Inconsistent payer rules are a major pain point for revenue cycles with direct clinical and financial impact on patients, according to Northwell Health's Christine Migliaro.
The prior authorization process is a well-known source of frustration for providers and a significant driver of administrative burden. In this HL Short, Christine Migliaro, vice president of front-end revenue cycle operations at Northwell Health, discusses the top challenges she encounters in the PA process. She outlines how a lack of standardization, staffing issues and slow payer response times create confusion and frustration for providers and patients alike.
Migliaro was a panelist during a recent HealthLeaders Revenue Cycle NOW Online Summit. Read more about the discussion or watch a recording of the full event here.
More than 40 payers have voluntarily committed to significant prior authorization reforms, but will this time be any different?
More than 40 payers have signed onto an agreement to limit and simplify prior authorization (PA), according to an announcement from AHIP.
AHIP maintains that PA safeguards patients from exposure to low-value and inappropriate care that deviates from evidence-based guidelines, but also recognizes the frustration that patients and providers feel when provider-recommended care is delayed or denied during PA review.
Signatories to the pact include Aetna, Cigna, Humana, UnitedHealthcare, and numerous affiliates of the Blue Cross Blue Shield Association. Proposed changes would benefit more than 250 million patients across multiple insurance markets, including the commercial, Medicare Advantage, and Medicaid managed care markets, according to the announcement.
The 6 Pillars of the Pact
Signatories to the pact have voluntarily committed to a set of six specific reforms.
Standardizing Electronic Prior Authorization
Lack of technological standardization across payers has long frustrated revenue cycle leaders. For instance, Ochsner Health has successfully automated some components of the PA process, but too few payers use digital platforms that cooperate with its core EHR to drive significant efficiency.
“We’re not able to connect this way to all of the payers and see that big volume that we would like,” Savanah Arceneaux, director of pre-service & financial clearance at Ochsner, said during a recent HealthLeaders Revenue Cycle NOW Online Summit.
As part of their pact to improve PA, signatories say they will develop standardized data and submission requirements using Fast Healthcare Interoperability Resources (FHIR) APIs.
Reducing the Scope of Claims Subject to Prior Authorization
Signatory payers offering Affordable Care Act marketplace and Medicare Advantage coverage say they will limit the use of PA to services most prone to variation. They will also share data to allow industry reporting on PA volume.
Ensuring Continuity of Care When Patients Change Health Plans
Currently, patients frequently require new PA approval when they switch health plans. Under the pact, signatories say that they will honor previous health plans’ PA approvals for 90 days when a patient changes health plans.
Enhancing Communication and Transparency on Determinations
Signatory payers are committing to improving member communications on PA denials. This will include notices that clearly explain next available steps for assistance to their affected members and clear instructions on how to appeal decisions.
Expanding Real-Time Responses
Electronic PA has the potential to reduce the administrative burden for providers and reduce turnaround times associated with the PA process. However, interoperability issues have limited widespread adoption.
Only 35% of PA interactions between providers and payers were fully electronic in 2024, according to a recent Council for Affordable Healthcare report.
As part of their commitment to adopt FHIR standards, signatory payers are also committing to submit 80% of electronic PA approvals in real time by 2027.
Ensuring Medical Review of Non-Approved Requests
AI has the potential to streamline and automate components of the PA process, but providers are concerned about using the technology to deny care. Signatory payers have agreed to only use AI to facilitate quicker approvals and require provider review for all PA denials based on medical necessity.
What are Revenue Cycle Leaders Saying?
There is a sense of muted optimism among revenue cycle leaders in response to the announcement from AHIP and signatory payers, particularly around the potential for standardization in electronic PA processes.
“The most noteworthy commitment for me is the push towards real-time authorizations using FHIR APIs,” Seth Katz, vice president of revenue cycle and HIM at University Health Kansas City, said in an email. “If that’s truly realized, it would cut down on delays and reduce friction for both providers and patients.”
These specific commitments largely align with requirements established by the Interoperability and Prior Authorization Final Rule issued by the the Centers for Medicare and Medicaid Services (CMS) in 2024, which would mandate the adoption of an API for PA by 2027. While those requirements would only apply to plans participating in government programs, healthcare leaders have applauded payers for embracing the proposed changes to commercial plans as well.
