Revenue cycle leaders are feeling the heat from payers, leading them to pursue more and more technology.
Healthcare organizations are deep in the trenches of technology implementation of all types, and revenue cycle leaders are tasked with finding the best solutions for their organizations, along with managing and measuring performance.
However, with technology continuously evolving, many leaders are learning that yesterday’s investments may not be able to streamline today’s complex processes, especially when it comes to payers.
During the 2023 HealthLeaders RevTech Exchange held in Raleigh, North Carolina, three main pain points emerged: building versus buying tech, making tech work for you, and leveling the playing field with payers.
Build or buy?
With new developments and innovations in revenue cycle technology, many leaders voiced their struggles with finding solutions that are “forward thinking” and able to keep pace with complex processes.
For these reasons, some organizations have looked into creating their own technology in house, much like how Lynn Ansley, the VP of revenue cycle management at Moffitt Cancer Center, helped facilitate its in-house creation of a clinical trial workflow tool.
It’s not an easy lift, though. For those considering developing their own solutions, the lack of technological expertise within their organization holds them back.
If building your own technology in house is not an option, executives in one focus group agreed that determining what tasks can be automated should be the first step, followed by finding a partner who can develop the solution or has a platform with the capabilities an organization needs.
It is also important to take the patient experience into account and factor their needs into the decision making and development process. Having staff in present in settings like appointment check-ins and registration maintains patient’s relationship with their provider.
Making technology work for your organization
The strategy for digitalization must be clear, and that begins with examining the processes within your organization and workflow. The importance of defining the “why” (what is it your organization is trying to accomplish?) and recognizing current processes that may be broken was also emphasized.
One way of doing this is, as Savanah Arceneaux of Ochsner Health illustrated, by utilizing the different revenue cycle management features within your organization’s EHR.
In a presentation, the director of pre-service and financial clearance for the health system walked attendees through the benefits of stepping up its EHR utilization.
“Streamlining EHR data into revenue cycle processes improved patient experience with better patient-provider communication, workflow efficiency, and management of prior authorizations and billing processes,” Arceneaux said.
These efforts also reduced the administrative burden of revenue cycle processes through automation, as well as medical errors.
“If you have a broken process, then technology can’t help,” one leader said during a roundtable discussion.
As an organization’s digitization efforts progress, there needs to a way to measure the solution’s performance and results. There should also be controls in place to make sure that organizational knowledge and information remains the property of the organization. This way, if one solution or vendor doesn’t work, there won’t be as much trouble moving to another.
Many leaders agreed that the purpose of revenue cycle solutions should be to allow revenue cycle staff the bandwidth to perform other tasks. In doing so, leaders should be explaining to staff that they’re not being replaced, but that the nature of their work is changing and will allow them to grow their capabilities.
Keeping pace with payers
A common grievance amongst the leaders were the increasing difficulties combating payers and denials management. While revenue cycle technology is now commonplace, the executives said they’re still struggling to keep up with the technology of payers, for example AI algorithms that deny claims without review and emergency department downcoding.
According to Jonathan Benton, assistant vice president of Atrium Health, there’s one way to fight back: by beefing up your own automation.
Revenue cycle leaders should automate tasks to reduce work burden on people and prioritize processes to steadily speed up revenue cycle operations while reducing the cost-to-collect, Benton says.
Another way to fight payers, he says, is to automate processes across the business office to interact with other departments and with payers to resolve claims and optimize staff resources across revenue cycle.
While the payer/provider relationship isn’t likely to improve anytime soon, adding in automation to level the playing field is key.
One rev cycle leader provides three tips for success after investing in the digitalization of his organization's billing cycle.
With patients paying more for the cost of healthcare and treatment, the patient financial experience is more important than ever. This means the need for a seamless billing process has increased.
Lack of transparency in the billing process can make accessing and paying for care a stressful experience, one that can disengage patients from their providers James Rohrbaugh, CFO and treasurer for Allegheny Health Network (AHN), previously told HealthLeaders.
