Many revenue cycle processes, including registration, prior authorization and claims management, are time consuming, repetitive and prone to human error.
As a result, many providers in the U.S. are looking into automation solutions to improve revenue capture, lower the cost to collect and remove the manual burden from staff.
However, many existing revenue cycle solutions make it difficult to reach those improvement goals, explained Malinka Walaliyadde, co-founder and CEO of Alpha Health, a company that offers a unified automation technology designed for the healthcare revenue cycle.
"It became very clear to me that capturing revenue was a very systemic challenge and that the healthcare industry was being vastly underserved by current technologies," Mr. Walaliyadde said. "So I put together a team spanning experts in multiple domains to solve the problem in a fundamentally different and better way."
Here, Mr. Walaliyadde discusses the revenue cycle challenges exposed by the COVID-19 pandemic, the benefits of automation and how providers can evaluate automation solutions. He also shared how Alpha Health is helping providers reach automation goals.
Editor's Note: Responses were edited for length and clarity.
Question: What revenue cycle challenges did the COVID-19 pandemic expose?
Malinka Walaliyadde: The pandemic exacerbated some problems that were already apparent across health systems and also exposed some new challenges. There are four main areas. The first being the need for staffing flexibility. Health systems across the country are seeing significant decreases in volume due to the pandemic. Eventually those procedures that were canceled will be rescheduled and the volume will come back, but it's going to come back in waves. Health system and revenue cycle leaders must be prepared to have the right staffing level to accommodate those waves. If system leaders don't predict perfectly, they're going to be either understaffed or overstaffed. The reality is that perfectly predicting staffing levels is unlikely, so leaders need to be able to manage through that volatility and have the ability to quickly scale up or scale down.
The second challenge is business continuity. During this crisis many staff shifted to working from home, which has been disruptive to a lot of folks. What some companies are seeing is a drop in productivity, which can result in the disruption of the entire revenue cycle. The challenge is to ensure that operations run smoothly despite some of these disruptions.
The third challenge is that with this reduction in volume, we're also seeing a drastic reduction in revenue. This will pick up when volumes return, but when the volumes come back it is going to have a significantly different payer makeup. In many cases, the change in payer makeup will likely be unfavorable to providers. As a result, any cost restructuring efforts that providers had taken before the pandemic are going to be even more critical as mid- to long-term revenue drops across the board.
Another challenge is that when providers were implementing revenue cycle solutions in the past, they often would have a group of consultants coming onsite to shadow staff. It is no longer going to be possible to bring that many people into hospitals, especially with strict visitor restrictions in place due to social distancing policies. Providers must start thinking through how to do virtual deployments as much as possible.
Q: Why should healthcare organizations prioritize revenue cycle optimization?
MW: An optimized revenue cycle can help healthcare organizations get through this challenging time filled with cost restructuring and payer mix changes. But, revenue cycle optimization is not new. Revenue cycle leaders are incredibly ambitious and focused on optimization, we just believe they have been vastly underserved by the technology world, and people in the technology world really have not stepped up to help those revenue cycle leaders meet their goals.
Q: How can automated revenue cycle processes benefit providers?
MW: A clear benefit of automation is that it reduces the amount of time staff spends on routine administrative tasks. We need to have revenue cycle staff focus their efforts on where the organization needs them, not on these routine tasks. There's this concept in the clinical world of working at the top of your license. We believe this applies in the revenue cycle as well. Automation can enable revenue cycle staff to work at the top of their license and spend their time on the tasks that return the greatest value to their organization. This reduction in time equates to a reduction in cost.
Q: How can providers find the right automation technologies for them?
MW: Providers should look for automation technologies that are flexible, meaning they can adapt to change and scale effectively. This is important because healthcare is a highly dynamic industry and typical technology like basic bots break when processes need to change.
When evaluating automation technologies, providers should also understand the different parts of the process, the full cost and time involved in deploying the solution. Many of the automation technologies out there today have significant amounts of hidden time and hidden costs. For example, we consider there to be three parts of the automation deployment process. Observing, which is mapping existing flows; learning, which is developing automation based on those workflows; and performing, autonomously performing those flows and maintaining through changing environments. Most leaders really think about the learning piece, like acquiring bots, when they think about automation deployment. However, with a focus on just that piece many providers are not aware upfront of the costs associated with process mapping and maintaining those flows after deployment.
That said, the most useful automation technologies are ones where all these pieces are incorporated upfront. Ideally the way you can ensure this is incorporated upfront is by working with automation technologies that are verticalized and specific to that domain. In this case, using solutions that have been purpose built for revenue cycle management in healthcare instead of trying to use horizontal technologies and force-fitting them into a specific vertical like healthcare.
Q: Can you describe how Alpha Health's solution differs from others on the market?
MW: Alpha Health's Unified Automation approach is entirely new. We built it from the ground up specifically for revenue cycle management in healthcare. Our machine learning models have been trained on 6 million claims and remittances covering more than $6 billion in gross patient revenue. We were very thoughtful about designing each component of our solution to fit perfectly together. It eliminates the need for a cumbersome patchwork of solutions, which is what exists today. So the three step processes of observing, learning and performing are all included. With other automation solutions, providers would have to work with potentially three different vendors to get those three core steps of automation completed.
In our solution, instead of sending an army of consultants onsite to shadow staff and understand where automation could be delivered, we have proprietary technology that we've built that can capture a multimodal 360-degree view of current workflows. You can capture a much larger fraction of the work that's currently taking place and use that to inform our machine learning models instead of using handwritten rules from shadowing staff. For the learn and perform pieces, our machine learning algorithms are trained using this data that we capture and then we can autonomously construct complex flows that would be extremely challenging to script by hand. Along the way, we also correct broken workflows and eliminate unnecessary work.
Finally, on the maintenance portion, if we actually look at what exists today, there doesn't really seem to be anything on the market that does this portion in a very streamlined way. As far as we've been able to see, what exists today on this part is that flows will break, health system customers will always find out days or weeks later, in which time they've lost significant revenue. Then they have to spend a lot more money to bring in someone else to fix it after those weeks, once they actually find out that something broke. With our solution, if something breaks, it is immediately triaged to one of our trained revenue cycle staff members. Then, our automation system is able to observe how our staff did that work and add it to the set of cases that it can do automatically in the future.
To learn more about Alpha Health and its revenue cycle automation solution, click here.