Payers and providers are stuck in a tug of war over claims, with AI as the driving force for each side.
Revenue cycle technology continues to evolve and innovate, and payers are keeping pace adopting artificial intelligence and pitting automation against automation.
With tools like AI algorithms, payers can deny claims in large batches and without human input.
“There is immense potential for generative AI and automated solutions in healthcare,” Kim Rometo, senior vice president and technology officer for the Atlanta Hawks and State Farm arena, said during the 2023 HealthLeaders Revenue Cycle Technology Exchange in November. “From streamlining tasks to increasing operational efficiency, flagging patient biases, and even counteracting payer algorithms or solutions that make it difficult to approve claims.”
In November, United Healthcare came under fire when a federal class action lawsuit was filed against them. Allegedly, after purchasing an AI algorithm to evaluate insurance claims, older patients’ claims for doctor-recommended stays in extended care facilities were wrongly denied, leaving patients with unexpected medical debt.
A statement from the Clarkson Law Firm, the firm that filed the lawsuit, explained that there’s a 90% reversal rate when these denials are appealed and that only 0.2% submit their claims for appeals. Additionally, medical oversight is only introduced during the appeals process.
“While AI technology holds incredible promise to advance the healthcare industry, United Healthcare’s algorithms is a prime example of the real harm it is causing when left unchecked,” Glenn Danas, partner at Clarkson Law Firm, the firm that filed the lawsuit, said in a statement.
Many revenue cycle leaders voiced their frustration with payers algorithms during November’s exchange. During his presentation to attendees, Jonathan Benton, assistant vice president of Atrium Health, provided five methods leaders could use to combat payer issues.
Best practices for the successful implementation of technology into your revenue cycle.
While helping the Healthcare Financial Management Association (HFMA) and FinThrive develop its Revenue Cycle Management Technology Adoption Model, Shanda Richards, understood that what health systems need is to free staff from repetitive tasks to handle more complex tasks.
The revenue cycle director at Central Peninsula Hospital in Soldotna, Alaska offered these best practices for leaders to consider when implementing revenue cycle technology solutions:
Have a strategy
"Don't just go off being reactionary, where you're solving the next problem with software. [Focus on] what you really need instead of being sold on what somebody's trying to sell you. Then, interview multiple vendors to get demonstrations and have a list of your deliverables ready."
Put aside your pride
"Don’t try to prove all the good work you've done, because if you're overselling what your current functionality is, or your current automation levels, then what you get out of it is only as good as what you put in. If you're overstating or being prideful about it, then you're not going to get good results, and you're going to miss things that you do need that you don't fully have but you said you already did."
Learn from the technologies you’re looking into
"There are things in the FinThrive Survey that are very emerging technologies, and I read some of them and like the name of them, and I didn't even know what they were. Then I hovered over it, [read] the description, and didn't realize that our industry could do that.
They built the survey to last into the future, so things that were brand new on the market, they added into the survey so that it would be relevant three to five years from now."
Get staff onboard
"An analogy that I used to give my new hires ... is that working in revenue cycle in healthcare is like being a private investigator without the fear of getting hurt.
I need you to discover and figure things out, but as the years have progressed now I have to say I need you to be a private investigator, but 80% of the time you're going to be a mall cop and you're just going to be writing tickets all the time.
But you're really going to love that 20% where you actually get to use your brain and sleuth around.
And so I assure you if you use that analogy and then talk about the software implementation, it's going back to the fact that ... software and technology [can] take care of the parking tickets so that you can go back to being the private investigator."
Editor's note: This story was updated on 12/21/2023.
"Finding the right vendor to implement and be your partner is so important," one leader says.
As the world of revenue cycle technology continues to evolve and innovate, providers and organizations struggle to find the best solutions for their needs and how to assess their efficacy.
In partnership with FinThrive, Inc., the Healthcare Financial Management Association (HFMA) has launched its Revenue Cycle Management Technology Adoption Model; a peer reviewed, five-stage guide for health systems to “leverage industry benchmarks to assess their current state of RCM technology maturity.”
Shanda Richards, Revenue Cycle Director at Central Peninsula Hospital in Soldotna, Alaska, has been involved with the model’s development, serving as a beta tester and offering feedback throughout the process. When it comes to revenue cycle solutions, from what she’s seen, organizations are mainly looking at technology solutions with features to help with price transparency, software capabilities to automate prior authorization, and claims and denial management.
