Addressing rising denial rates and reimbursement delays requires innovative approaches to technology strategy. As reimbursement becomes increasingly difficult, alleviating pressures on health system revenue cycles necessitates a new type of focus: one that values nuanced partnership assessments, prioritizes data utilization, and embraces technology-assisted decision-making.
At the HFMA Western Symposium, leaders in the field shared their experiences and strategies for navigating these changes.
Balancing In-House Development and Vendor Partnerships
Once of the key topics discussed was the decision-making process behind keeping projects in-house versus outsourcing. Sheldon Pink, Vice President of the Central Business Office at Methodist Health System, detailed his organization's rationale for internalizing certain revenue cycle functions.
"For claim status, one of the reasons why we kept it in-house was because we realized that it is going to be a perpetual task. Payers are going to continually change behavior, which means that we're always going to have to keep changing bots," Pink explained. "So, if you outsource, you'll keep paying a vendor indefinitely because the rules keep changing. Instead, we decided to build that talent in-house."
However, Pink acknowledged the challenges of this approach, particularly in troubleshooting. "An IT vendor has the advantage of having seen multiple scenarios across different organizations. When you're in-house, you only know what you've encountered, so problem solving can take longer."
Key Takeaways for Revenue Cycle Leaders:
💡As technology projects become larger, more interconnected, and technically more challenging than in previous years, health systems with future-ready revenue cycles will be those that excel at assessing, evaluating, contracting and negotiating partnerships with an expanding ecosystem of services and technology vendors.
💡As integration of AI is included in many projects, factors such as access to large data sets and the ability to continually invest in technology and innovate over time will play a more significant role in decisions to work with external partners.
Refining Data Quality for Enhanced Insights
Rudy Braccili, Director of A/R at Keck Medicine of USC, shared his organization's experience with gaining better denials management insights tied to a system coversion and the implementation of a new Denials Prevention Task Force.
"We've just converted from a 30- or 40-year-old patient accounting system," Braccili said. "It's a massive overhaul–new charge master, billing platform, general ledger interface. The decisions we make today will likely shape our organization for decades."
Alongside the conversion, Keck brought in a consulting group to revamp denials management. One of the first major challenges was ensuring data accuracy, consistency, and comprehensiveness.
"The very first report from our Denials Prevention Task Force showed $18 million in authorized denials from one facility. But our managed care director said, 'That doesn't make sense.' A deep dive revealed that payer-specific CARC and RARC codes weren't mapped properly. Payers use these codes inconsistently, making it difficult to get accurate insights into denials," Braccili noted.
The process of remapping codes took nearly a year, highlighting the need for robust data governance. "You've got gold mines of information waiting to be tapped, but you can't access real insights without rigorous data mapping," Braccili emphasized.
Key Takeaways for Revenue Cycle Leaders:
💡Developing mature data infrastructure and systems of data governance is integral for rapidly recognizing and responding to shifts in payer behavior.
💡Analytics capabilities and the potential for AI to be used in decision-making processes will depend on the quality of a healthcare provider's data. Without consistent and comprehensive data capture and mapping, organizations won't be able to fully capitalize on the capabilities of upcoming technologies.
Leveraging AI Within Your Denials Prevention and Management Projects
Tammy Bickle, Director of Revenue Cycle at Oregon Health & Science University, discussed the work of her organization's AI governance committee, which evaluates and sets recommendations around the use of AI across all departments. Her revenue cycle team has recently been exploring AI's potential to improve certain instances of appeal writing.
"Our newest project is a pilot focusing on AI-driven appeal letters," she said. "Currently, when we receive a medical necessity denial, we need input from multiple teams–coders, claim specialists, and clinicians–to justify the service."
Recent staffing cuts, rising insurer denial rates, and competing priorities for clinicians meant certain types of appeals wouldn't have the desired level of review and support. "Our AI tool integrates payer policies, scans medical records, and generates a structured appeal letter," says Bickle. With the tool, the organization hopes to supply clinical justification in some instances where it might otherwise have been unable to do so.
Key Takeaways for Revenue Cycle Leaders:
💡AI governance committees can effectively create frameworks for the use and monitoring of AI systems, including data privacy, security protocols, and ethical considerations. Collaborating with organizational leaders to establish a formal governance structure can streamline the process for revenue cycle leadership to quickly evaluate the feasibility, value and potential risks associated with proposed AI applications or partners making use of AI.
💡As technology projects grow increasingly complex, the problem solving skills demanded of revenue cycle teams are likely to shift. In addition to employees who are experts in traditional areas such as accounts receivable, revenue cycle leaders may need to seek out diverse expertise in IT, vendor contracting, and data integration and analysis.
About Knowtion Health
Knowtion Health is a leading provider of technology-enabled revenue cycle management services. The company leverages AI-driven technology and deep domain expertise to reduce denials and underpayments across all denial types, low balance accounts, and complex claims, while enhancing patient experience and satisfaction. Recognized as an Inc. 5000 fastest-growing company, Knowtion Health is a multi-year recipient of the Black Book award, which honors top partners as ranked by healthcare providers. To speak with an associate about your denials program, please give us a call at 561-995-1252 or email Services@KnowtionHealth.com.
