Deciphering value in new tools and strategies is a constant challenge for healthcare leaders. At the HealthLeaders RevTech Exchange, they came togetheer to discuss the best strategies and biggest hangups.
New technologies like AI may have a bright future in healthcare, but many revenue cycle executives say the ROI just isn’t there yet. And they’re having some tough conversations with vendors and their own staff about how to move forward with new ideas.
At this week’s HealthLeaders RevTech Exchange in Nashville, some 30-40 healthcare leaders discussed a variety of strategies for embracing new tech. Those strategies almost always focus on defining and seeing ROI, and that factor alone can make or break a new technology contract or scuttle a promising program before it begins.
“Some very good products don’t justify the expense” said Jonathan Davis, Executive Director of Patient Access and Revenue Cycle Analytics at Yale New Haven Health. 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.
RCM executives are in a tough spot right now, caught between the value-based care movement and business strategies that still adhere to episodic care. Their definition of value often clashes with clinical leadership, and it’s in technology that those differences hit the spotlight. ROI for a new tool that improves clinical outcomes is far different than the ROI for a tool that improves administrative efficiency.
At the same time, a new tool that greatly improves clinical outcomes won’t be useful to a hospital that can’t keep its door open because of unsustainable revenues. So the delicate balance of priorities continues.
Several exchange attendees said they follow a technology ROI threshold of 3:1, meaning a new product or program has to 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.
So the technology has have an immediate and impactful ROI, particularly at a time when so many health systems and hospitals are skating on thin margins. One of the first places to cut expenses is in innovation, putting the pressure on executives to be sure they’re finding the right vendors with which to partner.
Lynn Ansley, Vice President of Revenue Cycle Management at the Moffitt Cancer Center, says healthcare executives are becoming more critical in their evaluation of vendors. They’re asking for more details about products and avoiding ambiguity at all costs, and they’re looking at shorter contracts—three years was mentioned more than once—so that they can back out if the ROI isn’t there.
In many instances, RCM executives are asking for a detailed proof of concept from vendors, requiring them to map out how their product will benefit the health system and even asking for assurances or guarantees. That’s not unlike the shared risk that we see in arrangements between payers and providers.
And if there are multiple vendors vying for the same contract? How about a “bake-off,” in which they put their products up against each other to determine who’s better at proving ROI. Some health systems are even working with two vendors that offer the same tools, so that both are accountable and giving their best effort.
This is crucial, exchange attendees said, because payers often seem to be ahead of the game in tech adoption, particularly with AI. Some even said their health systems are moving fast to adopt AI just to stay in the game with payers.
“You show up at the contract table with any payer and they know more about your business than you do,” one executive pointed out.
In terms of staffing, which is a sore spot at every health system and hospital, RCM execs are defining ROI in automation and AI tools not by how technology can replace humans, but by how it frees up staff to handle more important tasks.
“There are other things that we need smart people for,” notes Ansley.
And they’re countering staff concerns that AI will replace them by pointing out that those upskilling opportunities often come with salary increases. That, in turn, helps with staff retention and hiring.
Finally, RCM execs are looking at a future that sees them playing more of a role in the patient’s healthcare journey. That means not only collaborating with clinicians to advance the right technology purchases but highlighting the role that revenue cycle staff can play in helping patients understand and fulfill their financial obligations.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
The company behind the stylish, AI-enabled CarePod has abruptly closed, following a similar spiral as the HealthSpot more than a decade ago. The news proves that healthcare innovators shouldn’t just be trying to recreate the doctor’s office.
Another kiosk-based telehealth company has shut down, proving once again that a high-tech virtual care platform isn’t the successful business model that disruptors think it can be.
Forward, which launched in 2016 with a cash-based model and unveiled the stylish, AI-enabled CarePod just last year, announced its abrupt demise in a company post this week, putting some 200 employees out of work. The company said it was immediately discontinuing its app, cancelling all scheduled visits and shutting down all operations, while keeping a support team available for about a month.
The collapse is reminiscent of the HealthSpot, a similarly-styled kiosk that debuted at the CES show in Las Vegas in 2012. The company behind the kiosk raised almost $50 million, built close to 200 kiosks and had deals in place with Rite-Aid, the Mayo Clinic, Cleveland Clinic and Kaiser Permanente before going bankrupt in 2016.