“We need to take the mundane aspects of these requirements that we have and the repetitive tasks that have to be done and automate them so that our staff can be freed up to perform the analytical portion of that requirement,” Richards told HealthLeaders.
Like most hospitals, Central Peninsula Hospital has been diligent in its efforts to digitalize its revenue cycle. In 2016, the hospital converted Meditech to Epic for their electronic health records. Since then, they have gradually implemented new functions within Epic’s software.
The hospital also tried out smaller, stand-alone solutions from different vendors, but found that they didn’t work as well as advertised or that they weren’t seeing a good return on investment.
There are numerous vendors in the revenue cycle technology market, but most are alike in that they taut the ability to build whatever solution an organization needs. However, because this is a new and continuously evolving market, Richards said, risks like developmental delays and steep learning curves are high.
“Finding the right vendor to implement and be your partner is so important,” Richards said. “If you have a vendor that keeps going through mergers and purchases to where your account manager keeps changing … that’s hard.”
“My best success has been with vendors where I have very strong relationships with the people behind the scenes.”
The model will also help health systems develop their own best practices to optimize their revenue cycle outcomes. The ongoing staffing shortage has more hospitals pressed to implement technology in their revenue cycle, as well as to prevent burnout in current staff, Richards added.
Going forward, she hopes that full-time equivalent (FTE) benchmarking will be implemented as a key performance indicator.
“[You] can use that in trying to get approval from the administration of your C-suite for the cost of a product,” Richards said. “Because a lot of times they ask what the return on investment [will be], and if you have a way to measure that, this a way you can say.”
As 2023 comes to an end and the holidays creep closer, revenue cycle leaders should consider adding these three challenges to their organization’s list of New Years resolutions.
Out Automating Payers
Much like healthcare organizations, payers have also begun adopting automated solutions, exacerbating denials management issues and prolonging payment for the care provided. Leaders voiced their frustration in November at the 2023 Revenue Tech Exchange in Raleigh, where Jonathan Benton, assistant vice president of Atrium Health offered five ways leaders can strike back, primarily by fighting automation with automation.
Another way to prevent denials, as HealthLeaders previously reported, is provider education, which can include sharing data on the financial impact of documentation inconsistencies and explaining how they can be prevented.
Updating the Patient Financial Experience
With patients covering more of their healthcare costs, price transparency and payment portals have grown in importance. A previous article on a patient payment communications report found 41% of patients didn’t feel like their provider was being transparent about the cost of their care, despite 59% of patients believing that they were.
There have been advancements in payment methods, with providers slowly adopting cash sharing applications like Zelle and Venmo for their accessibility and ease of use.
Strengthening Digitalization Strategies
Over the last few years AI, automation, and revenue cycle management have been used in the same sentences as organizations consider ways to streamline their revenue cycle processes. Efforts like these require a significant investment of time, people, and money, and many organizations struggle with developing a strategy.
When Allegheny Health Network began its digitalization efforts, they focused on patient billing and communications, which had become a growing issue. From there, leaders from both AHN and Highmark Health were involved in the decision-making process and they were able to find a solution that was curated for patient preference.
Denials have long been a sore spot for revenue cycle leaders and now they seem to have a worsening effect on an organization’s bottom line.
A new benchmarking analysis illustrates the negative financial impact of denied claims and delayed payments.
The data, compiled by Kodiak Revenue Cycle Anayltics (RCA), found that the value of claims taking longer than 90 days to paid has increased by 33% for commercial insurers and over 40% by Medicare Advantage plans since 2020. The main driver for these delays, according to the analysis, is a surge in initially denied claims.
“The initial denials cause delays sending bills to patients, and the longer patient billing is delayed after a procedure or hospital stay, the lower the collection rate for providers,” Colleen Hall, senior vice president and revenue cycle leader at Kodiak Solutions said in a statement.
“This amplifies the financial impact on provider organizations at a time when they are already under tremendous financial pressure.”
Nicole Clawson, vice president of finance and revenue cycle at Pennsylvania Mountains Healthcare Alliance (PMHA), previously spoke to HealthLeaders about her efforts to reduce denials and increase revenue.
“Our core revenue cycle model includes its shared service management division along with the technology in the systems it uses to gain efficiencies, best practices, and create an overall increase in cash collections and a reduction in denials and bad debt.” Clawson said.