AHN recently invested in a patient billing solution that provides patients with a connected financial experience integrating their payer, provider, and financial institution all in one place.
“It was clear to us that the patient billing process is broken, and that providers and payers alone can’t solve the systemic challenges,” Rohrbaugh explained.
AHN, alongside Highmark Health, implemented a financial engagement platform which uniquely allows them to integrate patient’s claims and explanation of benefits data between the AHN providers and Highmark members.
For revenue cycle leaders considering digitalization efforts in their own organizations, here are three ways to ensure success with revenue cycle technology solutions.
Partnership
Organizations should look for vendors with expertise and shared interests.
“Finding a vendor that understood consumer preference and understood it in other industries as well as the healthcare industry was important to our success,” Rohrbaugh said.
Incentivize
Develop key performance indicators where both parties are incentivized to achieve results.
“The success of it is measured by the results and both parties, the vendor and the provider in this case, both share [in it] and the improvement seen from the process.”
Review
Both parties should review the results and implement changes as needed.
“We use a monthly cadence of meetings where we look at the analytics from the process and we say what’s working well, what’s not working well, what can we change, and what can we do differently.”
Revenue cycle leaders are currently meeting to discuss insights and pain points, and two major challenges have already emerged.
Some of the nation’s leading revenue cycle leaders are gathering at the Umstead Hotel and Spa in Cary, North Carolina for the HealthLeaders’ 2023 Revenue Cycle Technology Exchange where their dissatisfaction with automation and payers were in the hot seat.
The revenue cycle leaders said they have been struggling to keep up with rapidly innovating and evolving technological solutions, developing digitalization strategies, and managing ever-present payer challenges including denials and prior authorization.
Organizations are all jumping aboard the automation train, but struggling to find the technology or solutions with the capabilities to complete or streamline the tasks they need. Some providers are finding that their organization’s solution is unable to evolve to accommodate the rapidly evolving issues throughout the rest of the sector.
Photo courtesy of HealthLeaders. Associate content manager Amanda Norris leads the master panel sessions at the 2023 Revenue Cycle Technology Exchange.
In fact, an attendee survey conducted at the beginning of Thursday’s event allowed the 35 leaders to voice their revenue cycle concerns and observations. Automation efforts are going strong, with about 34% claiming their organization has 10-25% of operations fully automated, and almost 28% said they have automated 25-50% of their operations.
However, when asked about their level of satisfaction with the tools and technology their organization currently runs, only one attendee said they are very satisfied, while over 51% said they were either disappointed or very disappointed with their current technology.
While the majority of the attendees show some amount of dissatisfaction with their technology, they aren’t giving up.
Prior authorization was overwhelmingly selected as the area within revenue cycle that leaders would be most interested in fully automating by the end of 2024, and mostly in an attempt to streamline processes with payers.
Aside from these pain points, more topics were brought to the forefront of the event.
During the exchange kickoff, Kim Rometo was able to provide an outside, yet insightful, perspective to the conversation surrounding the use of AI.
As senior vice president and chief innovation and technology officer for the Atlanta Hawks and State Farm arena, Rometo provided examples of how her organization has used AI to analyze game strategies, modernize fan communication, and develop sports content and how these strategies can be utilized in the revenue cycle.
"There is immense potential for generative AI and automated solutions in healthcare, from streamlining tasks to increase operational efficiency, flagging patient biases, and even counteracting payer algorithms or solutions that make it difficult to approve claims," Rometo concluded.
We’ll be back with more Rev Tech Exchange coverage including highlights from panel discussions featuring Savanah Arceneaux, director of pre-service and financial clearance at Ochsner Health and Jonathan Benson, assistant vice president of patient financial services at Atrium Health.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
To inquire about attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
We spoke with the organization about how they selected their automated solution, the key players involved, and results they've seen.
Pennsylvania based Allegheny Health Network (AHN) brings in $4.5 billion in annual revenues. Like many healthcare businesses, it has recently invested in the digitization of its revenue cycle, specifically the automation of patient billing.