The lesson to be learned in these closures is that technology alone won’t solve anything, and that consumers and business owners are looking past all the bells and whistles for convenient, no-frills healthcare connections. A kiosk that can replicate a complete visit to the doctor’s office may look and sound great, but it’s still a healthcare visit to a different location. If consumers want the experience to look that much like a doctor’s office, they’ll go to their doctor’s office.
To be fair, the kiosk concept is still enticing. Pursuant Health, which began as SoloHealth in 2007 with the EyeSite vision kiosk, now has more than 4,600 health kiosks in high-traffic retail and grocery stores across the country. And Canada-based UniDoc Health Group, which unveiled its H3 Cube Virtual Care Simulations Model (VCSM) at the American Telemedicine Association conference in 2022, rolled out the first commercial shipment this week, and is pursuing an international “AI-focused eHealth” strategy that would out its kiosks in remote and resource-thin regions around the globe.
Health systems and hospitals are also interested in the form factor. Rochester University Medical Center has partnered with Five Star Bank to locate smaller telehealth kiosks in several bank branches, eyeing a strategy that that improves access in rural upstate New York. And several healthcare organizations across the US have located smaller kiosks--some no more than a laptop and connected devices in a cubicle—in libraries, malls, community centers and other locations with the goal of giving consumers quick and easy access to virtual care providers for small health concerns.
As Forward and HealthSpot have proven, bigger isn’t better and telehealth companies, care providers and disruptors who are looking to recreate the doctor’s office in other settings are missing the point. Small, quick and easy may be the key to sustainability.
As the HealthLeaders 2024 RevTech Exchange kicked into action this week in Nashville, executives from dozens of health systems discussed how they're managing new technology like AI
Today's revenue cycle management leaders need to be agile. The healthcare industry is going through a significant period of change, buffeted by costs and quality concerns and workforce shortages and buffered by new technologies like AI. That's a challenging environment for any leader to navigate.
Roughly 40 RCM leaders from health systems across the country gathered in Nashville this week at the HealthLeaders 2024 RevTech Exchange to talk about those challenges and opportunities.
Here are a few key plot points from the first day of the Exchange:
Train, train, and train some more. And don't stop training. Due in large part to the advances in automation and the potential of AI, the revenue cycle workforce is evolving. Managers need to develop a strategy that prepares staff for that evolution. They need to address that worry that AI is taking people's jobs by pointing out that jobs aren't disappearing, but they are changing. RCM staff will become monitors, overseers and auditors, keeping a close eye on the technology that is doing all the manual tasks they used to do.
And that training won't stop. A key element of generative and predictive AI is that it keeps on learning, and RCM staff will need to keep on learning alongside those tools.
That goes for leaders as well. New technologies like AI are new to everyone, including those in the C-Suite. Healthcare leaders need to have a clear understanding not only of these new opportunities, but how they'll affect staff and workflows. Be ready to talk to people who are worried that AI will replace them, as well as staff who are perhaps a bit too eager to try something new.
Technology isn't the answer. "We look at technology like it's going to solve all our problems," says Derek Dudley, VP of Revenue Cycle Operations at Tidelands Health. "But a $200 hammer isn't going to make you a better carpenter."
As with clinicians, RCM managers need to understand that technology is a tool that will help them become better, but it won't solve all the pressing problems of healthcare on its own. Managers and staff need to understand how to use those tools to improve rev cycle performance.
For example, Beth Carlson, VP of Revenue Cycle at the West Virginia University Health System (WVU Medicine), noted her health system developed a tool to predict denials from a certain payer. The tool was wildly successful—but it was scrapped, because the denials were still happening. In other words, they'd created a great tool, but it didn't have any value.
Look for proactive solutions. Taking the WVU Medicine example one step further, what the health system needed was a tool that would identify the root causes of those denials, and develop a strategy for preventing denials in the first place.
Several health system executives at the Exchange emphasized the need to develop new tools and programs that tackle key pain points in RCM, such as denials, appeals and prior authorization hangups, before they happen. The appeal of AI lies in gathering all the data at hand and predicting when those issues occur, then using that data to plot the best way to avoid them.
Collaborate with IT and especially clinicians. Revenue cycle departments shouldn't exist in their own silos, and yet they sometimes think they do. Because of this, and because many of the sexy new AI tools address clinical care, RCM staff may be feeling a bit inferior to their medical counterparts.
