What You Should Know: 

– Healthcare automation company Olive today announced it will shut down its business after selling its Clearinghouse and Patient Access business units to Waystar and its Prior Authorization business unit to Humata Health. Olive sold off its utilization management solution and business unit to Availity and business intelligence solution to BurstIQ earlier this year.

– Founded in 2012, Olive is a developer of an artificial intelligence workforce, automated revenue cycle and claims management for the healthcare industry. The company secured over $900M in funding reaching a $4B valuation. Olive’s enterprise AI has been implemented at more than 900 hospitals across 40 U.S. states, including more than 20 of the top 100 U.S. health systems.

Healthcare providers are feeling the industry’s talent shortage in their administrative functions as well as clinical areas. One case in point: revenue cycle management. In a recent study, 63% of healthcare providers reported an inability to fill key revenue management roles. Reduced revenues and cash reserves are almost inevitable when providers don’t have sufficient staff to follow up on claims, manage appeals and help patients understand their financial responsibilities and options. 

Fortunately for providers, revenue cycle automation offers timely, cost-effective solutions to the talent shortage. Robotic process automation (RPA) is a proven technology for automating rote, repetitive processes that involve multiple steps and systems and/or substantial human and machine interaction. Using software bots, RPA essentially mimics the keystrokes of human operators. Many bots can be developed and deployed in a matter of weeks. They then work tirelessly and accurately, including during off-hours. At one institution, a software bot cleared a backlog of thousands of claims status checks in just a single weekend. It would have taken humans hundreds of days to accomplish that task. 

RPA is just the start. With software bots streamlining processes and improving data accuracy, the foundation is set for creating more sophisticated automation solutions built on AI and ML models. These can tackle more complex tasks that involve following business rules and making decisions based on the models’ data analysis.  These AI/ML solutions often are more expensive and take longer to implement than RPA. They are best suited for providers that already have standardized processes and cleaner data from their existing automation. 

Unlock revenue fast with robotic process automation

Automating RCM tasks frees up revenue management professionals to take on other, more complex activities, such as providing financial counseling during patient pre-registration activities. RPA solutions will also enable providers to improve revenue cycle productivity without adding additional employees. Many RCM tasks are excellent candidates for automation via software bots and RPA, including: 

Claims status checks. Bots can look up claims data and other information in payer portals, then update systems and even initiate next steps, eliminating these rote tasks and returning time to revenue professionals.

Automated patient pre-registration. RPA bots can link applications and systems together to automate more complex transactions and extract more value from them. Take a patient-facing, self-service registration portal. After a patient agrees to interact digitally with the provider, RPA bots can download patient registration requests; retrieve patient data from an electronic health record (EHR); then update the patient engagement system. The update can trigger the engagement system to send the patient a self-registration and payment link. When the patient completes those steps, the RPA bots can access the payment and patient demographic data and update the provider’s EHR. 

Digitally enabled prior authorization. Bots can easily retrieve patient data, insurance details, CPT codes, physician details, diagnosis codes and schedules from an EHR; flag cases requiring prior authorization; and submit them digitally to a payer portal. Then bots can update records with approved requests. They can also automatically route denied cases requiring additional information to the right clinicians, then refile them when updated. 

What about AI? 

RPA software bots essentially follow sets of rules. While a rule set can be complicated and involve several systems, software bots generally make preprogrammed if/then decisions. Outliers can be routed to finance professionals for follow-up. 

In contrast, automation solutions that incorporate AI and machine learning algorithms can evolve and eventually make autonomous decisions. Put very simply, an ML algorithm learns from the data sets to which it’s exposed, finding patterns and relationships. This makes ML potentially very powerful. ML algorithms can stratify patient accounts by a propensity to pay and automate financial assistance applications. That would reduce costs to collect while improving revenue realization. ML could also identify missing charges and help avoid revenue loss. Those applications, however, are complex. In general, the more advanced the technology, the more time and expense required to implement it. That’s not to take these options off the table. While they undoubtedly will play a role in coding and other tasks, ML and AI applications often are more than many providers need to solve immediate staffing and revenue realization issues. Healthcare organizations must carefully select which processes to automate to ensure the results meet their needs. 

Moving forward with automation

Providers must be clear about what they hope to achieve by automating their revenue cycles and realistic about the time and resources they have available to allocate to the project. The following steps can help guide decisions about which revenue cycle processes to tackle.

• Choose low-hanging opportunities first. Providers should build organizational automation experience before attempting more ambitious projects. The provider that solved its claims status check backlog with RPA initially applied the solution to claims from its largest payer. After succeeding there, the provider then expanded the initiative to claims from its other payers. 

• Choose opportunities that minimize IT involvement. Provider IT professionals often have many competing priorities. Developing RPA software bots requires minimal IT input. 

