Two executives discuss the use of automation and other rev tech solutions in the front end.
During HealthLeaders’ recent RevTech Exchange in Raleigh, North Carolina, we caught up with Anthony Cunningham, then newly appointed chief revenue officer for LCMC Health, and Jeanne Stokes, director of revenue cycle management for Ironwood Cancer and Research Centers.
We discussed the pros and cons of automation as a rev tech solution.
The following transcript has been edited for length and clarity.
HealthLeaders: What parts of your rev cycle process are automated?
Anthony Cunningham: I think the biggest thing we've been trying to automate, like many other folks, is the initiation of authorizations as well as the follow up; so the status of authorizations. A lot of folks struggle in that space. I think you can do a good job of revenue technology, maybe some of those straightforward authorizations, but when you get into surgeries and things like that, it requires people in my opinion, because of exactly what they're looking for.
Jeanne Stokes: We are constantly scrambling with eligibility on the front end, so retro terms are crippling for us.
If you don't have coverage, or you have new coverage and we didn't know about it, we now don't have an authorization. We do automate our eligibility, and the system presents us with the denials for coverage that people need.
We have self check-in kiosks and we thought that installing them would relieve some of the administrative burden. What we're now getting is apathy from our front desk staff because that was a big part of their job. Their job is to be the face of the practice and greet the patients, and now we've restricted them from coming around, helping people, and networking with the patients.
How can organizations help front desk staff maintain those relationships with patients?
Jeanne: The front desk has become the traffic guard, so we have to teach them how to engage. They’re losing that and they started losing it during the pandemic. I think we do need to find a way to redefine their roles and help them be ambassadors for the hospital, the practice.
Anthony: That front desk position is usually entry level with high turnover, yet it's very difficult to read those coverages. Then when you finally get somebody up to speed, they take another job.
Do you feel there’s a disconnect in the relationship between vendors, C-suite leaders, and those who perform the individual operations? How has this impacted the way you rev tech?
Anthony: I think the only way vendors are successful is if there’s truly a partnership with the organization and staff. A lot of the time, folks will look at a case study of what happened at one organization and they don’t know the amount of effort that went into making it happen. You assume you’re going to get the same benefit. There’s always a disconnect between what you think you’re going to receive and what’s delivered.
A vendor comes in and has their gloss presentation that shows you how everything is created, that you basically plug it in and it's going to work for you, but if it was that simple, everybody would have that solution. It’s that partnership that a lot of folks don't invest the time to make that vendor successful.
Prior authorization has been a consistent pain point for revenue cycle leaders, but hopefully not much longer.
The Centers for Medicare & Medicaid Services rule for the annual review of prior authorization policies went into effect on January 1. It’s too early to know if the rule, which will also ensure that policies stay in place for as long as a patient needs a service, may offer some relief to providers and financially strained health systems.
Here are some previous HealthLeaders articles to get you up to speed.
Prior authorization impacts patient access to care and provider reimbursement, making it an important part of the revenue cycle. With reasons for denials stemming from clerical issues or insufficient documentation, some organizations have embraced automation as a solution and seen results. Others, not so much.
A report by Kaiser Family Foundation found that over two million out of 35 million prior authorization requests were denied by Medicare Advantage in 2021. Adding to a December 2022 proposal, CMS proposed a new rule to strengthen prior authorization protections, including having policies reviewed annually.
Organizations like the American Hospital Association, American Medical Association, Medical Group Management Association, and Better Medicare Alliance voiced their support of CMS’ proposed rule.
The Medical Group Management Association conducted a poll among 601 medical groups on their experiences with prior authorization and Medicare Advantage. Results found issues had gotten worse over the last year, and less than 1% reporting requirements had decreased.
CMS' Medicare Advantage and Part D rule went into effect on January 1.
Will 2024 be the year providers get a handle on prior authorization struggles? With the Medicare Advantage and Part D rule going into effect on January 1, it’s too soon to tell.