That's a load of baloney. Successful health systems and hospitals thrive on collaboration, and it's important that executives look for those opportunities to collaborate on new tech and programs. Lynn Ansley, VP of Revenue Cycle Management at the Moffitt Cancer Center, said revenue cycle leaders should even go on rounds with clinicians to understand their workflows and see where RCM technology intersects.
In fact, revenue cycle managers should even find clinician champions, much like CIOs and CNOs will do to support the rollout of new clinical technology. Having clinician support and have clinicians understand how RCM technology benefits their workflows will go a long way toward establishing that elusive ROI.
Find that elusive ROI. This is the biggest challenge in healthcare technology today. New tools like AI may look great and even produce amazing results in pilots, but they need to prove long-term value, and that hasn't been easy so far. With health systems and hospitals on razor-thin margins and reluctant to spend money on new ideas (especially something as pricey as AI), there has to be a proven ROI attached.
Balance established tech with new tech. Many healthcare organizations don't have the resources to develop new technology like AI, so they outsource, looking for a company with a good background and product or even a startup that they support. On the other hand, EHR companies are developing their own tools that integrate into the medical record. Is it better to wait for that tool or spend money on an outsourced product that may have to be bolted onto the EHR?
It's not an easy question to answer. Some Exchange participants said they don't want to wait for their EHR provider to develop a tool they need now and are willing to look for help. Others are against bolted-on functionality and are willing to wait. And then there are those who would consider buying a new tool or capability and then switching over when the EHR provider comes along with that tool.
Look at RCM from the outside. Many of the new ideas coming into healthcare have proven themselves in other industries, like retail, banking and travel. And while the healthcare sandbox is a difficult place in which to play with new concepts, savvy leaders will look for ways to adopt them and adapt to the changes. Part of that process includes understanding how these ideas worked in other industries and learning how they might fit in.
Beyond that, RCM leaders also need to look at their departments from the perspective of other parts of the healthcare ecosystem. How does IT see the RCM process? How do doctors and nurses view those operations? This is particularly important when developing a culture of collaboration.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
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In this HealthLeaders podcast, Jim Blum, CMIO at University of Iowa Health Care and a Mastermind participant, talks about giving clinicians the tools to improve their workflows and patient care without hitting them over the head with governance.
Is it possible to do too much with AI governance?
James Blum, MD, thinks so. The CMIO at University of Iowa Health Care and a participant in the HealthLeaders Mastermind program on AI in clinical care, says the technology needs to be treated with the proper safeguards, but that doesn't mean separating it from all other innovative tools and processes.
"AI and healthcare probably shouldn't exist in the vacuum," he said during a recent HealthLeaders podcast. "And we shouldn't be acquiring AI for the sake of AI. We should probably be looking to solve problems that people have, and if that involves AI, great. If it doesn't, that's probably in many ways better because it takes out display of governance and potentially a lot of additional expense."
UI Health Care has launched two AI tools for clinical care: An ambient transcription platform developed by Nabla, which roughly 1,100 of the health system's 3,000 doctors are now using, and a chart mining platform from Evidently that collects all relevant data on a patient from multiple sources to give clinicians a concise view of the patient.
"I can see these very sick patients [with] long, complex medical histories and, really, I'm able to know as much about that patient as the intern that was up all night trying to comb through their entire medical history," he points out.
Blum says both tools were carefully reviewed by UI Health Care through a normal process for reviewing new vendors. With AI, that includes bringing in clinicians and IT personnel who understand the nuances of the technology.
"It is with a group of individuals that are qualified to review the AI right and really understand the performance characteristics and what can be expected of the technology in addition to our typical acquisition process," he said.
"And that's where the AI committee can get engaged and say, ‘OK. Let's look at the performance characteristics and training set and those types of things and give a thumbs up or thumbs down' as to [whether] they think the science behind the AI algorithms is good. And if it's not, then convey that to the groups that are doing the acquisition and say we really don't endorse this because we think it's not a product that's really going to deliver what they're purporting it will deliver to you."
Blum says AI is such an intuitive technology that it doesn't need the intensive resources and training for adoption that health systems typically set aside.
"With all types of departmental meetings and going to individual clinics and a lot of hand-holding … we would we would get nowhere near this level of adoption this quickly if we did it the way we typically roll out," he said.
Instead, with the ambient dictation tool, the health system held one training session and made that available on video. This takes the pressure off of the IT department and gives clinicians more of a responsibility to understand how AI will work for them.
"If it's not working for you, go back and do things [the old way}," he said. "So you don't need to have this really comprehensive, elaborate rollout and you can go ahead and basically turn the technology on and let the use of it grow organically."