• Choose a vendor that understands healthcare revenue cycle services. Working with a skilled, experienced vendor helps minimize the time and input a provider’s revenue professionals must give to the engagement. Vendors with RPA and healthcare revenue expertise can build flexible bot frameworks so bots can be extended to other applications with minimal programming.

• Prioritize opportunities that tangibly improve patient and employee experiences. Improving the patient financial experience is a growing priority. Automating tedious, repetitive tasks reduces errors and frees revenue staff to work on more complex issues that deliver more value to patients and the organization. 

• Evaluate the return on investment. Most RPA projects should deliver a return 2 to 3 times greater than the investment. Reconsider projects that have lower anticipated returns or that indicate a long time to ROI. 

The societal changes that have shrunk healthcare’s labor pool are here to stay. Automating the revenue cycle will position providers to improve cash flow, enable their revenue professionals to work at the top of their abilities and offer patients the streamlined digital experiences they increasingly expect. Most importantly, providers will have more of the financial resources they need to focus on their true expertise, delivering patient care and improving outcomes.

About Noel A. Felipe, CRCR
With over 38 years of experience in healthcare accounts receivable management, Noel has a proven track record of developing progressive client-based solutions and building strong cross-functional teams to implement those solutions and maximize client results. At Firstsource Noel maintains direct account management responsibility for strategic clients and leads the development team for Firstsource’s digital collection and digital pre-service collection platforms.  Noel attended Miami Dade College, is a member of the American Association of Health Administration Management (AAHAM); has served two terms as president of the Florida Chapter of HFMA and was appointed to HFMA’s National Advisory Council for Revenue Cycle.

What You Should Know:

– Autonomous coding enjoys a high level of trust among healthcare finance professionals who use or plan to use the technology, according to new survey from the Healthcare Financial Management Association (HFMA) on behalf of AGS Health.

– The survey reveals 45 percent of healthcare financial professionals indicate autonomous coding often works well and 16 percent place their complete trust in it. However, despite its emergence as a powerful tool for streamlining and improving error-prone manual coding processes, autonomous coding suffers from an awareness problem, with 52 percent saying they do not know what it is.

The Promise of Autonomous Coding for Revenue Cycle

Among the key benefits of autonomous coding is its ability to eliminate the potential for human errors that result in missed reimbursement opportunities, backlogs, delays, and claims errors, and its ability to push accuracy levels to near-perfect percentages. All of which can be achieved in near real-time with the right integration pipelines. Autonomous coding is also faster than its human counterparts – it can complete charts in seconds – yet it also understands what it does not know, flagging it for human review.

Despite fewer than half of respondents saying they fully understand autonomous coding, survey results nonetheless indicated that finance professionals are very aware of its potential:

· Nearly 67 percent believed it would accelerate the revenue cycle

· 63 percent said it would improve coding accuracy

· More than 59 percent indicated it would reduce the need for human intervention

· Nearly 56 percent said it would lower overall costs to the healthcare provider

· More than 48 percent responded that it would optimize coding for the greatest reimbursement

· Just over 23 percent said it would improve patient satisfaction

· More than 22 percent said it would improve patient care

“Autonomous coding is a rapidly maturing solution for many of the most significant pain points plaguing the healthcare revenue cycle, and we are already seeing its impact with productivity increasing by 20-35% on average,” said Emily Bonham, Senior Vice President of Product Management for AGS Health. “However, pushing its adoption past the tipping point requires closing the knowledge gap among healthcare finance leaders on what to expect from autonomous coding as well as how to design, deploy, and optimize a solution that works best for their organization’s needs.”

Survey Background/Methodology

AGS Health commissioned this survey of more than 450 healthcare finance professionals during the HFMA Annual Conference to determine the extent to which autonomous coding is taking hold in the healthcare industry. It also sought to pinpoint the value hospitals and health systems are gaining from a tech-enabled approach to coding and the barriers that stand in the way of implementation.

What You Should Know:

– Abridge, a company leading the way in generative AI for healthcare raises $30M in Series B funding led by Spark Capital, along with several leading healthcare innovators, including Mayo Clinic, Kaiser Permanente Ventures, CVS Health Ventures, UC Investments, Lifepoint Health, SCAN Health Plan, and the American College of Cardiology.

– Abridge’s generative AI scribe automatically converts a patient-clinician conversation into a structured clinical note draft in real-time, leveraging their proprietary AI pipeline.

“I want to care for patients, not paperwork.”

The solution has been proven to save clinicians over two hours per day from administrative burdens that previously took time away from patients and detracted from clinician work-life balance. In recent implementations, over 91% of notes across over 40 specialties were drafted solely with their AI, requiring minimal input from the clinician. The solution has been uniquely designed with trust and auditability, providing the ability to quickly see source data from any AI-generated summary.

Expansion Plans

The company plans to use the latest round of funding to support large-scale health system rollouts and accelerate product advances that will create additional value for patients, clinicians, and health systems.