The rule, issued by the Centers for Medicare & Medicaid Services (CMS), requires Medicare Advantage plans to review prior authorization policies each year, with the policies remaining in place for as long as the patient needs a service.
Revenue cycle leaders continue to struggle with prior authorization and denials management. With most Medicare Advantage enrollees having plans that require prior authorization for services, the issue is further exacerbated.
Some organizations have tried to solve their prior authorization problems by investing in rev tech solutions. Without a solid digital expansion strategy, organizations can end up with more issues.
In a previous HealthLeaders story, Shanda Richards, revenue cycle director of Central Peninsula Hospital in Alaska, emphasized this while acknowledging the sense of urgency to find a solution.
“We’re in a crisis. We’re delaying care because we can’t get prior authorization, so therefore we have to get something in place,” she said.
Prior authorization is the tip of the iceberg when it comes to organization’s issues with Medicare Advantage. Providers have long been vocal in their frustration with low reimbursement rates and frequent claim denials.
With many health systems struggling financially, it would be unsustainable to keep going back and forth, and many have begun terminating their Medicare Advantage contracts.
“A program intended to promote seamless and higher quality care has instead become a fragmented patchwork of delays, denials, and frustrations,” Steve Gordon, president and CEO of St. Charles Health System, said in a press release. The health system terminated its Medicare Advantage contract in 2023.
“The sicker you are, the more hurdles you and your care teams face.”
HealthLeaders surveyed over 80 revenue cycle leaders to see what they’ll be focusing on in the new year.
After a year rife with payer/provider tug of wars and trying to keep pace with the latest in the rev tech space, revenue cycle leaders have their work cut out for them in 2024.
HealthLeaders surveyed over 80 revenue cycle leaders to see what they’ll be focusing on in the new year, from the highest to lowest priority.
Organizations need clear steps and goals to manage the evolving and expensive rev tech space.
2024 is here, alongside the beginning of Q1, and organizations are initiating their plans to reach their goals for the year. For many, this includes expanding the use of technology within their revenue cycle processes.
As your organization moves forward with digitalization and expansion, keep these two words in mind: strategy and pacing.
Strategy
Rev tech satisfaction varies among organizations, typically due to solutions not being able to keep up with complex processes. With the excitement surrounding automated and artificially intelligent solutions, some organizations fail to develop a clear strategy in their rush to find and implement a solution.
In a previous HealthLeaders story, Shanda Richards, revenue cycle director at Central Peninsula Hospital in Alaska, emphasized the importance of organizations having a strategy and knowing what they want to guide their digital expansion.
“[Know] what you really need instead of just being sold on what somebody’s trying to sell you,” she said.
While different rev tech solutions have capabilities to manage or complete different tasks and processes, there’s a misconception that the digitalization process should happen all at once, which Richards also advised against.
“Don’t just go off being reactionary, where you’re solving the next problem with software. That’s oftentimes where we get the most movement,” she explained. “We’re in a crisis. We’re delaying care because we can’t get prior authorization, so therefore we have to get something in place.”
Pacing
According to Ravi Patel, vice president of digital health at Ann & Robert H. Lurie Children’s Hospital in Chicago, pacing is a critical part of digitalization because it allows organization’s to build a strong foundation for future efforts.
Before adding additional functions to the hospital’s patient portal or making any investments, Patel was able to increase utilization to 83% through the Every Patient, Every Time initiative, where patients are informed and offered patient portal access at each point of service.
With the increase in utilization from the initiative, Patel then added other functions to the portal, like a symptom checker and predictive chat bot to streamline contact and scheduling with physicians and specialists, as well as connect patients with social work resources.
“All of that was further investment made by the organization,” he said. “But the ability to go from 27% to 83% [patient utilization] didn’t require any investment. All it did was require time, effort, and a focus on equality.”
The rev tech boom shows no signs of slowing down as solutions continue to evolve.