"It's a much more targeted intervention and I think results in a much greater utilization," Blum added, noting the health system can identify who isn't using the new technology and help them if needed. "We're not going to go ahead and force you to use the technology you don't want to use, and we're also not going to spoon-feed you. But if you want to be better, you want to be more efficient, it takes a little bit of self-motivation. How many people went to a class on how to use their smartphone before they started using it?"
Blum says he's excited to see how generative and predictive AI evolve and are worked into the clinical space. And while UI Health Care is always looking for new partnerships, the health system will balance doesn't want to buy or build a new tool that will be rendered obsolete by a new capability from its EHR partner in a few years.
More important, he said, are the cost and data storage concerns that come with AI.
"All this stuff, all these large language models and all this processing and the tokenization just requires a ton of computational power," he said. "And this introduces an entire new realm of expense for health systems, without there being necessarily a great financial upside on these things."
Blum says health systems will have a hard time defining an ROI that will please everyone. AI might be great at reducing physician stress, but is that enough for CFOs and CEOs who want the health system to meet increasing patient demands?
"This leads to millions of dollars a year that you're spending on these types of technologies and you may not see a financial upside for that," he says. "And in this era of 1% margins, this gets to be a real challenge."
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CMS won't extend certain key pandemic-era waivers any longer, putting telehealth expansion plans in jeopardy. Will lawmakers step in and take action?
Pandemic-era telehealth waivers that allowed providers to expand their virtual care footprint will end this year unless Congress takes action.
The Centers for Medicare & Medicaid Services (CMS) announced in its finalized 2025 Physician Fee Schedule that it won’t extend most of those waivers any longer, putting back in place pre-COVID telehealth limitations. Those include restrictions on where telehealth can be provided and delivered, as well as who can use telehealth through Medicare.
The end of the waivers would curtail a number of telehealth strategies, especially for older Americans and those living in urban and suburban areas. It would also limit the use of virtual care by specialists and other types of care providers (such as physical and occupational therapists and speech language pathologists) and limit where telehealth can be provided to certain CMS-approved sites, like health clinics.
CMS has, however, included some changes in telehealth regulation for the coming year, including a one-year extension of the waiver allowing providers who bill Medicare for their services and deliver virtual care from their homes to list their practice as the site of telehealth delivery.
“Allowing appropriately licensed and credentialed providers to practice telehealth from their home improves patient access to healthcare services, reduces healthcare costs, while maintaining and meeting patient demand for care,” advocates said in an October letter to CMS Administrator Chiquita Brooks-LaSure. “This was necessary during the height of the COVID-19 pandemic and remains just as important today amidst provider workforce shortages and burnout, given that 78 percent of health care practitioners agree that retaining the opinion to provide virtual care from a location convenient to the practitioner would ‘significantly reduce the challenges of stress, burnout, or fatigue’ facing their profession and eight in 10 indicate that this flexibility would make them more likely to continue providing medical care.”
In addition, CMS is:
Finalizing a proposal to add several services to the Medicare Telehealth Services List, including caregiver training services on a professional basis and PrEP counseling and safety interventions on a permanent basis. For CY 2025, the agency will continue to suspend limits on the frequency of subsequent inpatient and nursing facility visits and critical care consultations.
Making permanent a ruling that Medicare telehealth services delivered to patients in their home can be done by two-way, real-time, audio-only communication technology (such as a phone) if the patient doesn’t have or want access to video services and the provider can offer that platform.
Making permanent a new definition of “direct supervision” for certain services that are required to furnish under the direct supervision of a physician or other supervising practitioner. The new definition would allow the supervising physician or practitioner to use real-time, interactive, audio-visual communications. For all other services, CMS is extending the use of supervision by telemedicine for one year.
Extending for one year a policy to allow teaching physicians to use telemedicine for purposes of billing for services furnished involving residents in all teaching settings, but only in clinical instances when the service is furnished virtually (such as in a three-way telehealth visit involving the patient, resident and teaching physician).
Led by the ATA, telehealth advocates are holding out hope that Congress will take action on one or more of several bills currently before lawmakers. They include:
The Bipartisan Telehealth Modernization Act of 2024 (R. 7623 and S. 3967) and the CONNECT for Health Act (H.R. 4189 and S. 2016), which would extend Medicare telehealth flexibilities through 2026.