“Today’s commitment by health insurers, much of which is a plan to implement the CMS requirements established in the Interoperability and Prior Authorization final rule, presents a meaningful opportunity to reduce the patient and provider burden associated with prior authorization,” Terrance Cunningham, senior director of administrative simplification policy for the American Hospital Association, said in a statement to HealthLeaders.
“We are encouraged to see their commitment to implementing these changes beyond federally regulated insurance offerings and across their commercial lines of business, which will enable these reforms to impact a greater number of patients,” Cunningham added.
Despite the optimism, years of push-and-pull between providers and payers has led to an acrimony that tempers expectations.
“I’ll admit, I’m cautious,” Katz said. “Health plans have been promising improvements for years, yet frontline staff still spend hours chasing faxes or sitting on hold resulting in delays of care impacting patients and frustrating physicians.”
“In short, the intent is right, but until there is accountability and measurable progress, most of us on the provider side are reserving judgment,” he concluded.
The numbers are in, revealing a clear performance gap between providers on eight KPIs. See the metrics that separate top-performing provider organizations from the rest and benchmark your own success.
Recent data from Kodiak Solutions shows a clear performance gap, with top-performing provider organizations outpacing their peers on eight revenue cycle KPIs. However, organizations that did not make the highlight reel should not despair. The variations in performance offer revenue cycle leaders a roadmap to plot their own success.
Read more here, or see the infographic below for additional details.
The latest data from Kodiak Solutions shows significant variation among provider organizations in their performance against key performance indicators (KPIs), offering insight into opportunities for improvement.
In its latest quarterly analysis of KPI benchmarking data, Kodiak Solutions found that 2024 performance against eight key performance indicators (KPIs) varied significantly from one provider organization to the next.
Kodiak releaseddata earlier this year that showed three trends working against revenue cycle leaders. However, top performers in the most recent analysis show that there are areas of opportunity for organizations to improve their revenue cycle performance.
True Accounts Receivable Days
The average true accounts receivable (A/R) days for all provider organizations included in the Kodiak analysis was 56.9, compared with 43.6 for the top 10 performers.
Partnering with clinical teams to improve the accurate documentation of services provided can help denials management teams limit the risk of request for information denials and improve performance against this KPI, according to the report.
Additionally, revenue cycle leaders should routinely follow up with payers to resolve denials, to better understand complex denials, and to receive payment.
True accounts receivable days greater than 90 days
At the top 10 performing provider organizations, the average true A/R days greater than 90 days was 22.5%, compared to 35.9% for all provider organizations.
Tweaking preregistration and prior authorization (PA) workflows to limit bottlenecks in the front-end can help to prevent delays in payment, according to the report. Provider organizations should also maintain focus on older accounts to ensure they are resolved.
Credit Days
The average number of credit days was 0.44 for the top 10 performing provider organization,s while the average for all organizations was 1.10.
Credit resolution is an area where automation can improve performance by leveraging past resolutions to identify and replicate effective past actions, according to the report. Of course, it is important to differentiate by types of credit balances. A strategy that works for credits qualifying as exemptions may not be appropriate for credits identified as over-contractualizations.
Days Not Final Billed
The average number of days not final billed was 9.6 at the top10 performing provider organizations, while the average was 8.0 for all organizations.
Days not final billed is another metric where strong alignment between clinical and revenue cycle teams can help to improve performance, according to the report. Quick response times to physician queries are key to limiting delayed billing.
Bad Debt as a Percentage of Gross Patient Service Revenue
Bad debt as a percentage of gross patient services revenue was nearly the same for the average of all provider organizations and the top 10 performing organizations, at 1.4% and 1.3% respectively. However, the overall top performer wrote of just 0.4% of this revenue as bad debts, about two-thirds less than the average organization.
Providers need to improve pre-service or point-of-service collections to prevent bad debt. To do so, organizations should consider expanding options for digital payments and educating patients on their financial responsibility for their healthcare bills.
Point of Service Cash Collections
Point of service cash collections was 18.9% for all provider organizations versus 25.6% for the top 10 performing organizations.
