Revenue Cycle Management Summit 2024
Thought Leadership Around Mitigating Challenges, Adopting Emerging Technology & Enhancing Cybersecurity

A Closer Look At Denials Management

Preventing denials by addressing front-end problems

• Most denials stem from eligibility/benefit verification, prior authorizations, and documentation/coding errors. Therefore, it is crucial to address these parts of the revenue cycle when attempting to reduce denials.
• Use real-time insurance discovery software and provide education for employees and physicians.
• Technology (e.g., ambient listening solutions) can eliminate unnecessary tasks and ensure data fidelity. Additionally, analyzing data fidelity and identifying points of failure can help reduce backlogs.

Insights on payer behavior and how to work together better

• Generally, healthcare organizations see payers as promoting good care at affordable prices; however, constant changes in rules and payer IT systems have led to increased denials.
• Some healthcare organizations feel that building partnerships with payers is becoming more challenging, citing reasons like payers having fewer account representatives, incentives being misaligned, and healthcare organizations sometimes receiving less payment than contracted. Additionally, healthcare organizations would like payers to share their wealth of data for AI development; doing so would make payers valuable partners.
• Healthcare organizations can preemptively do certain tasks (e.g., create letters of medical necessity) to facilitate payer relationships; however, transparency, shared goals, and continuous dialogue are critical for sustaining a long-term partnership.

The role of AI

• AI should increase efficiency around denials management without detracting from the daily staff responsibilities or increasing complexity. Ideally, AI should be able to resolve denials with minimal or no human intervention.
• Because AI is not always 100% accurate, rules-based automation (e.g., if this, then that) is beneficial. It is important to apply AI to the right problems (e.g., AI is particularly effective for prior authorizations) and recognize that not all issues require AI solutions.
• As AI evolves, healthcare organizations will need to keep up to date on advancements, manage governance, and seek transparency from vendors.

Strategies for Finding & Retaining Qualified Staff

Staff recruitment and retention are some of the biggest challenges in the industry, as workplace frustrations and operational inefficiencies are driving burned-out staff to other jobs and industries. Summit attendees brought up the following sustainable strategies for finding and retaining staff:

• Offer competitive pay and attractive benefits (e.g., flexible work arrangements, on-site amenities)
• Embrace remote work and flexible schedules while also maintaining team cohesion and culture
• Invest in training and development programs that focus on soft skills, technical skills, and the why behind certain tasks
• Create a positive work environment where employees feel valued, appreciated, connected, and able to grow
• Use effective recruitment strategies (e.g., identifying candidates via profile tests, hiring for personality and potential, looking beyond traditional healthcare backgrounds)
• Establish strong leadership, a clear vision and mission, and open communication 
• Be mindful when deciding to outsource—carefully weigh the costs and benefits of outsourcing, and if you do decide to outsource, be directly involved in the processes, have clear and frequent partner communication/documentation, and balance technology with human expertise

Insights on RCM Outsourcing

Pre-summit survey respondents report various sentiments toward RCM outsourcing, despite almost 80% saying that they currently outsource part or all of their RCM processes. This result suggests that although healthcare organizations prefer to keep RCM operations in-house, they have been pushed to outsource part or all of their processes due to staffing challenges. Still, outsourcing is a viable solution for tapping into additional talent pools and offloading staff recruitment and retention (visit the KLAS website for more findings on RCM outsourcing services).

Using these pre-summit survey results as context, attendees shared the following best practices for outsourcing:

• Treat outsourcing partners as an extension of your team: Build strong partnerships with firms via transparency, regular communication, goal alignment, and a unified approach that integrates on-shore and off-shore teams.
• Establish secure connections and data protection protocols.
• Have well-defined contracts and SLAs: Expectations around quality, volume, and outcomes must be clearly communicated in order to manage firm relationships and ensure high performance.
• Embrace automation and technology: This can significantly improve efficiency and reduce costs. Choose a firm that is committed to innovation and able to adapt.
• Perform thorough due diligence when selecting a firm: Don’t rely solely on reference calls. Conduct case studies and test projects to evaluate a firm’s capabilities and cultural fit.
• Proactively manage the relationship with the firm: Establish a strong relationship in the first 60-90 days of the engagement, continually monitor performance metrics, and regularly communicate about any issues
• Balance cost with other factors when making your decision: Cost shouldn’t be the only consideration factor; innovation, risk management, and cultural fit should also be considered.