“The investment and support of these iconic institutions is a game-changer for Abridge, dramatically accelerating what we can do to solve a critical issue facing every health system,” said Dr. Shiv Rao, co-founder and CEO of Abridge. “We are grateful to have an extraordinary and rapidly expanding group of partners who share our ambition to preserve the empathy and humanity in healthcare by enabling clinicians to be more present with their patients.”

In May 2022, a California doctor was sentenced to nearly eight years in prison for his involvement in a $12 million Medicare fraud scheme. His crime: performing unnecessary vein ablation procedures on patients, and using incorrect billing codes to receive larger reimbursements. He received $4.5 million in reimbursements from Medicare over a three-year period.

Compared to this example, most instances of “upcoding” and “overcoding” are not as malevolent or expensive. But even an innocent mistake can cause well-intentioned hospitals and health systems to attract attention from federal auditors, and result in stiff penalties for physicians and those who input the wrong billing codes.

Proper medical coding is crucial to accurately reflect the complexity and intensity of any services rendered. Physicians must stay updated on current coding guidelines and ensure that the codes selected reflect the true nature of the patient encounter. This is especially true in a healthcare industry ravaged by layoffs, where every line item is scrutinized and every budget is tight. 

As hospitals and health systems merge, consolidate, and find other ways to reduce operating expenses, having a dedicated team of coders offers critical oversight. They’re often the last line of defense between logging the correct code and a mistake that costs a provider millions of dollars.

Here are 12 best practices for avoiding a costly coding mistake:

1. Code accurately: Physicians should avoid both upcoding (billing for a higher level of service than performed) and downcoding (billing for a lower level of service). Coding should accurately reflect the medical necessity and complexity of each visit. 
2. Accurate Documentation: Complete and accurate medical documentation is essential for justifying the services provided. Clear, detailed, and comprehensive records support appropriate coding and billing, ensuring that services are reimbursed at the appropriate level.
3. Modifier Utilization: Correct use of modifiers can clarify specific circumstances that may affect reimbursement. For example, modifiers can indicate if a service was provided on the same day as a procedure, if a service was discontinued, or if multiple procedures were performed.
4. Medical Necessity: Demonstrating medical necessity is crucial to secure reimbursement. Physicians should clearly document the reasons why a particular service was necessary for the patient’s condition, linking the diagnosis to the treatment provided.
5. Utilization Reviews: Regularly reviewing utilization patterns can help identify opportunities to improve efficiency without compromising patient care. This can involve analyzing patterns of referrals, tests, and treatments to ensure they align with evidence-based guidelines.
6. Negotiate with Payers: Effective negotiation with insurance payers can lead to more favorable reimbursement rates. Physicians should emphasize their value in terms of patient outcomes, quality of care, and cost-effectiveness.
7. Value-Based Care Initiatives: Participating in value-based care models and accountable care organizations can lead to increased reimbursement based on improved patient outcomes and cost savings.
8. Minimize Denials and Appeals: Preventing denials through proper documentation and coding reduces the need for appeals, saving time and resources. When appealing denials, ensure that the appeal includes all necessary information and supporting documentation.
9. Patient Collections: Efficient patient billing and collections processes can improve cash flow. Clear communication about patient financial responsibilities and available payment options can lead to fewer outstanding balances.
10. Continuous Education: Staying informed about changes in healthcare regulations, coding guidelines, and reimbursement policies is essential to adapt to evolving requirements and opportunities.
11. Utilize Technology: Electronic health records (EHR) systems and practice management software can streamline billing processes, improve accuracy, and reduce administrative burdens.
12. Audit Readiness: Maintain records and documentation in a way that ensures readiness for audits. Compliance with regulations and guidelines is crucial to avoid penalties and loss of reimbursement.

When both human and financial resources disappear, in-house coders might face an increasing number of responsibilities that strain their ability to perform the basic, money-saving essentials of their job. It might be wise to outsource to an organization that focuses only on medical coding. These remote teams come with less overhead costs and lack the burden of having to acclimate to other aspects of a hospital’s functions. They can focus their professional development on staying current with coding and coding alone.

Outsourcing is often standard practice for independent physicians, who sometimes do procedures in a health care system but can’t use that system’s coders. Simply outsourcing all their coding becomes the more efficient choice.

Whether outsourcing or in-sourcing, staying current with the rules and regulations of coding is essential to a hospital or health system’s financial health. Physicians and their staff must regularly update their coding knowledge to stay in line with the latest guidelines. This prevents errors and helps accurately represent services provided. 

Although time and money are in short supply for nearly all healthcare professionals in 2023, taking resources away from coding can easily cost more money than it saves.

About Hilton M Hudson

Hilton M Hudson, MD, FACS, is a board-certified cardiothoracic surgeon and the Chief of Cardiothoracic Surgery at Franciscan’s Michigan City and Olympia Fields health systems. He is also the CEO of HPC International (HPC), the leading educational purchased services supplier for healthcare, corporations and academic institutions.

