7 Opportunities for Emerging Technology to Streamline Revenue Cycle and Claims Management

The challenges facing revenue cycle and claims management are well known: capture information upfront, prioritize correct diagnosis codes, minimize denials, etc. Finding a frictionless, scalable solution to do all this—that’s less obvious.

For decades, providers and digital health companies have labored away at these challenges. These “solutions” are manual, painfully slow, and riddled with their own problems: 

• Overlapping, ossified systems built for particular use cases and unable to handle new workflows or definitions
• Highly siloed functions with different operating systems for each team
• Disjointed data as there’s no common layer or standardization
• Heavy reliance on software vendors using waterfall approaches to build static platforms that may not deliver the expected value

But that’s the past. Now, we’re in the middle of a technological paradigm shift that promises to speed the innovation cycle in revenue cycle and claims management. Codeless development platforms, robotic process automation (RPA), machine learning, AI, and data infrastructure technologies have matured to become viable tools in building platform-based solutions.

For 15+ years, 3Pillar has helped digital health companies, health plans, and providers streamline their financial processes. From our learnings and conversations over the years, here are seven opportunities to leverage emerging technologies to streamline your billing processes.

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1. Recreate the health plan algorithm

Providers and their vendors all struggle to submit claims data in a way that maximizes acceptance and reimbursement rates. Part of the problem is health plan rules surrounding data formatting vary wildly—and are rarely disclosed. Beyond data formatting challenges, each payer has its own logic for accepting or denying claims. So you can optimize for one health plan, but there’s no guarantee that format will work with the next (in fact, it probably won’t).

This leads to a bizarre, low-tech troubleshooting process for denied claims. Back office teams compare denials to similar, successful analogs and update them accordingly. This painstaking process depends on institutional knowledge that, once a back office employee retires or resigns, is lost. 

A faster, more efficient approach is to use generative AI and machine learning (ML) to reverse-engineer each health plan’s unique rules engines. This involves a three step process:

• Use AI to extract historical data from past claims and tease out the appropriate rules—any mistakes are incorporated into the rules-based model and never made again
• Analyze your documentation: although clearing houses provide modern API documentation, these PDFs (hundreds of pages long) aren’t health plan-specific. Use AI to ingest publicly available call data and incorporate it into your rules engine.
• Leverage institutional knowledge by deploying configurable rules engines and subsequent robotic process automation (RPA) to capture and automate what your staff already knows—before they retire

2. Provide real-time coding assistance

There is little real-time support for clinicians as they code to minimize denials. Rather, the back office may manually evaluate claims against clinical notes to catch discrepancies; there is then  significant manual back and forth across functions before, finally, the claim is submitted and accepted. It’s a reactive process.

After building a model to reverse-engineer health plan algorithms, the next step is to pull those insights forward to the point of clinician coding. This can occur in three dimensions (in increasing order of good to best):

• 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.

3. Engage patients up front

The next opportunity—you guessed it—pulls the same approach we’ve discussed so far into the front office.

Most providers don’t collect member ID information until check-in. So there’s no way to verify their eligibility prior to service. What’s more, manual processes—collecting physical cards and entering insurance info—provide ample opportunity for human error.

Yet there’s a deeper issue here: these eligibility checks only determine whether coverage is active. They don’t prompt the patient to disclose secondary coverage, collect deductibles at the point of sale, or verify if the current visit is covered. All of these can seriously hurt the patient experience—namely by saddling them with unexpected bills.

Instead, providers can leverage advanced AI and ML platforms to:

• Digital check-in. Build a quality UI into your RCM system to engage patients upfront. The more you can customize your workflows to get the exact information you want, the better the overall patient experience will be.
• Improved eligibility data interpretation. Move beyond simply verifying active coverage and go deeper to retrieve the information mentioned above.
• Price transparency & POS collection. When coding happens in real-time, you’re able to have greater price transparency with your patients, and even collect payment at the POS. The problem is: most POS systems were built for copay plans, but most people now have deductibles. As such, calculating costs at the POS is more complicated than it’s been historically. An increased amount of automation and data is key to actually achieving this at the POS.

If you want a deeper dive into how health systems can leverage AI & ML to maximize clean claim submissions, download our playbook here.

4. Create interoperable, efficient internal work streams across Electronic Medical Records (EMRs)

It’s challenging for third-party digital health companies to standardize data across various EMRs. Subtle differences in definitions can cause disruption and broken workflows. This presents a serious obstacle to timely data access and standardization, which is necessary for RCM companies own internal workflows and product functionality, such as: 

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

For digital health companies who work across different EMRs from different providers, there’s an opportunity to capture data in real time, as opposed to periodic transfers. With this data as a common reference, you can create standard definitions of that data, then apply it across EMRs and clients. This is the only way to drive true interoperability.