The Telehealth Expansion Act (1001,HR 1843), which would permanently allow individuals with HDHP-HSAs to access telehealth services before meeting their deductible.
The Medicare Telehealth Privacy Act of 2023 (HR 6364), which would make permanent the provision allowing providers to bill for telehealth services using their practice address rather than their home address.
The Telehealth Benefit Expansion for Workers Act of 2023 (HR 824), which would permanently classify telehealth as an excepted benefit, enhancing access for workers.
New Advanced Primary Care Management codes will give providers more incentives to use virtual care and digital health to improve care management and coordination.
A new primary care model that allows providers to use virtual care and other technology to address patient care needs is getting the green light from the Centers for Medicare & Medicaid Services.
In the finalized 2025 Physician Fee Schedule unveiled last week, CMS included three new HCPCS codes for Advanced Primary Care Management. The codes, which take effect at the beginning of 2025, focus on physician interactions with patients at the time and place of their choosing and are billed monthly, rather than based on a specific number of minutes spent with a patient.
In a blog post earlier this year, Carrie Nixon and Kaitlin O’Connor of Nixon Gwilt Law said the new codes focus on specific activities by clinicians and using technology to address patient needs.
“The Advanced Primary Care Management (or APCM) HCPCS codes bundle elements of the existing Chronic Care Management (CCM) and Principal Care Management (PCM) codes set with Communications Technology-Based Services (CTBS) codes for virtual check-ins, remote evaluation of images, e-visits, and interprofessional consults to create what CMS refers to as an ‘enhanced care management’ bundle,” they wrote. “Unlike CCM and PCM services, the APCM codes are not time-based – meaning, care management services that do not meet the 20 or 30-minute requirements for CCM or PCM would be billable under APCM.”
Nixon and O’Connor also noted that CMS is expanding the rule to allow non-physician care providers, such as nurse practitioners and physician assistants, to order and bill for those services, as long as any practitioner who bills for those services “Intends to be responsible for the patient’s primary care and is the continuing focal point for all needed healthcare services.”
In a November 5 blog, Alexandra Shalom, senior counsel with the Foley & Lardner law firm, noted that because the new codes were designed to be consistent with existing codes for care coordination, providers need to be careful not to bill the new APCM codes alongside those overlapping codes. Examples of overlapping services include interprofessional specialist consults, remote evaluation videos and images submitted by patients, virtual check-ins and communications with patients through an online portal.
The three new codes are:
G0556: Level 1, for persons with one chronic condition.
G0557: Level 2, for persons with two or more chronic conditions.
G0558: Level 3, for persons with two or more chronic conditions and status as a Qualified Medicare Beneficiary.
In a fact sheet issued on November 1, CMS said it had received many requests to increase the valuation for the codes, and will be doing so for G0556.
“Beginning January 1, 2025, physicians and non-physician practitioners (NPPs) who use an advanced primary care model of care delivery as described by the service elements of the APCM codes could bill for APCM services when they are the continuing focal point for all needed health care services and responsible for all the patient's primary care services,” the agency reported. “This new finalized coding and payment better recognizes and describes advanced primary care services, encourages primary care practice transformation, helps ensure that patients have access to high quality primary care services, and simplifies billing and documentation requirements, as compared to existing care management and communication technology-based services codes.”
“The finalized codes also represent a step towards paying for primary care services with hybrid payments (a mix of encounter and population-based payments) to support longitudinal relationships between primary care providers and beneficiaries, by paying for care in larger units of service, and also help drive accountable care,” CMS added. “A practitioner who is participating in a Shared Savings Program ACO, a Realizing Equity, Access, and Community Health ACO (REACH ACO), a Primary Care First practice, or a Making Care Primary practice may satisfy requirements for these codes by virtue of meeting requirements under the Shared Savings Program or Innovation Center model.”
