FEATURE · REVENUE CYCLE MANAGEMENT
try to increase revenues again is intense; there’s just a real push to work smarter,” she adds. “You only have so many people and so many hands, and so many tasks to do.”
Dustin Cragun, the research director in
revenue cycle management at the Pleasant Grove, Utah-based KLAS Research, says that things remain challenging in terms of shifting into more advanced solutions. “Providers are just looking for a result; they just want an outcome,” Cragun says. “And I think to some extent, they don’t even care how they achieve that outcome, whether traditional RPA [robotic process automa- tion], or even screen-scraping, which work great for some things.” In that regard, Cragun says, patient
care organizations are tending to fall into two groups right now. “The first includes providers that have truly embraced digital transformation and are using it to drive competitive advantage for their entire culture. And that doesn’t just mean the tools, it speaks to the ways in which they use the tools.” The second group, he says, “tends to be focused on reducing costs, and start out by thinking they need to reduce headcount, particularly in staff- expensive areas like RCM. I don’t think there’s a right or wrong way to think about this,” he adds. “Every system is on its own journey. But it does bifurcate how the tools are adopted. The former group is more focused on the algorithmic processes, while the latter is focused on overall automation.” What’s more, Cragun says, “The bulk of the technology is still RPA-based. I’m not yet seeing fast adoption of AI in this area.” Indeed, he says, though interest in AI is “incredibly high, “RPA is provid- ing exception reports or isolating denials, and helping people to fix the claim and resubmit it,” and for many organizations, for now, that is what’s achievable. The question that those who would implement AI solutions need to ask themselves is, “Are you actually able to replace human intervention and resubmitting a claim without human intervention? That’s a pretty big chasm,” between what RPA solutions can do right now and what fully mature AI solutions might be able to do at some point.
In the trenches, ongoing challenges CFOs and others working in the trenches are determined to move forward, even as they find themselves addressing present- state issues. That certainly is the case at the four-hospital, 850-bed Nebraska Methodist Health System, based in Omaha, says Jeff Francis, the organization’s vice president and CFO. The pedestrian yet persistent issue of denials management remains a day-to-day challenge, he confirms. So
AI-based tools are extremely important. Prior to implementing an AI system (Methodist is a customer of AKASA) he reports, “We were finding that it was taking an average of seven minutes for a staff person to check the status of a claim; now, with our AI solution, they can do it in one minute; that makes us far more efficient.” In addition, the web-based solution they use made shifting to remote-based work during the pandemic far smoother a shift. And, where the rubber really, really meets the road, Francis confirms, is around staffing. “With the example of checking status on claims, we had open positions, we were having to run over- time. We have fewer open positions now because of the efficiency of the tool. We’re definitely in a market where attracting highly skilled workers continues to be a challenge.”
As for the leaders of RCM teams in patient care organizations, Francis says that “If they’re still just trying to deal with claims statusing and claims denials, they’ll use RPA, because that’s the best tool for that job. So if you’re going to act on a claim—if you’re at a point where you’re making a decision as to what to do with that claim, you’ll be getting into the more advanced technology to help make the best decision for that claim. And the best decision might be not to resubmit it but rather to freshen it up, clean it up; and you might need an algorithm to help you make that decision; and that would require AI.”
Peering into the future Bill Falconer, managing director for strat- egy and operations at the Impact Advisors consulting firm, based in the Chicago suburb of Naperville, Ill., who has spent more than 25 years in the RCM space in healthcare, working for hospitals, medical groups, and consulting firms, notes that “Something like a third to a half of organi- zations have at least dipped their toes into some form of RPA. When you start talking about true AI, native-language, we’re start- ing to see very progressive people going after these things,” says the Birmingham, Ala.-based Falconer, though he adds that fewer than 5 percent of revenue cycle teams have so far plunged directly into any kinds of AI solutions; but that number will soon accelerate, he predicts. “Besides the fact that AI can be multi- factorial and get into the predictive space, probably more than 85 percent of the data we have in healthcare is free-form and unstructured, and that’s always been this murky space we couldn’t do anything with,” Falconer continues. “AI has the potential to make that free-form data useful and actionable. That’s what’s exciting to me. There are clear use cases.
Everybody naturally goes to predictive denials” as a use case, he says, “and that’s valuable. But also, there’s a role for predictive admissions and transitions of care; in the value-based care space, the specificity and granularity of data are so important, in terms of doing a better job of taking care of the chronic and polychronic populations. So in the next two to four years, we’ll see meaningful change, and the folks involved in value-based care will move into the practical application of live implementation and expansion in that area.
How’s your foundation doing? Falconer emphasizes that he sees that “There are two typical paths that I see organizations taking to get to the point where they are right now. There are those organizations disciplined and focused on their current operations; they have a really optimized EMR and integration across their enterprise; they have very robust analytical capabilities; and they’ll be suc- cessful over time in RPA and comfortable in moving forward into AI over time. The organizations that are potentially at risk are the folks who haven’t taken care of the table-stakes, price-of-admission things. They’ve dabbled into RPA, but they’ve started to run into challenges with their existing foundations. For some of them, they’ll have to do some rework” to repair and strengthen their infrastructure founda- tions before moving ahead. As he puts it, “You can’t have analytics be an IT function only and think of RPA as operational, as RCM, and then try to get to AI. People have to think of it as a multi-dimensional approach. It also needs to be a care delivery challenge, and a patient experience chal- lenge. If you build the bricks all together, you’ll have success. You’ll struggle if all the different elements are disparate, with different owners.” Still, looking at the tre- mendous challenges of moving forward to optimize charge capture and keep their organizations financially stable, Falconer says that everything that’s happened in the past 21 months should be seen as a wakeup call: “For those who can look forward and see this as a general point of opportunity, I think it actually creates a lot of oppor- tunity. I’m inherently an optimist. I think we will see some clear winners emerge from this year-and-a-half-plus of material disruption.”
Meanwhile, Nebraska Methodist’s Francis emphasizes that becoming hyper- efficient will become the norm expected of RCM teams in patient care organizations. It will all be about “the challenges trying to reduce the administrative burden, and needing to invest as many dollars as pos- sible in patient care rather than the back office,” he concludes. HI
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