5 Competitive Use Cases for Health IT Vendors to Leverage Cutting-Edge Technology

Health IT vendors have a unique view of the healthcare payment ecosystem. Working across multiple providers or payers gives you the ability to tease out data patterns and business needs a single entity could easily miss.

Emerging technologies (like AI, ML, RPA, codeless application development platforms, etc.) can accelerate that process, allowing health IT vendors to move faster uncovering insights, introducing new value-add features, and automating internal processes. 

With reimbursements generally flat, departments at providers are under pressure to improve the cost and speed to collecting revenue. This makes the need for these changes more urgent than ever.

Below are five opportunity areas where health IT vendors can leverage new technologies to innovate faster.

Once you have a technology partner in your corner who can help you navigate the challenges listed above, here are five opportunity areas to drive more value for your customers and make internal operations more efficient.

Providers and their vendors all struggle to minimize claims denials. The inconsistencies and lack of transparency surrounding health plan rules has led to bizarre, low-tech troubleshooting processes for managing and fixing denied claims. 

As a health IT vendor, you have an opportunity to solve this pain by building an AI and machine learning (ML) engine that can recreate these health plan algorithms. This approach follows a three-step process:

• Extract clients’ historical claims data and tease out the rules
• Analyze available documentation (often hundreds of pages of PDFs that no one reads) to incorporate publicly available data into your rules engine
• Deploy configurable rules engines and subsequent robotic process automation (RPA) to capture and automate client institutional knowledge

Because this process deals with client-specific knowledge and data, you’ll want to make sure you have proper security and data usage protocols in place to maintain security and privacy.

A recreated health plan algorithm can serve as a foundation upon which you can build a host of applications and functionality for the customer’s entire organization. One of these is to build a real-time coding assistant powered by the rules engine.

There are three potential ways to operationalize this idea:

• Create a rules engine to flag potential documentation issues.After providers document and generate claims, an RPA-based application and workflow prompts potential billing issues, suggesting ways to fix it. 
• Autocomplete and co-pilot billing.The RCM system pulls historical data from the EMR and slots them into relevant fields.
• Ambient listening + real-time questions. These systems enable providers and their vendors to ask additional questions relevant to billing in real time, as well as give patients and doctors information about next steps, including real-time information about approximate costs. 

Another opportunity lies with the front office, where simple changes in the check-in process can have outsized effects on back-office claims success. 

Let’s start with the current status quo: most providers don’t collect member ID information until check-in. So prior to service, there’s no way to check a patient’s eligibility. And when front office staff do check patients in, they collect physical cards and enter insurance information manually, which provides ample opportunity for human error. 

Further, all a front office staff member can do at this point is determine whether coverage is active. They don’t take the next step to:

• Verify if the current visit is covered
• Collect deductibles at the point of sale
• Prompt the patient to disclose secondary coverage

Each of these details can seriously hurt the patient’s experience—namely by saddling them with unexpected bills.

Okay, so that’s the problem. What can you, as a health IT vendor, do about it? Since you’ve built a rules-based engine to minimize claims denials, you can simply built a front office application (or applications) that incorporates that logic:

• Digital check-in workflows to capture information relevant to claims submission process
• Verify both active coverage status and additional details to build a fuller picture of the patient’s coverage
• Build a POS application that’s built to handle deductible-based plans, which requires more advanced logic than a simple copay structure

Virtually every digital health application touches Electronic Medical Records (EMRs) in some way. Unfortunately, these systems contain subtle differences in data definitions that can cause disruption and broken workflows.  As such, data standardization across EMRs is critical for digital health applications to function effectively and interoperably:

• Running common, efficient codes and processes across all vendors
• Working denials and accelerate claims acceptance
• Providing financial dashboards with accurate, real-time information

By building workflows that capture data in real time (as opposed to periodic transfers), health IT vendors can build workflows that provide a common reference for all EMRs and clients. This not only improves the experience for all users, but makes further data-driven innovation possible. 

Most revenue cycle management (RCM) products aren’t built for interconnectivity. As a result, most clients and their data are locked into siloes—making platform modernization difficult at best, impossible at worst.  By modernizing your technology stack and converting from a series of softwares into a holistic platform, you can build deep connectivity to RCM functionality: 

• Build deep connectivity to RCM functionality across EMRs and other third-party solutions
• Integrate with a variety of systems—EMRs, collections, scheduling, digital patient check-in, billing managed services, financial reporting, etc.
• Build true platforms that transform the entire organization and fix revenue cycle breakpoints

Of course, you can move faster in these five areas by partnering with a product development company like 3Pillar. Our experience building for RCM and claims management means we know which best practices to implement—and the pitfalls to avoid.

If you’re ready to start implementing these—or any other—modern technological use case, make sure you have the right expertise in your corner. Learn more about 3Pillar’s healthcare-specific offerings here. 

Steve Rowe

Industry Leader, Healthcare Portfolio

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