REVENUE CYCLE MANAGEMENT Q&A
Artificial intelligence can enhance payment reform results. Are you prepared?
Bob Hanscom, Vice President of Risk Management and Analytics at Coverys, answers our questions about new value- based payment models, artificial intelligence (AI) and machine learning, and what health- care systems and hospitals should be doing today to prepare for tomorrow.
Regulatory mandates and payment reform pressures demand new rigor from healthcare finance leaders to optimize revenue/claims/ payment capture. What’s your perception of where finance
leaders are right now? Hospital CFOs are in transition, and they are feeling the urgency of where things are headed. As fee-for-service reimbursement continues to disappear, it’s crucial to pay attention to what is really happening. Value- based care reimbursement models are emerg- ing -- and will continue to emerge -- as the primary way by which physicians, practices, and hospitals will be paid. There are six value-based care categories
that will influence how healthcare organiza- tions and practices will be reimbursed for patient-care services: • Timeliness: How quickly are you and your organization responding to and managing the overall care of patients?
• Patient safety: Are you implementing proactive risk management tactics to improve outcomes? Are you adhering to established standards that ensure safe care?
• Effectiveness: Are you achieving qual- ity outcomes?
• Efficiency: To reduce the cost of care— are you identifying inefficiencies and eliminating unnecessary redundancies?
• Patient-centeredness: Are you bring- ing the patient and their family into the decision-making process?
• Health equity: Are you ensuring all patients receive the best care no mat- ter who they are or where they live?
How do you see hospital/health system finance teams evolving from the current business
processes to one leveraging the use of artificial intelligence (AI)
and machine learning tools? AI and machine learning will be the game changers to support implementation of the six value-based care factors impacting pay- ment reform success. AI, in particular, offers the promise of enabling greater leverage of clinical knowledge and expertise to help broaden consistent clinical decision-making. Unfortunately, one of the underlying factors in malpractice claims is variability in numer- ous aspects of how clinicians practice. AI has demonstrated robust potential in this area. During the pandemic, AI became critical,
helping to predict COVID exposure and risk. Now there’s continued exploration to see where AI and machine learning can offer the most value. Machine learning -- the abil- ity for systems to process data and improve from it -- can pick up things the human eye cannot, such as medical imaging analysis, pattern detection, and clinical discovery of data buried in medical records.
What are the main obstacles to leveraging of AI/machine learning tools in finance departments right now, and
how can they be overcome? Many CFOs have not had the bandwidth to start -- or even find -- the resources to build out these capabilities. What will help them more than anything is shared learning by groups that are experimenting with -- and demonstrat- ing -- how these tools can actually be put to work. At Coverys, have teams exploring the potential. This is an important opportunity for collective learning to truly make a difference. We can help providers remove variability and improve their consistency and decision support by automating processes that once required humans to complete. We’re using a combination of AI and machine learning for automating a number of standardized processes -- producing claims history, renew- ing insurance policies, and processing certain aspects of malpractice claims. We are continu- ing to look into new areas where robotics can improve our efficiency and bring costs down -- a goal highly relevant to healthcare.
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hcinnovationgroup.com | SEPTEMBER/OCTOBER 2021 Bob Hanscom
Vice President of Risk Management and Analytics Coverys
What do the next few years look like to you?
It could be a very challenging time for many. You can’t just flip a switch tomorrow with innovative practices. Almost every health- care entity lost significant revenue during the pandemic. Small hospitals were hit hard, and the pressure on independent practices has never been greater, with physician burnout being a huge factor. And, like it or not, value- based care payment models are coming at a fast pace. But we are optimistic. Preparation is key—
what your organizations do today and whom you choose to do it with, will be the differ- ence between those who thrive in this new environment and those who cannot.
Coverys is the brand name of insurer Medical
Professional Mutual Insurance Company (MPMIC) and its subsidiaries. For information regarding MPMIC and its subsidiaries, please visit our website at
www.coverys.com. Products may not be available in all locations.
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