According to Salom, providers seeking reimbursement under one of the three new APCM codes need to satisfy nine requirements:
Patient consent (inform the patient of the services, their right to stop, and of the potential cost sharing obligations;
Initiating visit (required for new patients and patients not seen by the practice in the last three years);
24/7 access and continuity of care (access to team member for urgent needs at all times and continuity through the use of a dedicated team member);
Comprehensive care management (systematic needs assessment, system-based approaches to ensure preventative services are provided, and medication reconciliation, and oversight of patient self-management of medications);
Patient-centered comprehensive care plan (the plan should be timely available to those involved with a patient’s care, routinely updated, and provided to the patient and/or caregiver);
Management of care transitions (ensuring timely exchange of electronic health information and patient follow-up after emergency room visits and hospital discharges);
Practitioner, home-, and community-based care coordination (coordinated referral management with specialists and other health care organizations through developing processes and procedures in the form of collaborative care agreements and electronic consultations);
Enhanced communication opportunities (for patients and caregivers to communicate with team members through additional asynchronous methods);
Patient population-level management (manage preventative and chronic care for the practice’s patient population and develop and implement strategies to improve outcomes); and
Performance measurement (quality, cost of care, and meaningful use of certified electronic health records technology).
“While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing,” Shalom concluded in her post. “HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.”
St. Mary’s Healthcare launched Suki’s AI tool through the MEDITECH EHR earlier this year. Officials say the technology is ‘life-changing.’
Small health systems and hospitals face the same problems as their larger counterparts, yet they often don’t have the same resources to address them. That’s why an ambient AI tool can be a literal lifeline to sustainability.
At St. Mary’s Healthcare in upstate New York, physicians began using Suki Assistant earlier this year to capture the doctor-patient encounter. The results so far, according to Julie Demaree, executive director of clinical innovation and transformation, have been “life-changing.”
“The big thing I can see is when the doctor says, ‘I can go to the gym after work,’” she says. “I can see that they’re relaxed. They can go in and just focus on the patient. They say, ‘I can just talk to the patient.’”
“We’re accountable to so many stakeholders,” Demaree continues. “We’re trying to document medical decision-making. We’re trying to document to communicate with the patient who’s going to go home and read it in the portal. We’re trying to document with our colleagues. We’re trying to document in case we ever get sued. We’ve just got all this stuff we’re trying to fit into a note. And especially in this rural area, we are their everything. We’re their cardiologist and pulmonologist and their dermatologist. So that visit – it’s complex. We’re covering the gamut. … It is life-changing for them.”
Ambient AI is by far the most popular new tool being embraced by healthcare organizations these days, a statement supported not only by the number of health systems and hospitals using the technology but also the number of vendors coming out with new products. It promises to not only reduce the time spent by clinicians in taking notes and transcribing the relevant data to the medical record, but also improving the accuracy of that interaction and its revenue cycle value by applying the right codes.
Demaree says she demonstrated the AI tool, accessible through the health system’s MEDITECH EHR platform, last fall, at which time she pretended to be an obnoxious parent with a sick child. Roughly 75 physicians were present.
A sometimes overlooked benefit of this tool is that it can be configured to recognize particular words or phrases (and identify the appropriate CPT codes for billing), enabling health systems and hospitals to program the technology for certain departments, like OB/GYN, ENT or the ED, as well as for specialties like oncology. Physicians can also adjust the platform to their specific needs.
“Physicians really have a lot of pride in what they put in their notes and how it looks,” Demaree says. “Everybody has their own style.”
“All they really want is the history and the plan, because that’s what takes them forever to do,” she adds. “Because the EMR has a kind of pre-configured physical [checklist] that they can just load and change what’s abnormal, that’s not really something that they need Suki for. But the story, that patient story, this long, rambling thing, and the plan, where they’ve already told the patient the instructions, but now they have to go back to their office and write, ‘Here was your diagnosis, and here’s what I’m ordering, here’s the plan, here’s what I want you to do. That’s now all captured, and they can just review it and put it in the note.”
Just as important, she says, the technology captures everything in one instance.
“You’ve already signed your note and now someone tells us you forgot [something], or you have already finished everything and you go to put the diagnosis in and it says that’s not specific enough and now you have [to go back and check your notes].”
And that’s what reduces stress and saves time, reducing the time spent in front of a computer and enabling clinicians to spend more of it in front of the patient.
Demaree says the ROI was almost immediate. Time to document completion dropped by 50%, which reduces the time patients spend waiting for referrals and payers spend waiting for the claim. The percentage of open notes also dropped, while E&M codes and RVUs have gone up—good for the bottom line, though annoying for patients.
That’s also where generative—and, eventually, predictive—AI could make a significant impact. Imagine a tool that not only captures the doctor-patient encounter and applies the correct billing codes, but one that also helps the doctor to diagnose and treat the patient’s medical needs. It would also outline preventive care and wellness options, alternatives to expensive treatments and drugs and links to other resources.
“It can all happen in one big bundle,” says Demaree. “That would be my dream.”