What You Should Know: 

– More than one-third of hospital and health system transactions announced in Q3 2023 involved a  party that cited financial distress as a transaction driver, according to Kaufman Hall’s latest mergers and acquisitions (M&A) report. The reports reveal third quarter M&A activity remained high with 18 announced transactions resulting in $8.2B in total transacted revenue.

– Kaufman Hall experts say transaction activity is regaining momentum as hospitals, health systems, and other healthcare organizations seek new alliances, partnerships, and ultimately, long-term financial sustainability. 

– Despite only one “mega-merger” transaction—in which the smaller party has annual revenues above $1 billion—Q3 average seller size and total transacted revenue remain above historical levels.

Other key findings from the report include: 

– Not-for-profit health systems were the acquiring or larger party in 14 of Q3’s 18 announced transactions, with for-profit systems acting as the acquiring party in the remaining four transactions. 

– Of the 14 not-for-profit acquirers, seven were academic/university-affiliated organizations (see discussion below) and one was a religiously affiliated organization. 

– The four transactions in which a for-profit system acted as acquirer focused primarily on smaller, financially distressed organizations: three of the four acquired organizations were financially distressed.

What You Should Know: 

– WellSky, a health and community care technology company, announced it has acquired Corridor, an end-to-end tech-enabled services platform for the post-acute care industry, from HealthEdge Investment Partners. Financial detials of the acquisition were not disclosed. 

– By adding Corridor to its portfolio, WellSky will expand its medical coding and revenue cycle management (RCM) offerings to help care providers increase efficiency and improve performance across clinical, financial, operational, and compliance areas.

Corridor Background

Founded in 1989, The Corridor Group Holdings, LLC (Corridor) is a leading provider of technology-enabled outsourced coding, revenue cycle and education solutions to the post-acute healthcare industry. Corridor has a proven track record as a leading tech-enabled services partner to post-acute providers, serving more than 2,600 client sites and supporting more than 52,000 clinicians. 

Post-Acquisition Plans

Given the increasingly complex and frequently changing regulations that complicate coding and billing processes, healthcare organizations are turning to trusted and experienced coding and RCM providers who can increase productivity and help ensure accurate reimbursement. 

The acquisition of Corridor allows WellSky to strengthen its position in home health coding and RCM and move into the skilled nursing facility billing business. 

As part of the acquisition, Corridor CEO Des Varady is staying on to lead the Corridor team, along with the Corridor leadership team, who will integrate with WellSky as they evolve and invest in the future of tech-enabled services. Corridor’s deep industry expertise in billing and financials, workforce issues, and medical coding complements WellSky’s aim to deliver innovative solutions that power providers’ success. Corridor clients will soon be able to leverage WellSky’s robust analytics, care coordination, patient engagement, interoperability, and EHR solutions to enhance care quality and better position clients for success with value-based care models.

What You Should Know: 

– Access Healthcare, a provider of revenue cycle management (RCM) and healthcare services, announced the acquisition of Envera Health, a market leader in patient engagement services. 

– This acquisition, a testament to Access Healthcare’s focus on providing innovative and superior revenue cycle solutions, broadens its service portfolio to include enhanced patient engagement capabilities.

Acquisition Stregthens Access Healthcare’s RCM Services

By leveraging Envera’s patient engagement capabilities, Access Healthcare will strengthen its end-to-end RCM services delivery and further enhance its proprietary workflows and process intelligence platform. This unique combination will deliver progressively improved outcomes to customers. With delivery capabilities across upstream and downstream processes, Access Healthcare is uniquely positioned to unlock insights derived from operational processes to prevent claim denials, maximize collections, and enhance the overall patient experience.

Healthcare providers are feeling the industry’s talent shortage in their administrative functions as well as clinical areas. One case in point: revenue cycle management. In a recent study, 63% of healthcare providers reported an inability to fill key revenue management roles. Reduced revenues and cash reserves are almost inevitable when providers don’t have sufficient staff to follow up on claims, manage appeals and help patients understand their financial responsibilities and options. 

Fortunately for providers, revenue cycle automation offers timely, cost-effective solutions to the talent shortage. Robotic process automation (RPA) is proven technology for automating rote, repetitive processes that involve multiple steps and systems and/or substantial human and machine interaction. Using software bots, RPA essentially mimics the keystrokes of human operators. Many bots can be developed and deployed in a matter of weeks. They then work tirelessly and accurately, including during off-hours. At one institution, a software bot cleared a backlog of thousands of claims status checks in just a single weekend. It would have taken humans hundreds of days to accomplish that task. 

RPA is just the start. With software bots streamlining processes and improving data accuracy, the foundation is set for creating more sophisticated automation solutions built on AI and ML models. These can tackle more complex tasks that involve following business rules and making decisions based on the models’ data analysis.  These AI/ML solutions often are more expensive and take longer to implement than RPA. They are best suited for providers that already have standardized processes and cleaner data from their existing automation. 

