital system headquartered in Boston.
Mercurio holds a distinctive vantage point: Aside from managing a team made up of on- and offshore FTEs, he helps other health systems automate their RCM processes as co-founder and executive vice president of strategic relationships at an AI-based medical coding company that launched in 2019 to commercialize the computer-assisted coding solution developed by Mass General Brigham's physician organization billing office.
The intersection of automated and outsourced solutions only stands to grow as nascent tech gains ground in healthcare. Whether it's robotic process automation (RPA), regular ol' automation, or the "complete revolution that's coming in the next three to five years based on AI," Mercurio says these tools are "going to really change, I think, a lot—if not most—of the way we do things, especially in the rev cycle."
Consider a hybrid approach
Just as Mercurio's role straddles vendor and provider, so too does his stance on outsourcing. Instead of contracting with a single entity for wholesale RCM support, he partners with "individual vendors that might do pieces and parts" based on Mass General Brigham's goals, as well as cultural, financial, and operational needs.
Today, roughly 40% of his team's FTEs are offshore, a proportion that he expects to increase in the coming years. "It's going to continue to be a big part of our footprint."
At the same time, though, tech stands to take over much of the RCM work handled today by humans, regardless of their organizational affiliation, says Mercurio, pointing to one of his team's RPA bots that, since its implementation a year ago, has assumed duties previously handled by 10 offshore folks.
Integration and automation are further streamlining performance in house, too. Mercurio just finished combining Mass General Brigham's hospital and professional billing teams. The two-year initiative involved integrating workflows and operations, creating a shared culture, and figuring out how to "act and function like a team," he says. "We're still in that process."
Additionally, the system's rev cycle team is automating more than 80% of their radiology-related coding activity. "The quality is excellent," says Mercurio. "We've seen a reduction in denials and therefore a reduction in cost on the back end, which we've been able to pass back to our practices or reinvest in ourselves by redeploying staff to areas [that] need it."
Beyond radiology, it’s tool now covers pathology, evaluation and management, endoscopy, and surgery, and Mass General Brigham is seeking to expand their use cases "so that we can get a bigger bang for the services that they're providing to us," Mercurio says.
It reflects a larger vision to maximize value from existing solutions, including those used to outsource operations. "Oftentimes, you buy one product, and you don't realize that there are other offerings that that company might have that would be really beneficial to implement," he explains. "So we want to really take a hard look at any of our existing partners if we're trying to do something new in a space or expand with a technology, because it's a lot easier to, you know, add a new statement of work than it is to bring someone new inhouse."
Hold your horses
All this merging and streamlining and automating and innovating means up to 30–40% of current revenue cycle roles might not exist in the next three to five years, Mercurio says.
He's struck in this moment by a quote from Henry Ford: "If I had asked people what they wanted, they would have said faster horses."
In other words, we humans are famously bad at envisioning the future.
"I don't think anybody had space shuttles or electric vehicles in mind in the early 1900s when cars started to become really popular," Mercurio says. "And so I don't think we can really appreciate what's coming next for AI that hasn't been thought of, it hasn't been developed, it hasn't been rolled out or no one's using it, but it's going to massively change the way we do a lot of things."
To stay competitive, he recommends that RCM professionals of all walks sharpen skills that are still distinctly human. "One thing that the AI doesn't demonstrate itself to be really good at yet is critical thinking and problem solving when it requires understanding workflows between physicians and insurance companies and the software used to communicate between the two," he explains. "The folks that can understand a problem … will be the ones that will have opportunities for advancement or staying in an organization because … those are the folks we want on our team anyway — even without AI — are critical thinkers and problem solvers."
Chief among the system's drivers of ROI is a coding automation platform grown close to home.
Let's face it: We're not getting any younger.
"Our population [is] getting older, more complex, more challenging, so there's always going to be more volume than we can keep up with," says Michael Mercurio, vice president of revenue cycle operations at Mass General Brigham, a 12-hospital system headquartered in Boston.
For revenue cycle teams, it means the pressure is on "to not only perform well and bring in as much cash as we can as effectively, compliantly, and quickly as we can, but [to] do it at a cost that isn't burdensome to the organization," he explains. "Because every dollar that they spend on me is one dollar [that] they don't spend on a clinician or on research or on community assistance or on direct patient care."