For now, the tool is a critical factor in St. Mary’s efforts to retain and attract physicians.
“I see this as step one in a huge change for us,” she says. “It’s hard for us to recruit physicians to a small town. It’s also really expensive when we lose physicians. So we’re trying to grow our way to profitability, and to do that you need doctors. And this community needs us.”
“I feel like we’ve done nothing but add things to doctors for years, and now we can we we’re giving something back,” Demaree adds. “I really think this is where things are going to get better.”
The decision from the AMA’s CPT panel will help health systems and hospitals scale and sustain smaller and more inclusive RPM programs.
(Editor's note: This article was corrected to note that the change will go into effect in 2026, not 2025)
A key deterrent to the development of remote patient monitoring programs is being removed, giving healthcare organizations a better opportunity to scale and sustain those services.
The American Medical Association’s CPT Editorial Panel has removed a requirement that RPM providers collect data on at least 16 of 30 days to qualify for Medicare reimbursement, opening the door to short-term and less frequent programs and coverage for a wider range of patients. The change is slated to go into effect at the beginning of 2026.
The panel’s decision, made during its September meeting, is a pleasant surprise for telehealth and RPM advocates, who had supported a proposal in May to create new “supply of device” codes that would have allowed providers to be reimbursed for less than 16 days in a 30-day period.
“Since separate payments for [RPM] services were established, industry stakeholders have advocated against this 16-day requirement arguing that it is clinically arbitrary and ignores conditions where a reduced number of days would be more clinically appropriate,” Thomas Ferrante and Rachel Goodman, partners in Foley & Lardner’s Telemedicine & Digital Health Industry Team, said in a 2023 blog.
The panel declined to support the proposal at its May meeting, leading to concerns that it wouldn’t be brought up again until next year. How or why the panel changed its mind at the September meeting isn’t clear, though it should be noted the change won't take place until the beginning of 2026.
RPM was initially recognized in 2019 by the Centers for Medicare and Medicaid Services (CMS) through a small set of codes for remote physiologic monitoring services, enabling clinicians to seek reimbursement for gathering data from patients through certain medical devices outside the hospital setting. CMS has slowly amended and expanded those codes since then, adding codes for remote therapeutic monitoring.
Advocates have long argued that the codes are too restrictive on everything from what devices can be used to what conditions are covered to what data can be gathered. In all, providers can only expect to receive about $170 in Medicare reimbursements per patient per month.
New research on the value of digital health in hypertension care finds that these devices work best when they connect the patient to a care provider or team who can provide medication management.
A new analysis of digital health tools for hypertension tracking says they are truly effective if they include medication management features, such as a virtual care link.
The report, from the Peterson Health Technology Institute (PHTI), finds that devices that only transmit data to a care provider or focus on behavior change “are less effective and do not provide clinically meaningful improvements,” whereas devices that enable patients to connect with a care team to manage prescribing and dosing “deliver rapid and clinically meaningful improvements in blood pressure that outperforms usual care.”
The research highlights a crucial aspect of remote patient monitoring that has long plagued health systems and hospitals. RPM devices might be great at gathering data in between healthcare visits, but unless that data is used in a meaningful way, it’s wasted.
The key here is that RPM programs need to combine tools with access to care providers who can help patients act on the data being gathered. That may be through an app or other virtual care link, and it could be synchronous or asynchronous.
The results hold true for any chronic condition. In this case it’s hypertension, which affects roughly 120 million Americans, of half of the country, and only about 27 million, or one-quarter, are managing their blood pressure. The rest are at high risk of a variety of health emergencies, like heart attack and stroke.
“Too many people are living with uncontrolled hypertension, but there are effective digital solutions to help patients improve their cardiovascular health, save lives, and lower spending over the long run,” Caroline Pearson, the PHTI’s executive director, said in a press release accompanying the study. “Digital medication management solutions support healthcare providers with virtual teams to monitor blood pressure and adjust medications to help bring patients into control within months rather than years.”
PHTI evaluated 11 digital health tools: Blood pressure monitoring devices from AMC Health, HRS and VitalSight; medication management tools from Cadence, Ochsner Digital Medicine and Story Health; and behavior change tools from Dario, Hello Heart, Lark, Omada and Teladoc (Livongo). The three categories were evaluated for clinical effectiveness and economic impact.
All three categories were found to increase net health spending initially, though the medication management tools had the best potential to offset those costs with improved clinical outcomes over the long term.
