Hospitals are seeing claims denials increase as insurers incorporate AI into the review process to quickly accept or reject claims. Hospitals are feeling the pinch as a result.
"We find more and more that claims can't find a way through to get paid," said Jim Heilsberg, CFO of TriState Health in Clarkston, Wash. "In the past, we were able to talk to individuals. We're now dealing with email and other solutions that don't allow us to get to the bottom of an issue. We find when we do get to what is perceived to be the bottom of an issue, we just find another one that props up for a claim."
TriState is working to implement AI solutions into the revenue cycle to stay ahead of the payers, but in general still "struggle to get claims paid." The challenge is particularly acute for Medicare Advantage and Medicaid programs, and commercial payers are "trying to push the envelope and not pay us," Mr. Heilsberg said.
"We are working with them trying to figure out what and why they're not paying," he said. "Without picking on any individual payers, I would say that, in general, all major payers have implemented solutions that are finding ways to deny claims and not allow us to be successful during appeals."
How can hospitals like TriState move forward? By relying on partnerships and optimizing current tools. TriSTate has the Meditech EHR and implemented Experian two years ago to help with the revenue cycle process.
"We've now had to move to what I've determined to be best of breed solutions that bolt on, where in the past, we never had to do that. Those solutions allow us to see more clearly areas that have issues," said Mr. Heilsberg. "They are supposed to allow us to deal with authorizations."
TriState is also working with Experian to implement new products identifying claims denied by code and predicting which ones will have the most success with appeals and/or highest dollar amounts. But the challenges persist with revenue cycle management and the potential for cyberattacks.
"We're an individual hospital, which really the pressure is trying to find ways to gain profitability that we can both pay for our operations, unprecedented increase in cost, and provide the needed building improvement and our maintenance we've continued to see falling behind," said Mr. Heilsberg. "Many hospitals are struggling to keep up. We're no different."
There is also big staffing challenges as wages increase with inflation faster than rate increases from payers. Hospitals across the U.S. are grappling with high labor costs, especially as the pool of qualified providers shrinks. But being too reactionary isn't the right approach, Mr. Heilsberg said.
"We don't need to be chasing money," he said. "We now chase a lot more dollars that we shouldn't have to. If we continue, we basically are continuing to decrease the foundation that allows us to be profitable."
Automation and adding clinical expertise can help.
"I'm excited about the capability of new tools related to AI, but more bots that can help improve our mostly manual workflows within the industry," said Mr. Heilsberg. "We have them throughout every organization, whether it be our support department and how we bill or collect patients, but also in our clinical environments. We do way too many manual things. If we can improve that, we hope to find ways to allow our licensed individuals to work up to the top of their license."