In the latest installment of our interview series for HealthLeaders AI and Finance Mastermind program, we spoke with Jacqueline Samuel, director of revenue cycle quality, strategy, and analytics for the system's billing subsidiary.
Many hospitals and health systems are looking to invest in artificial intelligence to optimize their revenue cycle operations. And while many are partnering with vendors, some are developing their solutions in-house.
Over the last few years, One Grady, the billing subsidiary of Grady Health, and its in-house developers have focused on robotic process automation (RPA) solutions. Now, the system is considering the possibility of expanding into AI.
AI and automation are often used interchangeably despite having different capabilities. Automation focuses on using technology to perform specific, often repetitive tasks, taking the pressure off of staff to do those same tasks. The introduction of AI takes that process further, using technology to generate results or take those tasks to the next level. Eventually, that technology will be used to recommend the next course of action or even predict outcomes.
As health systems and hospitals expand their use of AI, they'll be using the technology to not only improve processes but improve outcomes. In adding AI to their RCM solution lineup, One Grady aims to look beyond the technology's current capabilities and tap into its potential capabilities, says Jacqueline Samuel, director of revenue cycle integrity, stategy, and analytics and a participant in the HealthLeaders Mastermind program on using AI in finance and revenue cycle operations.
“What else can these solutions do as far as thinking for us and giving us the next steps, vs. the kind of programming that has to go into RPA processes?” she stated.
She’s particularly looking forward to using AI to improve denials management and data analytics.
“Our next steps would be exploring how to leverage machine learning to do predictive analysis so we’re taking that manual analysis off of our teams,” she said. “The less time we spend doing that work manually, the more we can focus on complex analyses, automation, and implementing AI solutions.”
One Grady’s staff meet quarterly to discuss prioritization as well as submit suggestions for solutions in development, detailing the process they’re hoping to implement and what the return on investment is. The forms are then reviewed during governance meetings and potentially added to the development pipeline.
Having leadership think through ROI helps ensure that it’s worth the effort for developers to build and implement, and that there isn’t an alternative solution. The success, or efforts, of the solutions are measured by revenue impact.
“Where was that revenue or where were those denials at before we implemented this solution, and where is our revenue impact now?” Samuel explained. “We created a dashboard that shows us on a month-to-month basis what the revenue impact is for each one of our automations.”
Their biggest challenge, Samuel says, is the size of their development team. One Grady’s has seven in-house developers, which could be considered small in comparison to larger, non-safety net organizations.
The developers also support the over health system, which consists of a hospital with significant patient volume, and several neighborhood clinics.
“We only have so many resources and time available. We have an excellent team with and excellent skill set, [but] we need them to be able to focus on certain things,” Samuel explained.
Another challenge is the learning curve that comes with the implementation of a new solution, particularly the number of staff that have to be trained and the time it takes to do so. However, Samuel says that as the solutions get smarter, so do the staff.
With the solutions being developed in house, accountability falls on the One Grady team should anything go wrong; an issue they have, thankfully, not had.
“We identify the issue, make sure we’re communicating with stakeholders and then do what we need to do to fix it,” Samuel said. “Sometimes that can take time, but we just make sure that we’re communicating our status updates with them and letting them know the breadth of the issue.”
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The vendor marketplace is growing and evolving, and leaders need to develop a strategy to find what they need.
Shopping is a breeze when you know what you're looking for. The same could be said for shopping around the revenue cycle management solution market. Leaders should take stock of their revenue cycle operations and identify the issues they want to address, but also consider how an RCM solution will work support their organization's operations as a whole.
In a letter the organization expresses concern over information unknown to the provider being used to estimate the cost of care.
Facing strict federal oversight, hospitals and health systems are prioritizing price transparency efforts, making estimation tools and pricing information available and easily accessible to patients. The work is often easier said than done.
In a letter earlier this month, the Workgroup for Electronic Data Interchange (WEDI) offered recommendations to the Department of Health and Human Services over the use of diagnosis codes when providing good faith estimates (GFE):
“Diagnosis, location, and many other variables inform accurate pricing, and this information may not always be known to the degree necessary by the provider to reliably produce an [advanced explanation of benefits] that is accurate enough to satisfy its purpose,” WEDI stated in a letter to HHS.
