Submitting and paying claims is the financial underpinning of the U.S. healthcare system, a system plagued with inefficiencies that create disconnects between health plans and health systems. As a result, revenue cycles and claims systems are clogged, the patient and member experience is disrupted, care quality is suffering, and innovations in care delivery are constrained.
The solution? Modernization.
Modernizing the healthcare ecosystem reduces wasteful administrative spending, enhances price competitiveness, and drives strategic value. Providers, health plans, and health IT vendors can all leverage artificial intelligence (AI), robotic process automation (RPA), and low-code/no-code tools to improve revenue cycle and claims management by building customized experiences and workflows specific to their unique business needs.
Here are seven ways organizations can leverage these modern technologies to improve revenue cycle management (RCM) and claim management.
1. Recreate the Health Plan Algorithm
Historically, revenue cycle teams had to manually examine all denied claims, identify the most frequently rejected categories, analyze accepted claims within that category, and then adjust their process accordingly. Providers now have the opportunity to streamline this laborious process with technology.
Generative AI and machine learning can analyze all historical claims submission data and health plan medical policies to understand why claims get denied. This can be supplemented by RPA rules engines that capture staff’s institutional knowledge. The same process can be applied to understand the different formatting requirements for sending and receiving information to health plans through a clearinghouse. By automating these manual processes, providers and health IT vendors can leverage AI to better understand various health plans’ claims requirements and medical policies.
2. Provide Real-Time Coding Assistance
In a typical billing office scenario, a provider submits a claim, a payer denies it, and the billing office manually determines the reason for denial and works with the provider to change the claim and resubmit it.
Most legacy RCM systems fail to catch expected denials up front. However, providers can now use intelligent coding processes to mitigate denials by creating a rules engine that flags expected issues at the point of documentation and coding. This presents a significant opportunity to proactively and automatically ensure that the claims being submitted are capturing all the relevant information from the clinical note, ultimately reducing user errors and improving reimbursement outcomes.
3. Engage Patients Up Front
Many healthcare providers wait until a patient checks in to collect member ID numbers. This means they can’t verify if the patient’s insurance is active or get information about secondary policies ahead of their appointment. Providers also often fail to check if the specific visit type is covered by a patient’s insurance and they also often forget to collect a patient’s deductible or coinsurance after the visit. This misalignment on cost can lead to delayed or missed payments.
Modernizing the process by implementing digital check-ins, using eligibility data more effectively, ensuring price transparency, and facilitating point-of-service payment collections will not only benefit health IT vendors and providers, it will also greatly improve the patient experience.
4. Create Interoperable, Efficient Work Streams Across Electronic Medical Records (EMRs)
Building modern application programming interfaces (APIs) enables health IT vendors to deliver and access real-time data across the payment ecosystem, replacing traditional periodic data transfers. This empowers them to standardize and normalize data for sharing among health plans and providers. Automating this process reduces the need for human involvement, creating efficient workflows and saving costs. This is especially beneficial for managed billing services provided by many health IT vendors, particularly for handling denied claims and collections.
5. Create Open Platform RCM Architecture
Legacy EMRs and third-party RCM software products weren’t designed for interconnectivity, resulting in siloed systems where clients and their data are locked in, making modernization difficult. This leaves health IT vendors vulnerable to more advanced platforms and limits their ability to provide cutting-edge tools to help their customers stay competitive.
Health IT vendors have the opportunity to modernize their own technology stack and applications to build deep connectivity to RCM functionality across EMRs and other third-party solutions. By connecting with a variety of systems such as collections, EMRs, scheduling, digital patient check-in, billing services, and financial reporting, health IT vendors can develop platforms that address revenue cycle problems for providers and health plans more effectively.
Modernizing their tech stacks positions health IT vendors to elevate the role of RCM by creating open architectures that other healthcare organizations can leverage to integrate data and workflows across EMR and RCM systems.
6. Serve as a Member Financial Concierge
Health plans now have the technologies to move beyond traditional telephonic outreach to develop digital, personalized campaigns to engage members and help them understand care costs. Conversational AI, for example, can be used to explain to patients how their plans work and how much they may pay for service with a given provider.
This technology simplifies getting answers to specific questions and allows health plans to scale their efforts beyond call centers. To achieve this level of personalization, health plans need the right data to identify members’ barriers to care, financial concerns, social determinants of health, and connect programs and services that will benefit them.
7. Reduce Provider Abrasion
Modernizing payer claims systems with more transparent submission guidelines will speed up claims and prior authorization processing times. This efficiency reduces provider administrative costs and helps health plans secure more competitively priced contracts with providers and hospitals.
There is an inherent conflict between providers and health plans over claims: providers see claims as revenue, while health plans see them as expenses. This friction can be reduced by updating technologies to share claims logic and building trust with hospital leaders. A modern platform can help members find care services, understand benefits, make payments, and improve efficiency, reducing delays in patient care.
Modern payment systems use analytics to help providers forecast and develop contracts based on historical data, analyze unusual data, and understand how denials affect reimbursement rates, ultimately leading to more competitive contracts. Modernized payment architectures improve provider insights with analytics to forecast models that inform contract development based on historical data and analyze non-standard data to understand the correlation between denials and reimbursement rates to secure more competitively priced contracts with providers.
A New Era in Healthcare Payments: The Way Ahead
Modernizing the healthcare payment ecosystem is no longer a luxury but a necessity. By embracing advanced technologies such as AI and RPA, healthcare organizations can significantly enhance their revenue cycle and claims management processes. These innovations can reduce administrative burdens, increase efficiency, and improve patient and provider experiences. As the healthcare landscape evolves, those who invest in modernizing their payment systems will be better positioned to meet the demands of an increasingly complex and dynamic industry.
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About Steve Rowe
Steve Rowe, Healthcare Portfolio Industry Lead at 3Pillar Global, brings 15 years of experience launching new healthcare products with health systems, payers, distributors, retailers and pharmaceuticals. At 3Pillar, he partners with clients to identify the product and technical work that will deliver the strongest value.