Hospitals and health systems across the country are experiencing unprecedented rates of claims denials, which are dampening their revenues and causing growing tensions in their relationships with payers.
During a February Becker's Hospital Review webinar sponsored by Aspirion, five revenue cycle leaders discussed how AI technology combined with human subject matter expertise can help organizations manage this trend.
Panelists were:
- Sheila Augustine, director, revenue cycle, Nebraska Medicine (Omaha)
- Jim Bohnsack, chief strategy officer, Aspirion
- Jason Kane, vice president, hospital revenue cycle, Jefferson Health (Philadelphia)
- Sheldon Pink, senior vice president, revenue cycle, Luminis Health (Annapolis, Md.)
- Kris Seymour, director, revenue cycle transformation and PMO, Wellstar (Marietta, Ga.)
Three key insights were:
- A high rate of denials raises multiple challenges for providers. Those challenges include elevated administrative costs, forced changes to resource allocation, risks to patient satisfaction, sudden process alterations to keep up with changing payer requirements, increased investments in staff training and a diminished return on investment.
Adding to these financial and logistical burdens, some payers' denial processes are antiquated, causing further frustration and delays. "You still have to fax, you have to mail, you can't do things automated," Ms. Augustine said.
At the same time, payers are leveraging automation in other parts of the workflow to deny more claims faster, creating a vicious cycle. "Payers are deploying technology at a pace that the provider community is not geared to deploy that way," Mr. Bohnsack said. - Applying AI to the revenue cycle can reduce or successfully appeal denials at scale. To support denial prevention and management initiatives in this new era, organizations need advanced technology tools.
Ms. Seymour said AI-powered tools that can detect patterns of denials and automatically address the underlying issues can be particularly helpful. These AI tools mean that organizations do not have to allocate additional FTEs to manually do those tasks. "Staffing is already a complicated issue in itself, so anything that relieves that is something that we're excited about and very interested to know more about."
However, the hallmark of an organization using AI tools well is selecting the right use cases for any given AI technology — and then making sure the technology is implemented successfully.
"There is value in AI, but it's how you can implement it in your organization," Mr. Pink said. "Everybody's hospital has their own DNA and that is the strength of your IT team, the strength of your revenue cycle team, your budget to support what kind of tool you can purchase. When you put all of that together, you can come up with a solution." - To prevent and appeal denials, providers are turning to specialized vendors. Beyond AI technology, provider organizations also need higher levels of specialized expertise to fend off the bulk of denials coming their way. The reason is that under the pretext of payment integrity programs, payers are increasingly shifting the burden of proof for medical necessity and claims appeals to providers. As a result, hospitals and health systems are having to involve not only more clinicians — at the expense of pulling them away from providing direct patient care — but also attorneys to justify those claims.
Vendors of revenue cycle management technology with specialized expertise in managing complex claims denials can provide a streamlined solution to those challenges. Aspirion relies on over 150 attorneys and over 65 clinicians to fill those gaps of expertise for providers.
"The volume that [Aspirion] can handle is far beyond what we were able to do," Mr. Kane said. "That takes a lot of stress off our internal utilization management team and allows them to focus on getting things better up front, so we can mitigate those appeals."
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