The organization had the following recommendations:
Diagnosis codes should be included on the GFE for insured patients when services are scheduled. It is expected that providers will usually know the appropriate diagnosis codes at this point.
If known, diagnosis codes should be included on the GFE for shopping services. Providers should be encouraged to identify the diagnosis codes when a patient requests a GFE.
When a request for a GFE is made and the provider cannot determine appropriate diagnosis codes, the GFE can be sent, but the patient should be advised that the AEOB may not be due to the lack of a diagnosis.
It was also recommended that the federal government work alongside providers and shareholders explore whether or not current price transparency tools can be used to meet these needs.
This isn’t the first time price transparency efforts have been under scrutiny by the WEDI. In 2022, the group voiced its concerns over the regulation of good faith estimates and the patient-provider dispute resolution process, noting the former’s potential to increase the administrative burden on hospitals and health systems.
Price transparency has been a cause for concern among providers since the passing of the No Surprises Act in 2022. In April 2023, the Centers for Medicare and Medicaid Services (CMS) announced that noncompliant hospitals would have to complete a corrective action plan, impose earlier civil monetary penalties, and streamline the compliance process.
The number of No Surprises Act disputes continues to soar, with providers blaming insurers for taking advantage of the law.
Lifepoint Health was able to adapt its practices to the new regulations, having developed an internal price transparency team a year before the new rules were implemented.
“The team continues to meet regularly to confirm there have been no changes to the requirements,” Tina Barsallo, vice president of revenue cycle operations, told HealthLeaders. “And the revenue cycle team handles on-going monitoring of the websites and links, as well as the annual refresh.”
Payer tech is putting administrative pressure on providers.
Despite being an evergreen issue in revenue cycle operations, denials management issues seem to have reached a new level.
Payers are embracing new technology fare more quickly than health systems or hospitals, and that’s putting pressure on providers to handle an influx of denials.
“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, previously told HealthLeaders. “Which, ultimately, if something [happens] on their side, it takes time to resolve, which ultimately delays processing or receipt of payment on our side.”
Illinois-based Carle Health has seen a 22% increase in denials year-over-year, many of which ask for additional documentation or information. While the system uses RCM solutions to aggregate data and populate forms, their revenue cycle partners are still pulling a significant amount of weight.
The partners meet monthly to review prior authorization and denials, to monitor the progress of working through them and make note of any trends. System leaders and the operation teams are also included in the process so they can assist in the resolution of denials.
A recent report by Strata Decision Technology found that administrative costs make up more than 40% of a hospital’s total expenses when delivering care to patients. Denials from commercial insurers have seen an average increase of 20.2%, and those for Medicare Advantage claims have seen an average increase of 55.7%.
The reason for these increases? Machine learning algorithms and AI tools.
As more RCM products enter the market and become more accessible to hospitals and health systems, payers may lose their edge.
“I think it will level the playing field and there will come an equilibrium where the payers and the hospitals are keeping each other in check so no one is out of bounds,” said Bill Arneson, director of business operational transformation for Moffitt Cancer Center.
"We want our staff to perform at the top of their scale."
Bringing AI into revenue cycle operations has the double benefit of increasing efficiency and freeing up staff to work on more complex tasks. Shannan Bolton, Vice President of Revenue Cycle Optimization for Stanford Health Care, discusses how AI solutions have enabled the system to place staff where their efforts would have the greatest impact.
Does it really matter who develops the solution as long as it gets the job done? Let’s weigh the pros and cons.
The AI market is continuously expanding, with vendors tailoring their solutions to specific pain points. Some hospitals and health systems develop solutions in-house, while others look to outsourced products..
Payers are currently outpacing providers in their use of AI and automated solutions for revenue cycle and finance operations. However, Bill Arneson, director of business operational transformation for Moffitt Cancer Center, believes that the healthcare sector will catch up.
“I think it will level the playing field and there will come an equilibrium where the payers and the hospitals are keeping each other in check so no one is out of bounds,” he said.
When it comes to in-house development vs. vendor solutions, Arneson, who’s participating in the HealthLeaders Mastermind program on AI in revenue cycle and finance operations, believes it’s good to leverage both, but the best fit may vary by situation.