This is another area where organizations can improve performance by tweaking the patient access components of their revenue cycles to improve patient communication and education to ensure payments.
Final Denials as a Percentage of Net Patient Service Revenue
The average final claim denial rate at the top 10 performing provider organizations was 2.2% compared to the average 2.8% rate for all organizations.
Again, alignment between clinical and revenue cycle teams is critical to limiting denials, according to the report. Provider organizations should also consider using advanced analytics to identify and mitigate the root causes of denials and devoting more resources to denial management teams.
Six-Month Lagged Cash to Net Revenue Value
The average percentage of six-month lagged cash to net revenue value was 98.7% at the top 10 performing provider organizations, versus an average of 94.1% at all organizations.
Leveraging analytics and automated tools to limit administrative denials and focusing on high-dollar unbilled accounts are two ways to improve in this area.
The data from Kodiak reveals a clear performance gap among provider organizations when it comes to KPIs. Closing these gaps require revenue cycle leaders to build strong partnerships throughout their organizations, to strategically implement technology, and to improve the patient financial experience.
In its latest quarterly analysis of KPI benchmarking data, Kodiak Solutions found that 2024 performance against eight key performance indicators (KPIs) varied significantly from one provider organization to the next.
Kodiak released data earlier this year that showed three trends working against revenue cycle leaders. However, top performers in the most recent analysis show that there are areas of opportunity for organizations to improve their revenue cycle performance.
True Accounts Receivable Days
The average true accounts receivable (A/R) days for all provider organizations included in the Kodiak analysis was 56.9, compared with 43.6 for the top 10 performers.
Partnering with clinical teams to improve the accurate documentation of services provided can help denials management teams limit the risk of request for information denials and improve performance against this KPI, according to the report.
Additionally, revenue cycle leaders should routinely follow up with payers to resolve denials, to better understand complex denials, and to receive payment.
True accounts receivable days greater than 90 days
At the top 10 performing provider organizations, the average true A/R days greater than 90 days was 22.5%, compared to 35.9% for all provider organizations.
Tweaking preregistration and prior authorization (PA) workflows to limit bottlenecks in the front-end can help to prevent delays in payment, according to the report. Provider organizations should also maintain focus on older accounts to ensure they are resolved.
Credit Days
The average number of credit days was 0.44 for the top 10 performing provider organization,s while the average for all organizations was 1.10.
Credit resolution is an area where automation can improve performance by leveraging past resolutions to identify and replicate effective past actions, according to the report. Of course, it is important to differentiate by types of credit balances. A strategy that works for credits qualifying as exemptions may not be appropriate for credits identified as over-contractualizations.
Days Not Final Billed
The average number of days not final billed was 9.6 at the top10 performing provider organizations, while the average was 8.0 for all organizations.
Days not final billed is another metric where strong alignment between clinical and revenue cycle teams can help to improve performance, according to the report. Quick response times to physician queries are key to limiting delayed billing.
Bad Debt as a Percentage of Gross Patient Service Revenue
Bad debt as a percentage of gross patient services revenue was nearly the same for the average of all provider organizations and the top 10 performing organizations, at 1.4% and 1.3% respectively. However, the overall top performer wrote of just 0.4% of this revenue as bad debts, about two-thirds less than the average organization.
Providers need to improve pre-service or point-of-service collections to prevent bad debt. To do so, organizations should consider expanding options for digital payments and educating patients on their financial responsibility for their healthcare bills.
Point of Service Cash Collections
Point of service cash collections was 18.9% for all provider organizations versus 25.6% for the top 10 performing organizations.
This is another area where organizations can improve performance by tweaking the patient access components of their revenue cycles to improve patient communication and education to ensure payments.
Final Denials as a Percentage of Net Patient Service Revenue
The average final claim denial rate at the top 10 performing provider organizations was 2.2% compared to the average 2.8% rate for all organizations.
Again, alignment between clinical and revenue cycle teams is critical to limiting denials, according to the report. Provider organizations should also consider using advanced analytics to identify and mitigate the root causes of denials and devoting more resources to denial management teams.