Unlock revenue fast with robotic process automation

Automating RCM tasks frees up revenue management professionals to take on other, more complex activities, such as providing financial counseling during patient pre-registration activities. RPA solutions will also enable providers to improve revenue cycle productivity without adding additional employees. Many RCM tasks are excellent candidates for automation via software bots and RPA, including: 

Claims status checks. Bots can look up claims data and other information in payer portals, then update systems and even initiate next steps, eliminating these rote tasks and returning time to revenue professionals.

Automated patient pre-registration. RPA bots can link applications and systems together to automate more complex transactions and extract more value from them. Take a patient-facing, self-service registration portal. After a patient agrees to interact digitally with the provider, RPA bots can download patient registration requests; retrieve patient data from an electronic health record (EHR); then update the patient engagement system. The update can trigger the engagement system to send the patient a self-registration and payment link. When the patient completes those steps, the RPA bots can access the payment and patient demographic data and update the provider’s EHR. 

Digitally enabled prior authorization. Bots can easily retrieve patient data, insurance details, CPT codes, physician details, diagnosis codes and schedules from an EHR; flag cases requiring prior authorization; and submit them digitally to a payer portal. Then bots can update records with approved requests. They can also automatically route denied cases requiring additional information to the right clinicians, then refile them when updated. 

What about AI? 

RPA software bots essentially follow sets of rules. While a rule set can be complicated and involve several systems, software bots generally are making preprogrammed if/then decisions. Outliers can be routed to finance professionals for follow-up. 

In contrast, automation solutions that incorporate AI and machine learning algorithms can evolve and eventually make autonomous decisions. Put very simply, an ML algorithm learns from the data sets to which it’s exposed, finding patterns and relationships. This makes ML potentially very powerful. ML algorithms can stratify patient accounts by propensity to pay and automate financial assistance applications. That would reduce costs to collect while improving revenue realization. ML could also identify missing charges and help avoid revenue loss. Those applications, however, are complex. In general, the more advanced the technology, the more time and expense required to implement it. That’s not to take these options off the table. While they undoubtedly will play a role in coding and other tasks, ML and AI applications often are more than many providers need to solve immediate staffing and revenue realization issues. Healthcare organizations must carefully select which processes to automate to ensure the results meet their needs. 

Moving forward with automation

Providers must be clear about what they hope to achieve by automating their revenue cycles and realistic about the time and resources they have available to allocate to the project. The following steps can help guide decisions about which revenue cycle processes to tackle.

• Choose low-hanging opportunities first. Providers should build organizational automation experience before attempting more ambitious projects. The provider that solved its claims status check backlog with RPA initially applied the solution to claims from its largest payer. After succeeding there, the provider then expanded the initiative to claims from its other payers. 

• Choose opportunities that minimize IT involvement. Provider IT professionals often have many competing priorities. Developing RPA software bots requires minimal IT input. 

• Choose a vendor that understands healthcare revenue cycle services. Working with a skilled, experienced vendor helps minimize the time and input a provider’s revenue professionals must give to the engagement. Vendors with RPA and healthcare revenue expertise can build flexible bot frameworks so bots can be extended to other applications with minimal programming.

• Prioritize opportunities that tangibly improve patient and employee experiences. Improving the patient financial experience is a growing priority. Automating tedious, repetitive tasks reduces errors and frees revenue staff to work on more complex issues that deliver more value to patients and the organization. 

• Evaluate the return on investment. Most RPA projects should deliver a return 2 to 3 times greater than the investment. Reconsider projects that have lower anticipated returns or that indicate a long time to ROI. 

The societal changes that have shrunk healthcare’s labor pool are here to stay. Automating the revenue cycle will position providers to improve cash flow, enable their revenue professionals to work at the top of their abilities and offer patients the streamlined digital experiences they increasingly expect. Most importantly, providers will have more of the financial resources they need to focus on their true expertise, delivering patient care and improving outcomes.

About Noel A. Felipe, CRCR
With over 38 years of experience in healthcare accounts receivable management, Noel has a proven track record of developing progressive client-based solutions and building strong cross-functional teams to implement those solutions and maximize client results. At Firstsource, Noel maintains direct account management responsibility for strategic clients and leads the development team for Firstsource’s digital collection and digital pre-service collection platforms.  Noel attended Miami Dade College, is a member of the American Association of Health Administration Management (AAHAM); has served two terms as president of the Florida Chapter of HFMA and was appointed to HFMA’s National Advisory Council for Revenue Cycle.

If you’ve ever worked behind the scenes at a provider organization, you likely gained a deep understanding of what makes medical practices tick, giving you the ability to make fairly accurate assumptions about how patients will probably behave in different scenarios. However, when it comes to the patient payment experience, inevitably some patients respond differently than expected.