She added that PMHA spent years developing their current system and making it specific to the region they serve, as well as payers. This included designing algorithms for billing workflows, optimizing function for cash acceleration and reimbursement.
A larger report by Kodiak RCA notes that patients themselves are taking longer to pay providers as they have begun to shoulder more of their healthcare costs. In the third quarter of 2023, commericially insured patients were responsible for 23% of their bill for inpatient and outpatient care.
While this isn’t a problem for the revenue cycle, so long as patients can afford to pay, the number of aged accounts receivable older than 90 days is growing for both commercial insurers and Medicare Advantage plans.
The self-pay after insurance collection rate for these patients was 36.1% of the claim’s value.
Payer challenges continue to be a nuisance for revenue cycle leaders.
With slower claims processing times, algorithms denying claims without review, and vague policy details on behalf of payers, leaders are struggling to find solutions to keep claims out of limbo or unfairly denied.
At HealthLeaders’ 2023 RevTech Exchange, Jonathan Benton, assistant vice president of Atrium Health offered attendees five solutions to combating such issues.
Prioritization
Use algorithms to score priority based on which accounts have the greatest potential value (ex. likelihood to recover/likelihood to deny)
Automation
Automate tasks to reduce work burden on people and prioritize processes to steadily speed up revenue cycle operations while reducing cost to collect. Example: Using bot technology for adding coverage or COB/eligibity denials.
Cultivation
Organize work to maximize system automated priority and embed daily behaviors and techniques. Use performance scorecards for self-directed improvements, measuring productivity and effectiveness to establish a standard.
Analysis
Focus on the root of an issue and be proactive rather than reactive. Keep track of factors impacting KPIs. Create strategic partnerships with physician advisors and vendors.
Resilience
Don’t let up on payers, and inundate them with appeals and follow up on automated denial responses. Be forward thinking and look at trends, develop insights, and observe what other organizations are doing.
Ease of use and accessibility in the front end are crucial and affects the quality of your organization’s patient experience.
When Ariana Urquia joined the executive leadership team at Florida-based Nicklaus Children’s Hospital in 2019, she recognized the need for the hospital to embrace technology.
As vice president and CFO, she found that revenue cycle challenges like poor prior authorization processes, increased clinical denials, and coding underpayments were costing the hospital money.
Urquia knew that those challenges needed to be streamlined as soon as possible not only to save on the bottom line, but to improve the patient experience too.
“It’s almost impossible to be able to tackle all of those issues without some type of [technological] solution,” Urquia told HealthLeaders.
How was it done?
In 2020, the hospital partnered with a revenue cycle management company to implement its technology within its billing and collection processes. By leveraging technology and AI solutions, organizations can reallocate their in-person staff to focus on more complex tasks within the revenue cycle, for example, denials management for complex cases or authorizations.
Another way the hospital has leveraged technology has been their charge capture solution, which evaluates patients’ medical records and checks them against the charges listed on their bills.
There are also CDI specialists that review special cases to ensure appropriate documentation.
“We use tools to help prioritize which patient accounts we should be looking at,” Urquia said. “Based on the documentation that exists in the medical record at a point in time and other parameters to say ‘Hey, you may want to take a look at this account.’”
As a children’s hospital, families largely rely on the hospital’s services, so ease of use and accessibility in the front end are crucial.
Urquia explained that while in the past, patients would complete the registration process when they arrived. However, after introducing the concept of a positive patient experience, there are more efforts to make the process more efficient to cut down wait time.
“As we start evolving as an industry and you start thinking of patients as consumers of healthcare and start really thinking about how technology can help leverage this,” she said. “We can continue to think about how we’ve always done things before and just layer technology on top of that to improve efficiency or we can just look at it in a completely different way.”
Another initiative the hospital has launched is their digital front door, which allows patients to complete their registration at home, including uploading insurance information.
While some patient’s families prefer to complete the registration process before their appointment, others still prefer to speak with an actual person; which shows in person interactions are still an important part of patient experience.
“For us, this really means it’s not taking one thing away from the other or replacing,” Urquia said. “But it’s really providing different options for patients so that we can meet them where they’re at.”
Meeting patients where they are and providing solutions like these helps the revenue cycle flow from the front end to the back end seamlessly.
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.