He prefers the in-house approach, which allows him to develop staff and add to internal knowledge that can be shared throughout the organization. This, in turn, also helps with security.
However, Arneson does note that in-house developers can be more expensive than partnering with a vendor and more time-consuming.
With vendors, he said, there’s much faster implementation, and their solutions are tailored to specific tasks and processes.
“If you have a vendor that’s very narrow in their scope, they’re going to be very good at the thing you’re hiring them to do,” he said. “You’re getting an expert and it’s very quick.”
A downside of working with vendors, Arneson continued, is being locked into a contract. Much like training and developing in-house developers, he also notes that it takes time to maintain positive relationships with vendors.
Moffitt leverages both in-house and vendors in their RCM operations due to the volume of work they have and the opportunity they have to scale their workforce per project.
“It’s a great thing that we can outsource and then our internal staff can do more development work or free them up for other things,” Arneson said.
The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This revenue cycle Mastermind series, sponsored by Flywire, features ideas, solutions, and insights on excelling your revenue cycle program.
To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com
The less time spent in accounts receivable, the sooner the payment becomes part of a provider’s cash flow.
Now that patients’ financial responsibility for their care has grown, patient collections are a top priority for revenue cycle leaders. Many providers have seen success in adopting or expanding the capabilities of their patient portals, turning them into one-stop hubs for care updates and payments.
In addition to being able to pay bills with ease, many patient portals have capabilities allowing patients to view detailed billing statements and communicate with a representative through bots or email.
Here are three stories that show how patient portals are simplifying the billing and collections process.
Ochsner Health’s MyOchsner portal allows patients to schedule visits, interface and coordinate with their healthcare team, and request prescription refills in addition to paying their bills.
Eduardo Benitez, director of physician payments, estimates patient portal utilization to be between 35-45%, with factors like a patient’s location or the department they need to contact coming into play.
For providers looking to focus their digital expansion on patient collections specifically, using electronic billing or mobile payment platforms offers a more siloed approach. When Lake Washington Physical Therapy was looking to improve its operating margins and decrease its accounts receivable, CEO Ben Wobker implemented an electronic billing platform.
According to Wobker, the platform, along with the efforts of billing staff, the clinic’s accounts receivable decreased by almost 50% within the first month.
With patients paying more out of pocket, there’s no room for error when it comes to billing. There are many pieces that have to come together before a patient receives a billing statement, each with their own complex process.
First, there’s the coding process, then a lengthy back-and-forth of communicating with payers to appeal any denied claims. While surveys have shown that patients prefer price transparency from the beginning, some organizations are still struggling in their efforts.
Return on investment doesn't just have to impact revenue.
The capabilities and evolving potential of AI may seem like a remedy for revenue cycle optimization, but it isn’t that simple.
When judging a vendor’s proposal, Shannan Bolton considers the following: What is the current state of revenue cycle operations, what are the challenges she’s wanting to address, and how would the solution being presented support the system’s efforts.
Bolton, vice president of revenue cycle optimization for Stanford Health and a participant in the HealthLeaders Mastermind program on AI in revenue cycle and finance operations, also notes that the return on investment doesn’t have to impact revenue, but simply be beneficial to the system.
“[Let’s say] there’s a tool that we have in place, but its [performance] is stagnant. I’m looking for continuous optimization,” Bolton said. “So, I’d look at it holistically: What are they offering or doing for other organizations that our current vendor hasn’t thought of or isn’t moving towards even if the changes are small or in a focused area.”
After market research, deciding on a vendor, and signing on the dotted line, you’re ready to begin the implementation process, which is where the real work begins.
At this stage, a service line agreement with the vendor will detail expected deliverables and timelines, from the official launch of the solution.
Bolton emphasizes the importance of SLAs as an accountability measure for both health systems and vendors.
“If we’re not able to implement [it] on time, and it’s because [the vendor’s] team wasn’t ready to go, then maybe our first payment doesn’t start till six weeks later than we planned,” she explained. “These are the commitments that I’m going to build into those service line agreements.”
A common misconception around AI is that it is self-sufficient once implemented, but there are limitations to the technology which require oversight. For example, Bolton notes that most AI solutions manage simpler tasks, but not middle revenue cycle tasks that require more detail and clinical knowledge.