Seasoned healthcare workers have likely experienced a number of common misconceptions about patients’ behaviors, demands, and preferences. While many providers and staff may already be aware of these misconceptions, the broader healthcare community may not be as familiar. Here are a few scenarios where provider expectations sometimes fail to align with reality. T

EXPECTATION: Patients have a thorough understanding of their own medical coverage.

REALITY: Common health insurance terms such as “in-network,” “deductible,” and “copay” are used so frequently in medical practices that they are recognized and understood immediately by staff. However, for many patients – particularly those who only interact with the medical system a few times per year – these phrases and concepts are much less familiar. Acronyms like EOB and EHR only add to potential confusion. 

For example, one consumer survey asked insured adults about how well they understand key aspects of their health insurance – what it covers, what they will owe out of pocket when they use care, how to find information about provider networks, what their explanation of benefits (EOB) statements say, and common terms used in health insurance. 

The survey found that 51% of insured adults say they find at least one aspect of how their insurance works at least somewhat difficult to understand. Further, education level did not appear to help as 58% of college graduates said they had difficulty understanding an aspect of their insurance coverage.

EXPECTATION: Patients expect lengthy appointments and a time-consuming in-office experience.

REALITY: Patients today are pressed for time and expect the convenience from healthcare that they’ve experienced in other consumer interactions. They are less tolerant of delays that some providers may view as a routine part of doing business.  However, by embracing new technologies such as self-service online check-in, providers can reduce manual paperwork and improve the patient experience.

EXPECTATION: Patients comprehend their financial responsibility.

REALITY: When it comes to understanding their out-of-pocket costs for medical bills, patients are often left in the dark until insurance documents arrive in the email. For example, one survey found that only 52% of patients fully understood their financial responsibility for a recent medical bill. The same survey revealed that 60% of patients surveyed said they are at least somewhat likely to pay their bill upfront if a cost estimate is offered in advance or at the time of service. To help patients improve healthcare literacy while also boosting patients’ engagement in their own care, providers can educate patients on their coverage and what it means, whether via online resources, in-office signage, or a one-on-one conversation at the time of service.

Additionally, because patients are more likely to pay when they know upfront costs, delivering accurate up-front estimates is a best practice for providers. Cost estimation tools can create clear projections that enable patients to know what will be owed at or before the time of service. After clarifying responsibility with patients, it becomes easier to facilitate payment and gain a card-on-file prior to the patient leaving the office. Additionally, the transparency and predictability provided by accurate upfront estimates can improve patient trust and loyalty.

EXPECTATION: Patients adequately budget for medical expenses.

REALITY: Four in 10 U.S. adults have some form of healthcare debt, according to a Kaiser Family Foundation survey. Uninsured adults, women, Black and Hispanic adults, parents, and those with lower incomes are especially likely to say they have healthcare-related debt.

Further, about half of adults – including three in 10 of those who do not currently have health care debt – are vulnerable to falling into debt, saying they would be unable to pay a $500 unexpected medical bill without borrowing money. Of course, the ability to pay varies by patient, but medical bills sometimes go unpaid due to other more immediate needs. 

EXPECTATION: Older patients prefer traditional payment methods.

REALITY: While conventional wisdom holds that young people are more likely to use digital technology than seniors, that doesn’t mean that older patients don’t take advantage of more modern convenient options. For example, a PYMTS survey recently found that 8% of Baby Boomers and seniors had made a payment through a physicians’ website, which matched the percentage of Generation Z. Similarly, more than 20% of seniors and Baby Boomers reported making a payment through a patient portal. Clearly, digital payment options are not just for the young. 

Reality doesn’t always conform to our expectations, and the reality of patients’ healthcare payment habits is no different. By understanding healthcare payments through the eyes of patients, providers can take steps to improve the payment experience. 

About Ryne Natzke

As Chief Revenue Officer of TrustCommerce, Ryne Natzke is responsible for managing the integrated health and payments strategy and largest, strategic accounts across our key verticals, including both large merchants and software partners. Previously, he worked with early-stage digital health companies at HealthX Ventures and managed partnerships at Epic.

What You Should Know: 

– The American Health Information Management Association (AHIMA) today announced that it acquired HCPro and its associated brands from Simplify Compliance. The strategic acquisition broadens the reach of both organizations.  

– AHIMA will operate HCPro as a for-profit, wholly-owned subsidiary, enabling the organization to remain focused on caring for its clients.  

HCPro Background

HCPro is an industry leader in integrated information, education, training, and consulting products and services in healthcare compliance and revenue cycle management. HCPro provides education solutions designed to help healthcare organizations deliver consistent training, achieve compliance, and maximize efficiencies across the revenue cycle, resulting in measurable clinical, quality, and financial improvements. The HCPro family of brands includes DecisionHealth, Association for Clinical Documentation Integrity Specialists (ACDIS), National Association for Healthcare Revenue Integrity (NAHRI), and the Association of Home Care Coding & Compliance (AHCC).  