The revenue cycle technology space has seen an influx of innovative solutions over the last few years, most notably artificial intelligence (AI). AI and automated solutions, along with machine learning and robotic process automation, have quickly integrated themselves into the revenue cycle processes of many healthcare organizations.
A survey, commissioned by AKASA, of over 450 chief financial officers and revenue cycle leaders found that 74% of respondents were “actively automating” part of their revenue cycle. However, 24% of survey respondents stated that they have never used any kind of automated solution in their revenue cycle.
2% of respondents said they no longer use automated solutions.
Organizations are eager to implement automated and AI solutions due to their ability to streamline revenue cycle processes and increase operational efficiency. With the ongoing staffing shortage, this also helps organizations save money on recruiting and hiring additional staff.
Despite the enthusiasm surrounding digitalization, there have been mixed results among organizations. During HealthLeaders’ 2023 RevTech Exchange in Raeliegh, North Carolina, revenue cycle executives were vocal with their frustration of vendors and solutions that fail to complete the processes needed or lack the forward-thinking innovation to keep up with complex payer issues.
Considering the significant financial investment needed for an organization’s digital expansion, ensuring a return on investment is also important. When Allegheny Health Network was looking for a financial engagement platform, building a contract with the vendor where both they and health system had a stake in the success or failure of the solution helped with accountability.
The tracking key performance indicators, in addition to operational metrics, former chief financial officer and treasurer James Rohrbaugh said, allowed the AHN to balance the financial metrics alongside patient engagement and satisfaction to gauge its success.
Patient portals can make or break a positive care experience.
As the healthcare sector begins to embrace the idea of patients as consumers, having an efficient and easy to use patient portal is a necessity.
But of all the information given to patients during check in and registration, how can providers and their staff emphasize their digital front doors as part of their patient experience?
Since joining Ann & Robert H. Lurie Children’s Hospital in 2020, Ravi Patel has increased patient portal usage from 27% to 83%. Here are some best practices the vice president of digital health implemented with his efforts.
Always offer access
Through the Every Patient, Every Time initiative, patients are offered access and assistance with activating their patient portal account during each interaction with a point-of-service staff member. According to Patel, this simple step created a “steep increase” in portal utilization.
Flex the functionality
An efficient patient portal gives patients more control over their care, enabling them to view upcoming appointments, schedule future appointments, pay bills, and view test results. They’re also able to state a preference in how they communicate with providers.
As patient portal usage increased, after one year the hospital began to invest in adding more functions to the portal. For example, to simplify and streamline the scheduling process, online and over the phone, patients are asked questions based on an algorithm to connect them to the right provider or specialist.
The hospital has also since integrated telemedicine and a symptom checker tool into their patient portal.
Use the data to identify and address other issues
As digital strategies were initiated and more functions were added to the patient portal, it was important to monitor its performance for both productivity and efficiency.
“[Performance management] becomes a critical component of success because now you can measure how you’re doing in real time,” Patel said. “And then be agile enough to flip the switch and go back and forth [to see what is an isn’t working.]”
Doing so enabled the hospital to identify problems within their patient population, typically related to socio-economic disparities, and provide solutions. For example, the portal’s text messaging feature can connect patients who need assistance with transportation to their appointments with social worker’s resources to help them, which helps reduce their no-show percentage.
One exec made it his mission to increase patient portal usage with the help of point-of-contact staff.
Patient portals have become an important part of the revenue cycle front end. Aside from scheduling and registering for appointments, they often enable patients to gauge what their experience with a provider will be.
When Ravi Patel joined Ann & Robert H. Lurie Children's Hospital in 2020 as senior director of digital health, the hospital had a patient portal in place, but it wasn't being fully utilized.
Patel then started to strategize ways the organization could better utilize its patient portal and boost patient engagement and satisfaction, and the results were vast.
"One of the first things we looked at was patient engagement with the tool and more so enrollment with the tool," he said. "And what we found immediately was this significant disparity, and like every other organization, had previously been chopped up to resource differences."