To tackle the network's growing issue of uncoordinated bills and fragmented communications between patients, payers, and providers, they looked for a solution that would benefit providers and payers while also helping patients understand healthcare costs.
James Rohrbaugh, CFO and treasurer for AHN, explained to HealthLeaders that now that patients are shouldering more of the cost of their healthcare, not trusting the billing process and not understanding their benefits makes for a frustrating and stressful experience.
It can also cause the patient to disengage from the healthcare system, he added.
"It was clear to us that the patient billing process is broken, and that providers and payers alone can't solve the systemic challenges," Rohrbaugh said.
Technology selection
When brainstorming options for streamlining billing and insurance process, leaders from Highmark Health were involved in the decision-making process along with AHN staff from the communications, information technology, revenue cycle, and finance departments.
Previous strategies and technologies AHN implemented weren't curated for customer preference and, Rohrbaugh added, customer preference should be the main driver in patient-facing technology.
That's when Highmark Health and AHN partnered to implement a financial engagement platform from Cedar that improves the end-to-end journey for its patients. Patients now have a connected financial experience that integrates their payer, provider, and financial institution.
A unique element of the solution AHN chose is that they're able to integrate patient's claims data with explanation of benefits data seamlessly between Highmark and AHN.
Customer preference regarding how patients can choose how they communicate with the AHN network had previously been an area that AHN had been behind the curve on, Rohrbaugh said. The network's new tool assists with this and includes a portal where patients can choose a payment plan and access different self-service tools to meet other healthcare needs.
Once decision-makers found the patient billing solution that aligned with the AHN's goals, during the implementation process, they identified specific priority areas for the network to focus its efforts on collectively.
Testing the tool with a pilot group of patients, they measured the results to see what was and wasn't working, making the necessary adjustments to meet their objectives.
Investing
When considering an investment like this, financial leaders must consider cost and return on investment. According to Rohrbaugh, building a contract with your vendor partner where both parties share in the success, and failures, is also important.
"Ongoing tracking of the KPIs that will drive value and financial [growth] is a critical part of return on investment," he added. "I would also say having operational metrics as well, because we need to balance the financial metrics with making sure that the patient engagement and patient satisfaction is equally important."
Absence of this, he said, creates situations where people don't want to access care.
Outcomes
Since implementing the tool into the network's operations, AHN has seen a $17 million increase in patient payments, a 33% lift in the utilization of HSA/FSA accounts, and an 11% reduction in call center inquiries. Patients have also been satisfied with the new payment process.
The healthcare landscape is ever evolving, and revenue cycle leaders need to be creative when bolstering the patient financial experience.
As more organizations are looking to improve patient experience, revenue cycle and finance leaders are getting creative with new payment options.
Complex billing processes can translate into a disjointed patient payment experience. In fact, a recent report by US Bank found that common complaint amongst patients is that their bills are “confusing and unclear,” leading 55% of finance leaders to reevaluate their vender and customer payment experience altogether.
The accessibility and ease of use of an organization’s payment method makes a difference in the speed of an organization’s payment reconciliation process, and in turn is a crucial part of the revenue cycle.
In an effort to keep up with the ever-changing landscape, more organizations are looking to be more creative with their payment options.
According to the report, 54% of providers have already begun utilizing cash sharing applications like Zelle and Venmo for patient payments, and those who haven’t are planning to do so in the future.
Not ready to make the leap to Venmo? That’s OK but streamlining the patient payment process in any way is a must for the revenue cycle.
HealthLeaders previously spoke with Drew Smith, director of revenue cycle at Main Street Family Care, on its decision to implement a text-based bill pay process with its patients. Smith said the goal wasn’t to just increase payment speed but reduce cost to collect as well.
“Paper statements cost $6 per statement for our organization based on paper and postage costs, the time it takes to post physical checks and respond to returned mail and the need for a lockbox,” he explained.