What You Should Know:

– Augmedix, a provider of ambient medical documentation and data solutions, announced the early access release Augmedix Go, a clinician-controlled mobile app that uses generative AI to instantaneously create a fully automated draft medical note after each patient visit.

Augmedix Go harnesses proprietary natural language processing (NLP), large language models (LLMs), and structured data sets, key components of Augmedix’s tech stack. This powerful technology is utilized in a thoughtful manner to ensure comprehensive and highly accurate medical notes with appropriate guardrails that safeguard against errors.

Clinician-Controlled Mobile App for Acute & Ambulatory Settings

The new solution offers a variety of features to support busy healthcare clinicians throughout their clinic day, including summaries of key medical events, reminders of unfinished notes, and flexibility for post-visit dictation and text editing. The mobile app includes output control through a multimodal interface and can be utilized in both acute and ambulatory care settings. The new app can be deployed quickly across hospitals and health systems. Clinicians can get immediate access to review, edit and approve their medical notes, and can be integrated into any leading electronic health record (EHR) system.

“Augmedix was the first to bring to market the practice of ambient medical documentation to the nation’s leading health systems,” said Augmedix Founder, Director, and Chief Strategy Officer Ian Shakil. “Building upon the success of our full-service Augmedix Live and Augmedix Notes products, Augmedix Go is unique in that it reimagines the clinician experience at scale. This product serves as a prime example of the future of AI medical documentation.”

What You Should Know:

• Rising healthcare expenses, lack of certainty over costs and financial support and poor coordination between providers and payers have caused consumers to feel more stressed than ever before about their healthcare bills. According to the 2024 Healthcare Financial Experience Study, 72% of consumers cite affordability as the biggest challenge to paying larger healthcare bills—not that they don’t want to. Struggling to afford healthcare bills isn’t just a headache, it can directly impact patients’ healing from their hospital visit, with 47% saying their well-being or healing has been negatively impacted by difficulty paying a healthcare bill.
• The annual study was commissioned by Cedar, an enterprise financial engagement platform that improves the end-to-end journey for consumers, and conducted by EI Studios, the custom division of The Economist Group, and fielded via online methodology among over 1,200 US consumers.

Insights into Healthcare’s Unaffordability Crisis

“Healthcare costs continue to increase, and as most large employers are self-insured, the impact to them has been considerable,” says Vincent Tammaro, chief financial officer at The Ohio State University Wexner Medical Center, who was interviewed for the report. “As a result, over the last ten years, many of these self-insured employers have in turn asked their employees to share a larger portion of those costs. On average, even folks who are insured through some type of employer plan are ultimately paying about 30-33% of their healthcare costs. I think that is really contributing to a lot of the angst from a patient/consumer standpoint.”

The escalating growth of healthcare expenses is causing significant anxiety, yet many consumers remain unable to access or are simply unaware of available financial assistance resources. Despite 63% of individuals being unable to afford more than $750 in unexpected out-of-pocket expenses, an equal percentage are unfamiliar with the financial aid options at their disposal.

With a substantial 58% of consumers expressing stress when it comes to paying healthcare bills, it’s clear that providers alone cannot mend this dysfunctional system. The 2024 report highlights the imperative for collaboration among payers, providers, and financial institutions to streamline and make healthcare’s financial aspect more affordable. A staggering 71% of consumers find the process of reconciling billing issues between their health insurer and healthcare provider to be stressful, and 4 in 10 will withhold payment if they cannot comprehend the administrative procedures.

Organizations that prioritize consumer-centric technology are more likely to witness an improvement in their financial performance, as patients are more inclined to promptly resolve their bills and are more likely to return. Over half (58%) of consumers have returned to healthcare providers due to a positive billing experience, while more than one-third (38%) have switched providers because of a negative billing experience. This phenomenon is even more pronounced when payers and providers collaborate, as an overwhelming majority (96%) of consumers deem coordination in billing and payment between their provider and payer as vital to their overall satisfaction with their health insurer.

Consumers are expressing a strong demand for increased financial support and clarity in the healthcare system. Many are concerned about their ability to cover medical expenses in the coming year, with 23% unable to handle surprise bills exceeding $250. A significant 71% of consumers would be more inclined to seek medical financial aid if they had accessible and clear options.

Navigating the complex healthcare ecosystem remains a challenge, as 73% of consumers desire a unified platform to view real-time benefits information alongside their provider bills. Confusion about insurance benefits has led to bill payment delays for 28% of consumers, and 34% have refrained from using medical spending accounts due to unfavorable experiences.