In terms of clinical effectiveness, the blood pressure monitoring devices were found to be slightly better than usual care in reducing blood pressure but not enough to be clinically meaningful, while the behavior change tools saw limited incremental declines in blood pressure.
Executives in HealthLeaders' Mastermind program on AI in RCM and finance operations say the technology will help them integrate with other departments in the health system and even work with patients to pay their bills.
Imagine an AI tool that can calculate a patient’s bill factoring in insurance coverage, a health plan’s tendency to deny a certain claim, and social determinants of health that may factor into the patient’s ability to pay. Then imagine that tool helping a hospital to work with the patient on a payment plan, compare its pricing structure with competitors and track social media mentions.
AI is seen as a tool to reduce administrative work and help clinicians get in front of their patients, but in the revenue cycle management and finance space, sometimes it’s hard to see beyond the dollars and cents and measure AI’s true impact.
Participants in HealthLeaders’ Mastermind program on the use of AI in RCM and financial operations connected those dots during a recent roundtable in Chicago, where they discussed the evolution of a technology already well-entrenched in their departments. One aspect of that conversation was to use AI to bridge the financial and clinical sides of the hospital.
AI has been put to work in the RCM and finance space over the past few years to address administrative tasks and do the number-crunching and data retrieval that would normally occupy staff time. Now the focus has shifted to generative AI, in which RCM and financial data is used to give staff pathways to better results; and on the horizon is predictive AI, which will give staff better ideas about where those pathways end.
Not only will the technology evolve, but how health systems and hospitals use it will change as well.
Beyond the applications in coding and denials management, executives see an opportunity for AI to learn how payers deny claims and help RCM staff proactively address, even avoid, those denials, or to tackle the complexities of the prior authorization process to reduce friction. As these tools evolve, Jane Lombardo, director of revenue cycle optimization at Stanford Health Care, said RCM staff will become “stewards” of the technology, overseeing how it’s applied and monitoring its effectiveness.
Steven Kos, MSHCA, CHCIO, senior director of revenue cycle applications at Florida’s Baptist Health, said the development of AI tools will also compel healthcare organizations to rethink RCM and finance skillsets, perhaps adding staff who are skilled at revenue cycle informatics, revenue integrity and patient advocacy or engagement.
Shannan Bolton, Stanford Health Care’s vice president of optimization and performance improvement, sees AI becoming a powerful tool for education and financial counseling, helping patients to both understand their financial responsibilities and the options available to them for paying their bills.
“That’s where we fall short with patients,” she said.
And Christina Slemp, MHA, MSHI, vice president of revenue cycle for Tennessee-based Community Health Systems, added that AI can help reduce the stress for patients by giving them the information they need quickly, rather than waiting around for explanations.
In fact, RCM are in the unique position to integrate clinical and financial data, helping both patients and their care teams. Some health systems are already experimenting with ambient AI to capture the doctor-patient encounter and code that encounter at the same time.
That strategy can also apply to patient scheduling, Bolton says, identifying a key element of the revenue cycle and a hotspot. Patient scheduling drives revenues when handled in an efficient manner, but it can also cause headaches when patients struggle to schedule their appointments or miss them. Ai tools that enable patients to self-schedule and help providers coordinate their workflows.
Beyond helping patients to schedule their appointments, RCM and financial executives say AI will become critical in reducing the complexity around billing and collections. That includes working with payers to fine-tune coverage and reduce denials and working with patients to make sure they understand and can pay their bills.
And that’s where the technology may make the biggest impact in the future.
Kos and Clark Casarella, PhD, senior data scientist at Sanford Health, said Ai will be used to improve the way hospitals and health systems work with patients on their financial responsibilities, creating a patient scorecard of sorts that researches in real time their ability to pay a bill. And Bolton pointed out that the technology can help organizations better understand why a patient has financial insecurity, thereby addressing the underlying social determinants of health that affect the revenue cycle process.
At the end of the day, patient financial responsibility is just one small part of a healthcare organization’s RCM and financial operations, but it’s an important and often-overlooked part. And it’s one that will become more important as the healthcare landscape shifts closer to patient-centered and value-based care. AI has the potential to help, giving both patients and providers the data and tools they need to work together.
The HealthLeaders Mastermind program is an exclusive series of calls and events with healthcare executives. This AI in Finance Mastermind series features ideas, solutions, and insights on excelling your AI programs.
To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com