Patel, now the hospital's vice president of digital health, found that these differences ranged from internet and device access to technical knowledge. As a result, there was some hesitancy around pushing the use of the patient portal for fear of putting more pressure on these disparities.
At the time, scheduling an appointment for a new patient took around 40 minutes on average and 27% of patients utilized the patient portal. Of that percentage, less than a third were logged on within three months of their appointment.
In September 2020, the hospital launched its Every Patient, Every Time initiative, where point-of-service staff offered portal access to patients at each contact.
"What we found was just purely telling them about it…was enough to get them activated," Patel said. "So we started to see a steep increase with performance management."
Over 200 members of the hospital's staff got patients to utilize the patient portal, and since 2020 portal usage has gone up to 83%. With more patients using the portal, those who are unable to due to the previously mentioned disparities are now able to call in with shorter waiting and call handling times.
As the hospital continues to manage the performance of the patient portal, it also works alongside its local government to find ways to solve issues related to the disparities it sees.
"If you think about the digital divide that exists, especially when you think about it in socio-economic terms and racial-ethnic terms, it's heavily driven by a lot of preconceived notions," Patel explained. "Those preconceived notions are preventing us from actually closing that gap because we often attribute it to structural pieces."
"I'm not saying that those structural pieces aren't there, but there are things that we have full control over, and I can now proudly say that our organization has fully conquered; that when we offer it consistently to everyone, our patients do get activated."
Artificial intelligence is here to stay and going further.
Artificial intelligence has moved from a buzzword to an established presence in revenue cycle technology. Revenue cycle and finance leaders alike are looking to AI to streamline processes and automate tasks, which will allow them to use staff more efficiently as the sector-wide staffing shortage persists.
HealthLeaders previously spoke to Joann Ferguson, vice president of revenue cycle for Detroit-based Henry Ford Health on how they’re using AI to help with coding.
“First, it automatically codes the simplest procedures, taking that work off our coders’ plates,” she explained. “By ‘simplest,’ we mean the procedure notes that match closely or exactly with how the ICD codes themselves are written.”
Denials management is an area revenue cycle leaders continuously struggle with. Going into 2024, Sierra View Medical Center in California have begun working with a vendor that uses AI to help with the appeals process.
“On the inpatient side of business, we have seen a large increase in denials for lack of medical necessity,” Julie Franer, administrative director for revenue cycle, told HealthLeaders. “Our [utilization review] department now reports to finance and will be focusing on education related to documentation to avoid medical necessity denials.”
An organization’s adoption of AI or any technological solution is dependent on a few different factors. Where are they currently with technology, and how much should they expand? Will C-suite executives be onboard? Can they afford the investment?
“Many organizations have already begun to optimize processes utilizing technology while others are still in the infancy stages,” Shawishi Haynes, director of revenue cycle operations at Valley Presbyterian Hospital in California told HealthLeaders.
“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.”
When CMS’ released the 2024 inpatient prospective payment system rule, it included 395 new diagnosis codes. Additionally, there were 12 revisions and 25 deletions to the ICD-10-CM diagnosis code set.
Some of the new codes enhance the tracking and progression of Parkinson’s disease and more reimbursement for certain social determinates of health. The codes went into effect on October 1.
The American Hospital Association (AHA), the American Medical Association (AMA), the Blue Cross Blue Shield Association wrote a letter to CMS asking the organization not to implement its proposed prior authorization standards. The groups argued that the provisions would create two sets of standards that would slow implementation and add unnecessary costs.
In a survey by AKASA, revenue cycle leaders said that their most time consuming tasks were denials management and prior authorizations. Other issues included insurance follow-up, eligibility and medical necessity checks, along with patient cost estimation and price transparency requirements.
Allegedly, Cigna’s PXDX algorithm has been denying claims automatically without a proper review process. The algorithm previously caused issues for the insurer when it was reported that it denied 300,000 requests for payments over two months in 2022.