Smith added that Main Street Family Care isn’t charged for having the wrong number for a patient or if the text wasn’t delivered successfully. Since starting their mobile pay option in 2019, 14% of their patients use it to pay their bills. Within that group, 80% pay before a paper statement is ever printed.
Revenue cycle technology is everywhere, but it’s not without financial risk.
While many organizations are implementing technology to save money or streamline processes, assessing the risks of new technology is the first place revenue cycle and finance leaders need to start.
Revenue cycle leaders know there’s zero room for error with a costly investment, luckily there are three factors that can help ensure technology success.
In a new report by US Bank, healthcare finance teams ranked the pace of technological innovation and digital disruption as their third-most important business risk.
According to Shawishi Haynes, EdD, MS, FACHE, director of revenue cycle operations for Valley Presbyterian Hospital, there are numerous tasks within the revenue cycle that can benefit from technological solutions but, the state of an organization’s finances and current utilization of technology will determine whether the investment is worth the risk.
“It will take time to see every organization using technology in the same way due to the differences in organizational philosophy, financial position, and technological growth,” Haynes told HealthLeaders.
So how can revenue cycle leaders best asses the risks of new technology and ensure success? According to the report, there are three factors that can slow organizations down and hinder success:
Unclear strategy
Revenue cycle leaders should work with their chief financial officer and other C-suite leaders to ensure that the potential investment will be in alignment with future tech-focused plans for organization.
Failure to get employees onboard
Reluctant employees were considered the second biggest obstacle to successfully integrating new technology into operations. To encourage usage, employees whose responsibility it will be to use the new technology should be included in the decision-making process.
Lack of expertise
There needs to be employees or a group of individuals within the organization with extensive knowledge about the technology being used. Another way to continue to get employees onboard would be to get the organization’s technology and digital teams to access the needed expertise.
Other factors that can slow down an organization’s technical advancement include lack of budget, fear of business disruption, and figuring out what the return on their investment will be.
The latest code sets include Spanish-language descriptors and streamlines SDOH data capture.
Documentation and coding are a crucial element to the revenue cycle, making it even more important for leaders to stay up to date with changes and new additions to the code sets.
Here are some of the most recent HealthLeaders stories on coding, including updates for 2024.
The American Medical Association released the 2024 code set in early September, with over 300 updates including 230 additions. Over 50 codes related to COVID-19 vaccination were consolidated, and rev cycle leaders should be sure to review the clarifications made regarding the reporting of evaluation and management services.
Spanish language descriptors were also incorporated into the code set in an effort to improve accessibility for Spanish-speaking patients.
Another code update includes the 2024 diagnosis code set. These changes affect the way certain diseases, accidents and injuries, and social determinants of health (SDOH) are reported.
To better address patient’s social need and broader social determinants of health, 30 new diagnosis codes were added for factors influencing health status and contact with health services. There are also special guidelines for reporting these codes.
In early October, CMS published an infographic illustrating ways organizations can improve upon the ways they collect SDOH data.
SDOH data enables revenue cycle leaders to better predict healthcare utilization patterns and allocate resources more efficiently to ultimately lower healthcare costs. CMS’ recent attention to SDOH data suggests there may be focus on future reimbursement for these services.
Patient access errors are a top reason for denials, which could be costing revenue cycles a lot of cash.
Mistakes during patient access or registration are the main cause of initial claims denials by payers, a new survey found.
This doubles down on the idea that revenue cycle leaders need to address denials management and embrace tech solutions, and they should have done so a long time ago as the financial implications of denials is huge.
Over 350 chief financial officers and financial leaders at health systems and hospitals across the nation ranked the common reasons for initial payer denials and the top five reasons, in order, were as follows:
Errors in patient access/registration
Lack of documentation to support medical necessity
Missing or incorrect patient information
Physician documentation issues
Utilization management
Other reasons mentioned included coding errors, duplicate claims, and untimely filing of claims.
Its obvious that issues with eligibility and registration occurring at the front end of the revenue cycle are affecting the reimbursement process, so what can revenue cycle leaders do?
The key to avoiding these denials may lay in automation.