Billing transparency and ease significantly impact consumer loyalty, with 92% emphasizing the importance of coordination between providers and payers in their likelihood to recommend a healthcare provider. Positive billing experiences have prompted 49% of consumers to leave favorable reviews for their providers, and 43% express a greater willingness to expedite bill payments if provided with clear explanations regarding deductibles and out-of-pocket maximums’ impact on their bills.

Typically, hearing the terms “Automation or AI” elicits one of two responses– an immediate sense of apprehension and avoidance, or a complete overestimation of its capabilities, though in some cases those two responses go hand in hand. However, neither view is particularly helpful as one is trying to understand the tremendous power of this capability and employ it in appropriate places within their business. 

The truth is, automation and AI are here and they’re here to stay. Though there are new capabilities and tools in both areas, those tools are really the outgrowth of a technology-focused transition that exists across almost all industries. Businesses that choose not to understand and adopt new technologies will be left behind. Still, others who rely too heavily upon it without proper planning and understanding may put their businesses at risk. Automation, including AI-enhanced automation, is certainly not a magic wand. It’s simply a tool, and like anything else, must be utilized strategically. A thorough understanding of the capabilities and limitations of the technology and a strategic utilization of its functionality are what’s needed to ensure success. It’s all about balance. 

Within the healthcare revenue cycle specifically, automation can be a transformative force in enhancing efficiency, reducing errors and cutting costs. However, for healthcare systems looking to employ automation, whether AI-enhanced or more traditional, there are key principles to keep in mind to ensure technologies are being utilized in the best ways and in the most impactable areas to achieve maximum and sustainable results. 

1. Automation within healthcare systems must always be balanced with a patient-centric approach. Over the years, mainly due to cost-cutting measures, many healthcare systems have discontinued or reduced the scope of patient advocacy and engagement programs. With the recent focus and shift to automation capabilities as an additional cost-cutting measure, it will be critical to keep a patient-centric approach at the forefront, maintaining critical patient touches, patient education, and an omnichannel communication strategy while employing automation. 

2. Automation is not a substitute for effective process design and management. In fact, in most cases, automation requires more. Automation will amplify the accuracy of a well-designed process, and similarly, will amplify the flaws of a poorly designed one. To be effective, automation requires a foundation of meticulously designed and managed processes which must be created before any automation is implemented.  

3. Automation without an understanding of underlying processes and the mechanisms of the automation can be a risk to an organization; there should always be a fallback plan. When organizations choose to implement automation without a thorough understanding of the underlying processes and mechanisms, there can be significant risks to the organization. For example, when an automated system encounters an anomaly that it isn’t programmed to handle, the errors that result can have far-reaching negative impacts on the organization’s revenue cycle and bottom line.  It’s critical that organizations have not only a thorough understanding of the technology doing the automation but also of the systems and processes being automated and the potential errors and anomalies that could arise. A fallback plan should be implemented to handle these issues, including gaps and or lapses in the execution of the automation themselves, to ensure business continuity. 

4. Automation initiatives must consider full costs (design, development, maintenance) as a part of ROI determination. Before undertaking an automation project, all costs must be evaluated. This includes costs of any technology, initial design and development, and regular, ongoing maintenance which will be critical to ongoing success. All these costs must be factored in to determine the true ROI delivered over time. For example, some automation initiatives could require substantial investment in IT infrastructure and ongoing maintenance, so initially, it could appear that labor costs may be reduced, but once the calculations are complete, the anticipated cost savings may not be realized as compared to current processes or alternative approaches. 

5. In prioritizing and evaluating the value of automation initiatives and opportunities, consideration should be given to incremental value and not just cost-cutting opportunities. Yes, automation can reduce labor costs and other operational expenses, but its value extends much further. It also has the potential to enhance accuracy; reducing the rate of billing errors which improves patient safety and trust in addition to any tangible cost savings. It also improves compliance by ensuring that every step of a process is performed consistently, in accordance with regulations. Lastly, it can also speed up processes, enabling the organization to handle higher volumes of work without increasing staffing levels or it can free up human resources from mundane, routine tasks to focus on more critical and strategic objectives. 

Automation, particularly when enhanced with AI, holds great promise and potential for many businesses and specifically within the healthcare revenue cycle. However, to be successful, organizations must make balanced and informed decisions when evaluating these opportunities. With a patient-centric approach, careful process design and management, a deep understanding of the underlying processes and automation mechanisms, a comprehensive view of the costs with a balanced evaluation of the value, automation can truly be a game-changer.  

About John Hataway

John Hataway is the Senior Director of Continuous Improvement and Automation at Savista, a revenue cycle management consulting and staffing company.

What You Should Know: 

– TeleVox announced it has acquired the Odeza patient engagement business from Ensemble Health Partners (Ensemble), a revenue cycle management company for hospitals, health systems and physician practices. Financial terms of the acquisition were not disclosed. 

– The acquisition will make TeleVox’s technology available to Ensemble’s customers, offering healthcare providers a comprehensive solution from patient acquisition to discharge and beyond.