To help those dollars more readily reach their intended targets, Mercurio has half a dozen "bot builders" implementing robotic process automation (RPA). "We're looking to continue to expand that as quickly as we can," he explains.
Ahead, more ways Mercurio taps tech to keep pace with RCM's ever-upping ante.
Cracking the CAC code
Today, Mass General Brigham's rev cycle team is automating more than 80% of their radiology-related coding activity with CodaMetrix's platform, which Mercurio helped launch in 2019 to commercialize the computer-assisted coding (CAC) solution developed by the system's physician organization billing office.
This focus has paid off big, Mercurio says. "The quality is excellent, and we've seen a reduction in denials and therefore a reduction in cost on the backend, which we've been able to pass on to our practices or reinvest in ourselves by redeploying staff to areas [that] need it as opposed to working things that would have been denied."
When considering automation, Mercurio recommends starting with higher-volume service lines where notes typically follow a standard template or format, such as radiology or pathology. "There's significant volumes of those, so the machines can learn very well on past history and do a really good job predicting the future," he explains.
Making humans happier
Apart from creating economies of scale in house through CAC and RPA, Mercurio sees an opportunity for tech advances to make work more joyful for the humans in the loop.
"Our providers are severely overburdened and that's causing a lot of challenges clinically from an access perspective and doctors losing the joy of medicine. So AI is going to help there," Mercurio says. "From our [RCM] perspective, it's really making us think, ‘do we really want to do X if technology is going to maybe potentially give us a boost or a lift or resolve this problem for us?'"
He points to new AI tools on the horizon, along with companies offering tech that tees up appeals to denials likeliest to get overturned based on a payer's policies and historical activity.
Laying the groundwork
Though such possibilities are ripe for ROI, they risk being waylaid by waning budgets and bandwidths. "There are so many companies and technologies and opportunities out there," Mercurio says. Though there's no silver bullet for these "killer bees," the following strategies are some worthy repellants.
Talk shop
"I rely heavily on my network," Mercurio says. "If someone's already using a vendor or a process, that's a good head start to narrow it down." He recommends asking peers which partners and solutions they've chosen and/or shortlisted, and based on what criteria, "so we don't have to do that market scan ourselves."
Avoid vaporware
Tapping your network also means you can learn from their mistakes. Mercurio recalls a peer who ran into early misunderstandings about an AI product they were purchasing that, one full year after implementation, left them where they thought they'd be on day one.
"It's so new, and there's a lot of hype, and people are quick to jump on to that," Mercurio explains. "If you're not asking the right questions or doing the right reference checks, and really digging in to understand the full breadth and depth and scope of your potential partner—which you should do for anything, not just AI—then you could end up getting bitten."
To sniff out potential snake oil, he recommends connecting with a peer organization already using a prospective solution to discuss how implementation went. "There's a very big difference between selling and installing," he notes.
Empower teams
System leadership is generally supportive of tech-enabled experimentation to "drive more value at a lower cost and a higher quality," Mercurio says.
As for staff whose roles might be directly impacted, such as coders, buy-in "comes down to the communication and the trust that your team has in you as a leader and your leadership team," he explains. The objective, he tells his staff, is to elevate team performance so members can build capabilities and take on more valuable work—not lose their jobs.
"We're not looking to eliminate any of the coders on our teams because of technology. We have more volume than we can keep up with," he says. "We want to make sure that we have the right coders who are trained in various subspecialties and are experts in their field and can really provide the value to our overall organization."
Put value over cost
Though price is "obviously important," Mercurio is "more interested in the quality of the outcome of the service we're buying, the relationship that we're going to have with that vendor," he explains. "We want them to be sticky. It's not a great idea to save 60% and then have seven times as many problems and constant turnover with account managers or teams where you're then managing more than you were to begin with and you're spending more than you were to begin with."
See the vision
"I like to try to find the companies that are really trying to do something different and special," Mercurio says. "That's who we would want to partner with to see if we can elevate our game and provide more value to our patients and our providers and our practices."