5. Create open platform RCM architecture

Neither legacy EMRs nor third-party RCM products are built for interconnectivity. As a result, clients and their data are locked into a series of siloed systems. This makes platform modernization difficult at best—meaning digital health companies can’t deliver the leading-edge, advanced capabilities necessary to remain competitive.

Think about it: if your workflow doesn’t automatically check eligibility upon scheduled service, you risk either uncompensated care, or saddling the patient with an unexpected bill and seriously degrading their user experience. 

There’s a significant opportunity here for EMR vendors to modernize their tech stacks, building deep connectivity to RCM functionality. This will turn them into a full-on platform, not just another software vendor: 

• 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

6. Serve as the member financial concierge

Patients have long turned to doctors for medical guidance, but these clinicians often recommend care without understanding the financial implications for the patient. Previously, they could safely assume that patients would simply pay a copay, with the confusing details of billing relegated to the provider and health plan.

That reality has since changed. The emergence and growing adoption of high deductible plans means members have more interest in understanding where to go for care, the cost, and whether their bills are accurate. This means members are more aware of and engage more frequently with health plans, as their policies and rules govern this process.

Some examples of where this rubber meets the road include patient demands for modern, easily accessible provider directories to identify in-network care. Plus, members want a better understanding of how their plans work—as no one is reading a ten-page statement of benefits PDF. In fact, the interests of the health plan and the member are highly aligned—both want to know if bills are legit, and both want to avoid paying if they aren’t. And health plans will have far longer-term relationships with their members than any provider.

Then there’s the added wrinkle of Medicare Advantage, which empowers members to choose their plans upon retirement. The experience you provide when a member is 35 will go a long way to guide their decision when they turn 65. The better the experience, the more likely they’ll stick with a health plan into retirement.

Health plans, then, have an opportunity to differentiate themselves in the commercial market—namely among HR purchasers—by distinguishing themselves as the concierge advocate for the member. The easier you make it to provide value to members through modern data platforms, conversational AI, and other modern solutions, the better.

For health plans who want to remain competitive in a dynamic market, prioritizing the user experience is critical. Download our Revenue Cycle Playbook to learn how.

7. Reduce provider abrasion

On the surface, there’s a natural, zero-sum conflict between providers and health plans over claims. Submitted claims are revenue for the provider, but cost for the health plan. I’d even go so far as to argue that health plans have an incentive to make claims submission difficult. 

One head of RCM at a provider organization put it this way: “The entire system makes sense once you believe that payers do not want to pay you.”

As providers begin to reverse-engineer health plan claims acceptance and denial logic (see #1 above), local health plans have a unique opportunity to differentiate from national competitors and reduce provider abrasion—by sharing claims upfront.

This may seem counterproductive. But ultimately, it provides significant benefits for local and regional health plans: 

• Reduce costs by removing the need for endless provider and member questions
• Stop wasting resources on denials that will end up getting paid anyway
• Speed up patient care, which prevents them from receiving more expensive care within the same financial year
• Secure more competitively priced contracts as a result of reduced administrative costs

One way to accomplish this is to create a developer API portal that enables providers and their vendors direct access to data relevant to the claims submission process. This is far more efficient than directing them to a PDF that’s never updated and too unwieldy to manage.

Get started with RCM modernization

That’s a high-level view of how health plans, providers, and digital health companies can leverage modern technology and work collaboratively and cohesively to improve the situation for all involved. But how do you take all this and put it into practice in a way that doesn’t become a cost sink? 

Based on our decades of experience with RCM among a range of healthcare clients, we recommend the following steps:

• Assess your goals. Technology is never an end in itself. Before you decide whether modernization is a good investment, ask yourself: how will this new technology align with our overall business strategy?
• Build a roadmap. Don’t aim for a monolithic modernization of anything and everything. Start with initiatives that minimize time to value, accomplishing them one at a time. Then iterate from there to maintain project momentum and finish the roadmap.
• Start with data. Before you build a new platform, smooth out the data and workflows underlying and flowing through your various systems. Without this critical step, you’ll take all the problems of your broken processes and import them into a more expensive environment.
• Measure after each iteration. Once you define your business goals, measure your new modern platform to determine whether those goals were reached or missed. If you need to readjust, do it before you move to the next step.

Adopting this proven approach to RCM modernization can help reduce administrative spending and waste, resulting in a healthier bottom line—not to mention increased satisfaction across the healthcare ecosystem.

For more detail on how this can work and how to get started, download our whitepaper: The Revenue Cycle Playbook: 7 Opportunities to Modernize the Healthcare Payment Ecosystem.