“That space becomes more complex and the rules can change often by payer, location, or specialty,” she said.
Technology managing the simpler, repetitive tasks leave staff available to handle more complex tasks, like denials management. However, you can’t successfully implement a new solution without staff support, and leaders must be open and transparent in their conversations and messaging.
“We want our staff to continuously perform at the top of their scale.” Bolton said. “This means proactively developing the staff to upskill them once we bring in AI to perform that more simplistic work.”
Whenever the system starts a project related to AI or automation, they begin by assessing the current staff’s experience and expertise. This allows leaders to repurpose staff by placing them in areas where their skills are needed, provide additional development opportunities to those wanting to move to the next level or empower staff to make other career decisions that better align with their current skills and goals.
“From a humanity standpoint, it’s so important,” Bolton said. “Making sure that the staff know we have their best interests at heart, that we’re going to develop you, support your career development, even if that means it’s not in this organization.”
The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This Virtual Nursing Mastermind series features ideas, solutions, and insights on excelling your virtual nursing program. Please join the community at our LinkedIn page.
To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
Patients are becoming responsible for more of their healthcare costs. And that’s driving hospitals and health systems to put more emphasis on the financial experience.
As a result, the concept of patients as consumers has made its way into business and finance strategies.
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, said. “Quite honestly, I think it’s a benefit to our patients to make sure they’re fully informed in advance of services.”
Patients are already under financial strain. This puts hospitals and health systems in a precarious position where they must mitigate costs to patients, while also maintaining competitive pricing.
Ensuring value to patients across all services is one of the system’s goals, Klein added.
The reimbursement process between providers and payers can be difficult for patients to understand as well. It’s up to providers to make sure patients are fully informed and can understand their out-of-pocket expense, Klein said, whether it’s before care is provided or after the service.
To assist with this goal, staff are educated on the patient financial experience so they’re better equipped to assist patients in their understanding of copays, coinsurance, deductibles, and out-of-pocket expenses.
“We do have an obligation to try to educate them to the best of our ability because it does come back to patient relationships and ensuring that they continue to have access to care over the long term,” Klein said.
Calendar year to date margins have remained slightly above 4% since February 2024.
After a rocky few years post-COVID, hospital operating margins are trending in a positive—and profitable—direction. However, leaders shouldn’t let up on their financial budget and revenue strategies.
In its annual National Hospital Flash Report, Kaufman Hall published a calendar year to date operating margin index, illustrating a steep increase from 2.7% in December 2023 to 4.9% in January 2024. After a slight decrease in February 2024 to 4.4%, margins have consistently remained just above 4%.
Regional operating margins were mostly positive, with hospitals in the Great Plains being the exception, having a margin of -7%. The report noted that 340B settlement payments also contributed to improved margins.
Containing Costs
Hospital leaders have seen success monitoring and containing expenditures. Revenue cycle management technology can be beneficial here, particularly automated solutions which can complete redundant administrative tasks with quick efficiency.
At One Grady, a subsidiary of Atlanta’s Grady Health System, staff rely on automated solutions within the EHR and those created by in-house developers to streamline workflows, minimize staff effort, and cut costs.
“Beyond that,” Monica Richey, vice president of physician revenue cycle for One Grady, said. "We’re having to be very intentional and strategic about the way in which we handle denials and really dig into how we operationalize our workforce to be able to manage those denials.”
In addition to sporadic policy updates, payers are implementing technology into their operational processes, outpacing the solutions hospitals and health systems are using. Because of this, leaders are leveraging the efforts of staff and solutions to their full capabilities.
While the RCM solutions can aggregate and cross-reference information from different sources, staff can form siloed teams to analyze claims and prior authorization denial data for trends.
Revenue cycle specialists at Carle Health take this strategy a step further by bringing system leaders into the process so that they’re able to assist with resolving the denials.
“Payers rely on technology solutions just like we do to manage processes on their side,” Aron Klein, the system’s vice president of finance operations and supply chain, said. “Which ultimately if something [happens] on their side, it takes time to resolve, which ultimately delays processing or receipt of payment on our side.”
