COVER STORY · REVENUE CYCLE MANAGEMENT
navigate the health insurance exchanges; in other areas, it might be around how to set up a payment plan, or how to navigate their insurance benefits.” Per that, asked which technologies are helping the most right now, he says that it is “the ones that handle a lot of the prior authorizations. The denials are still a problem, but the ones that can ensure that edits are going through and that all the appeals are done as expeditiously as possible. Helping patients through the preauthorizations, and making everything that can be, is automated. And then beyond preauthorizations, it helps to divert staff to work with the payers to eliminate categories that require preauthorizations. If 99 percent of the preauthorizations are approved, maybe we don’t need to do that.”
On the border between RPA and AI Many in the industry are very excited by the potential of artificial intelligence and machine learning to dramatically improve processes in revenue cycle management; but inevitably, Impact Advisors’ Akimchuk says, RCM leaders are going to have to get there through stages. For one thing, he observes, “We haven’t even gotten to the point yet where the majority of RCM departments are truly working by excep- tion. What’s happened is that we’ve been able to eliminate some widget-level activity by utilizing technology through editing and grouping activity to create a subset pre- dictable in terms of its outcome, to modify workflows, so that they’re automating their systems as much as possible. Where auto- mation has now expanded is in the ability to identify and interpret scenarios based on payer behavior, allowing us to preemptively respond without a human intervention.” Among the examples he cites are
“Things like eligibility mismatches, requests for information, payer pends on certain types of claims every time, where you can’t submit information until you get the request, because of HIPAA require- ments. Historically, most of our intelligence has been based on anecdotal information or small subsets. Now, with technology, we’ve been able to look at large amounts of data, so you can identify the small number of situations that prompt denials. We can build process around that without having to involve human interaction. That’s the new space that we’re starting to get into.” Is that the border between robotic pro-
cess automation (RPA) and actual machine learning-based AI? “It’s actually two pieces of the same solution,” Akimchuk says. “If you think about AI as the intelligence to identify and capture and RPA as the ability
to act on that intelligence, each has value, and combined, they have more value. The knowledge by itself gets you something, but not enough to drive towards a goal; and the action is only as good as the intelligence driving it. Traditional RPA has relied on a defined set of scenarios or rules: when A happens, you do B; when C happens, you do D. Machine learning/AI goes in and identifies those patterns. So instead of having a set of rules and outcomes, you can identify a set of hypotheses, and can program the RPA to act based on the insights you obtain. AI is a snipper: I may have hypotheses that I will use my machine learning to validate. Machine learning has the ability to take large pieces of data and establish its own hypotheses, based on identifying patterns. And you can then create process automation to react to that, or change your input before it happens.” How far along are hospitals on using
AI? “It’s early days,” Akimchuk says. “In healthcare right now, AI/machine learning is becoming prevalent in terms of diagnos- tics, such as in the mammogram/breast cancer space. AI identifies patterns and correlations, determines hypotheses, and then validates those hypotheses to deter- mine veracity. Everything we’ve done has prioritized the clinical. The business side of what we do has always lagged; and that’s appropriate, frankly. We’re in the business of helping people. This use of AI and even earlier, with the beginning of RPA, hasn’t changed that construct. So we are very much at the beginning of how we can utilize this; the value proposition that most organiza- tions are up against is simply, do I take my intellectual capital required to generate and create this, from the clinical to business solu- tions? And quite frankly, I’m less worried about whether we’ll get there and more focused on our best opportunities to get there early. If we can find and demonstrate the right use case, then it starts to get legs.”
A journey of 1,000 miles Looking at this complex landscape, where do experts think most hospitals, medi- cal groups, and health systems are right now on this journey of 1,000 miles? “So many hospitals are devoting more of their resources to clinical care and health IT, and we tend to undervalue revenue cycle management, because it’s seen as a cost center,” HFMA’s Gundling says. “But that prevents as good a consumer experience as with other types of experiences.” How might the technology advance
over the next few years? Impact Advisors’ Akimchuk says that, “As we go further down
6
hcinnovationgroup.com | JULY/AUGUST 2023
the path with better-defined technology, I believe that we’ll start to see more and more capsulized uses of this technology. Think about how data warehousing started—with a group of people trying to cobble together different tools into a solution. I believe that this is going to be similar to that; that it will take time for people to demonstrate value; and a technological approach to simplify this, whether that’s through visual program- ming or some other means.” Meanwhile, asked whether revenue
cycle leaders are moving forward with alacrity, Premier’s McBride says that “I think they want to do all of it; I think they’re very much interested in automa- tion and such solutions; but budgetary issues, getting it into the cycle, and having IT resources available, are among the bar- riers right now, she says. “One client said, ‘Our IT department has two years’ worth of projects they still have to go live on.’” Importantly,
though, Premier’s
McKasson observes, “The environment is becoming more difficult overall” in terms of the financial constraints under which RCM departments are operating, with the ongoing staffing shortages facing RCM leaders, and the realization of the need for hyper-efficiency. “It’s becoming harder overall, and they have to be cre- ative,” he says. “Also, retention becomes a big thing. If these individuals are hourly employees, going down the street for an extra dollar per hour, they’re willing to leap away. And then after you’ve trained them, you’ve wasted that time. So they’re implementing retention bonuses as well.” In this time of challenge and uncer-
tainty what should senior health IT leaders be doing? “I would want them to partner with the revenue cycle leaders, especially around robotic process automation,” Premier’s McBride urges. “The revenue cycle people have a level of IT knowledge, but supporting bots and other transforma- tive types of solutions—we need an IT partner to push that technology forward; it’s a joint effort. I would look to them to co-lead or help spearhead the effort. IT puts it in and supports it, but they don’t run it. The most successful implemen- tations have been when they’ve been co-led efforts with revenue cycle and IT. It’s technology-enabled operations. Your operations need to change and adapt; and IT, they’re scanning what’s out there seeing what’s out there and looking at IT solutions; when they partner with each of the individual operational groups, it leads to a better outcome. It’s not just implementation, it’s optimization.” HI
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36