Patient access plays a tremendously important role within the revenue cycle, Alicia Auman, former director of patient access at KSB Hospital in Dixon, Illinois, previously told HealthLeaders.
"If you can get it right up front, you're ensuring accuracy, preventing rework, and preventing denials," Auman said.
KSB Hospital implemented front-end technology that included automated claim verification, front-end claim scrubbers that catch errors immediately, and tools to collect copays and payments at the point-of-service.
KSB now has real-time edits that prompt the registrar to talk to the patient at the point of service, as well as eligibility verification, which automatically checks eligibility.
“Access related denials were around 21%, now they're around 7% of total denials,” Auman said.
And since implementation, KSB’s technology has prevented an average of $800,000 per month in denied charges, with more than $20 million in total savings that would have been denied, Auman explained.
Patient access errors are a top reason for denials, which could be costing revenue cycles a lot of cash.
Mistakes during patient access or registration are the main cause of initial claims denials by payers, a new survey found.
This doubles down on the idea that revenue cycle leaders need to address denials management and embrace tech solutions, and they should have done so a long time ago as the financial implications of denials is huge.
Over 350 chief financial officers and financial leaders at health systems and hospitals across the nation ranked the common reasons for initial payer denials and the top five reasons, in order, were as follows:
Errors in patient access/registration
Lack of documentation to support medical necessity
Missing or incorrect patient information
Physician documentation issues
Utilization management
Other reasons mentioned included coding errors, duplicate claims, and untimely filing of claims.
Its obvious that issues with eligibility and registration occurring at the front end of the revenue cycle are affecting the reimbursement process, so what can revenue cycle leaders do?
The key to avoiding these denials may lay in automation.
Patient access plays a tremendously important role within the revenue cycle, Alicia Auman, former director of patient access at KSB Hospital in Dixon, Illinois, previously told HealthLeaders.
"If you can get it right up front, you're ensuring accuracy, preventing rework, and preventing denials," Auman said.
KSB Hospital implemented front-end technology that included automated claim verification, front-end claim scrubbers that catch errors immediately, and tools to collect copays and payments at the point-of-service.
KSB now has real-time edits that prompt the registrar to talk to the patient at the point of service, as well as eligibility verification, which automatically checks eligibility.
“Access related denials were around 21%, now they're around 7% of total denials,” Auman said.
And since implementation, KSB’s technology has prevented an average of $800,000 per month in denied charges, with more than $20 million in total savings that would have been denied, Auman explained.
In a survey commissioned by AKASA, 78.7% of financial and revenue leaders said denials management required the most subject matter expertise. The same survey found that only 38% of hospitals and health systems are currently automating denials management.
With the risk of inefficiencies and mistakes, investing in artificial intelligence or other technological solutions could potentially save organizations time and money, enabling them to utilize physical staff more efficiently.
According to the 2023 Plutus Health Revenue Cycle Management Challenges Index, 40% of providers are losing over half a million dollars each year due to claim denials and 18% losing over a million.
Claim denials remain a significant issue for providers, making denials management the top priority for many revenue cycle leaders. Some organizations have embraced technological solutions, but the index also reports that others are hesitant to do so; despite benefits like improved efficiency, fewer errors, and accelerating cash flow.
Two Cigna members filed a class action lawsuit against the insurer for failing improperly denying their claims due to its PXDX algorithm. The algorithm allegedly allows doctors to automatically reject payments in large groups at a time, without opening or reviewing patient files.
This isn’t the first time PXDX has been scrutinized. In March it was reported that 300,000 requests for payment were denied over two months, with the algorithm spending 1.2 seconds reviewing each case.
A report by the Office of Inspector General found that Medicare managed care organizations (MCOs) denied one out of every eight prior authorization requests in 2019. The report illustrates a lack of denial oversight in most states.
Of the 115 MCOs reviewed in the report, 12 had a prior authorization denial rate over 25%. It was also found that state Medicaid agencies didn’t review the rates, and many failed to collect and monitor related data.