Six-Month Lagged Cash to Net Revenue Value
The average percentage of six-month lagged cash to net revenue value was 98.7% at the top 10 performing provider organizations, versus an average of 94.1% at all organizations.
Leveraging analytics and automated tools to limit administrative denials and focusing on high-dollar unbilled accounts are two ways to improve in this area.
The data from Kodiak reveals a clear performance gap among provider organizations when it comes to KPIs. Closing these gaps require revenue cycle leaders to build strong partnerships throughout their organizations, to strategically implement technology, and to improve the patient financial experience.
Panelists during a recent National Association of Healthcare Revenue Integrity webinar shared how they are forming strategic partnerships in their health systems to streamline the revenue cycle.
In a recent webinar hosted by the National Association of Healthcare Revenue Integrity (NAHRI), a panel of revenue cycle leaders gathered to discuss the results of NAHRI's recently released 2025 State of the Revenue Integrity Report and associated survey.
The discussion featured important insights on denials management, communicating the value of revenue integrity, and AI in the revenue integrity space, among other topics. Panelists were Jennifer Gardiner, senior director of revenue integrity at the University of Maryland Medical System; Kay Larsen, revenue integrity senior charge assurance associate at Adventist Health Glendale; and Evan Martin, vice president of revenue cycle management at ZoomCare.
Where revenue integrity teams can offer additional assistance
While denials management doesn't typically fall directly under the umbrella of revenue integrity departments, it is certainly an area where they can help. Nearly 60% of survey respondents claimed denials management was a secondary function for their teams.
However, as claim denial rates increase and denials become more complex, revenue integrity departments could help to "pull a lot of the pieces together," Gardiner says.
Revenue integrity teams could also add value in supply management, according to Martin. Providers will too often begin using a new supply, believing it to be reimbursable when that is not the case. By involving revenue integrity early, health systems can ensure that they achieve more value from supplies used in surgeries and other clinical procedures.
Similarly, health systems will often launch a new service line without input from revenue integrity departments, according to Larsen, who relayed an anecdote about a request for support two weeks after the launch of a new line of service. Engaging with revenue integrity departments before new services go live can help health systems to maximize revenue streams from those services.
Communication is key
As Larsen's anecdote indicates, revenue integrity departments can sometimes be overlooked. They need to conduct outreach to draw attention to the value they add.
"We can be proactive and working with departments," Larsen says.
She says she downloads charges for different departments every day, looking for patterns that reveal opportunities to improve, and will call the department to see if the revenue integrity team can help make adjustments.
Although she technically works remotely, she'll occasionally travel to the hospital to work elbow-to-elbow with providers and administrators. During these times, she is often able to help departments optimize their EHR functionality to reduce administrative burden in billing processes.
Similarly, the revenue integrity team at University of Maryland Medical Center conducts what Gardiner calls "revenue integrity roadshows," which are essentially opportunities to meet with practice leaders and show how the team can help.
On the flip side, it is important that revenue integrity teams avoid taking on responsibilities that belong to someone else. It is common for a revenue integrity team to do a task outside of its purview once or twice, and then it becomes a pattern, according to Gardiner.
AI and revenue integrity
Only around half of health systems are using AI in their revenue integrity departments, according to survey results. However, there was a lot of enthusiasm among panel participants for its potential.
AI platforms can be trained in charge capture and charge edits to replicate what human medical coders do in certain instances, according to Martin. This would help to mitigate staffing challenges and free up time for revenue integrity team members to work on tasks that require more complex knowledge.
Additionally, as more health systems adopt AI-powered digital scribe systems, there is potential to reduce the burden of documentation on providers.
However, "revenue integrity needs to be part of that conversation," according to Martin. Revenue integrity involvement ensures that the scribe captures information and uses verbiage that aligns with what is being charged for.
Providers should prepare for the fallout following a recent CMS announcement that it will take a more aggressive approach to auditing Medicare Advantage plans.
The Centers for Medicare & Medicaid Services (CMS) recently announced it will take a more aggressive approach to Medicare Advantage plan audits. Beginning immediately, CMS will conduct annual audits of each of the approximately 550 MA plans available to healthcare consumers, up from the 60 or so it currently conducts each year.