How Vendors/Firms Can Improve Relationship with Clients

Strong partnerships are critical for achieving RCM success. Panelists shared the following recommendations for how vendors/firms can strengthen client partnerships:

Keys to Success When Adopting Technology

Things that healthcare organizations can do internally:

• Get buy-in from all key stakeholders (e.g., physicians, IT, operations, executives)
• Identify the problem that your organization is trying to solve—then find the technology that is the best fit for helping you solve it
• Don’t make a decision too quickly; take the time to evaluate different vendors and get third-party insights from KLAS Research and others
• Establish clear metrics and goals to track the implementation’s success
• Have a strong governance structure to help ensure technology projects align with overall business goals
• Prioritize optimization over innovation; get the most out of existing technology before investing in new solutions
• Make the most of pilot projects; pilots allow organizations to test technology and identify potential issues before rollout while also creating the opportunity to identify internal champions
• Have a clear communication plan and make sure everyone is aware of the implementation and how it will impact them
• Use data to make decisions; this will cultivate trust and ensure the implementation is successful

Things healthcare providers can do externally:

• View vendors as partners; work with them to co-create a change management plan
• Establish clear expectations around vendor relationships; define roles, responsibilities, and communication protocols

Governance Is Critical When Adopting Technology for RCM

Keynote speaker J.D. Whitlock, CIO of Dayton Children’s Hospital, emphasized the importance of governance as organizations adopt technology. The following are key takeaways:

• RCM leadership and IT leadership should evaluate emerging technology together (e.g., autonomous coding, RPA, features available via the EHR)
• RCM leaders can partner with IT leaders to eliminate poor-fitting technology/vendors early in the selection process
• Thoroughly digesting KLAS content can be helpful for assessing new technology
• AI should be considered as a helpful tool, despite it not being the solution to everything; there are fewer opportunities for legal repercussions when using AI for RCM compared to clinical or diagnostic use cases

Ambient Speech Vendors Encourage RCM Leaders to Get More Involved with Ambient Speech

Founders and/or CEOs of six ambient speech vendors joined a panel to discuss how RCM leaders can get involved with ambient speech, marking the first time that these vendors’ executives were together on the same stage. They highlighted the following:

• Although ambient speech technology is being widely piloted and adopted by many healthcare organizations, the involvement from RCM leadership is low. This is surprising, as ambient speech technology has downstream RCM effects and can facilitate more thorough and accurate documentation, coding, claims, and billing.
• Ambient speech technology is opening the door to changes in the clinician, patient, and billing experiences. The executives on this panel envision patient encounters where (1) physicians are focused entirely on the patients without technology in the way, (2) patients receive optimal care, and (3) the billing is accurate and nearly instantaneous once encounters are complete.

Actions That Organizations Took in Response to Incident

Preventive Measures & Assessment Questions That Can Help Prevent Breaches 

Keynote speaker Mike Green, Commissioner of EHNAC (Electronic Healthcare Network Accreditation Commission) and CISO at Availity, spoke about how cybersecurity breaches are a growing threat in healthcare. He suggested that RCM leaders implement the following three preventive measures:

1. Use real-time alerts and notifications for changes in electric funds transfers (EFTs); this will allow leaders to quickly detect fraudulent activities.
2. Restrict EFT access during administrative data changes to mitigate risks.
3. Reinforce validation checks during user registration to prevent synthetic IDs.

Green also stressed the importance of collaboration between RCM and IT security teams. Healthcare organizations should ask HIT vendors the following questions to assess solution security:

• Can you explain your advanced security features? (Look for vendors with industry-leading encryption, secure data centers, and strict access controls.)
• Are you up to date on regulatory compliance? (Vendors should adhere to current industry standards.)
• What is your risk management strategy? (Vendors should aim to proactively identify and mitigate potential threats.)
• Is a redundancy plan in place? (Vendors need robust backup systems to minimize downtime and ensure business continuity.)
• Do you offer 24/7 monitoring? (Look for vendors that provide around-the-clock support for immediate issue resolution.)
• How in depth is your network coverage? (Vendors should have robust direct connections to necessary payers to maintain connectivity and business continuity.)