While MA payers will feel the direct impact of heightened regulatory scrutiny, the move has major implications for revenue cycle leaders and their health systems.
See the infographic below to learn how increased action from CMS will affect provider revenue cycles, or read more here.
Provisions of the reconciliation bill currently being considered in Congress combined with expiration of Affordable Care Act tax credits would have significant implications for provider revenues.
Looming policy changes would have significant financial consequences for providers, according to an Urban Institute report funded by the Robert Wood Johnson Foundation. If changes to Medicaid currently under consideration in Congress go into effect and Affordable Care Act tax credits are allowed to expire, providers would see an estimated $1.03 trillion decline in revenue from 2025 to 2034. A surge in the number of uninsured individuals could also lead to a $278 billion increase in uncompensated care costs, according to the report.
See some key figures from the report in the infographic below, or read more here.
While CMS proposes a modest Medicare payment bump and an increase in uncompensated care funds, industry leaders argue it's not enough to offset rising costs, especially as potential Medicaid cuts loom.
The Centers for Medicare & Medicaid Services (CMS) has announced proposed changes to the Inpatient Prospective Payment System (IPPS) that would result in a net 2.4% increase for fiscal year 2026. This reflects an estimated hospital market basket increase of 3.2%, minus a 0.8% productivity adjustment, which anticipates an increase in hospital efficiency.
The proposed rule would also increase uncompensated care payments to disproportionate share hospitals to $7.29 billion, an increase of approximately $1.5 billion from fiscal year 2025.
The proposed increase falls below increases set by CMS in each of the past two years. The IPPS increased by 2.9% for fiscal year 2025 and by 3.1% for fiscal year 2024.
Unsurprisingly, the American Hospital Association (AHA) was quick to criticize the increase, paying special attention to the productivity adjustment.
“We are very concerned that this update will hurt our ability to care for our communities,” Ashley Thompson, AHA senior vice president for public policy, said in a statement. “Indeed, many hospitals across the country, especially those in rural and underserved communities, already operate under unsustainable financial situations, including negative margins.”
There is some data to support Thompson’s position. A recent report from Fitch Ratings found that nonprofit hospitals ended fiscal year 2024 with a razor-thin median operating margin of 1.2%. And these hospitals had just found stable footing, raising the median operating margin from -0.5% in fiscal year 2023.
The increase to Medicare payments proposed by CMS would also be unlikely to match the amount that many of these hospitals will lose in revenue from Medicaid should proposed policy changes go into effect.
“Federal budget cuts that may decrease Medicaid reimbursement and increase uninsured care would reduce hospitals’ ability to recover operating costs," according to the Fitch Ratings report. "Providers, particularly those with a higher share of Medicaid patients, could cut services, close locations, or reduce staff."
Hospitals stand to lose $408 billion in revenue over 10 years if changes to Medicaid currently under consideration are enacted and Affordable Care Act tax credits expire, according to a separate report from the Urban Institute and Robert Wood Johnson Foundation. Researchers also estimated that the resulting rise in uncompensated care would reach a value of $248 billion over the 10-year time frame.
While revenue cycle leaders await the release of a final rule on changes to the IPPS, they should continue identifying areas for improvement in operational efficiency, optimizing collection of patient payments, and developing contingency plans for potential changes to Medicaid.
In this episode of HL Shorts, Abeni Lee, director of physician revenue cycle at Grady Health System, talks about the challenge of identifying providers who could benefit from coding education and how to build communication pipelines to reach them.
Physician coding education can help to bolster revenue cycle integrity, but it must also meet provider needs. In this episode of HL Shorts, Abeni Lee, director of physician revenue cycle at Grady Health System, talks about the importance of tailoring coding education to specific needs and how to communicatie the availability of coding education to providers and practice leaders.
New survey data show that patients desire streamlined, transparent, and digital front-end experiences. Meeting these needs is essential to boosting patient collections and financial success.
Patient expectations are evolving within the shifting healthcare landscape, and their preferences could have a direct impact on health system revenues. Understanding what patients value in their healthcare journey can help to improve efficiency, satisfcation, and upfront payment rates.
Check out the infographic below to see what matters most, according to a recent Experian Health survey. Or, read additional coverage here.
