It would be an understatement to say that artificial intelligence (AI) and automation are “trending topics” today. Everywhere you look, there’s a headline about a new use case for OpenAI’s ChatGPT — from college essays to law exams, real estate listings to blog posts.
Even in healthcare, we’re seeing the trend take over. Yes — slow-moving, hesitant-to-adopt healthcare is boarding the automation train.
Healthcare revenue cycle management (RCM) is one area ripe for an automation upgrade. Although there has been encouraging progress in revenue cycle management automation, there are opportunities to improve further and innovate.
Let’s dive into the promising world of revenue cycle automation and what it means for growing private practices and health tech companies.
What Is Revenue Cycle Management Automation?
Revenue cycle management automation uses technology to manage the tasks and workflows involved with an organization’s revenue cycle. The revenue cycle is the financial process that allows a practice, physician or healthcare organization to receive reimbursement for care.
RCM automation eliminates the need for manual, human-powered intervention within the revenue cycle. In other words, it offloads tedious work related to eligibility, claim submission, denials and payments.
Why We Need Revenue Cycle Automation in Healthcare
Anyone who has worked within RCM knows how tedious and time-consuming it can be. Sure, reimbursement sounds simple on the surface, but beneath that surface is a behemoth of tricky coding and complex payer rules that make it challenging to get paid.
The tedious processes of RCM exacerbate major pain points our industry feels today:
- Provider and employee burnout (often from mountains of administrative work)
- Lower compensation and reimbursement rates amidst rising inflation
- Increasing patient expectations and the rise of healthcare “consumerism”
When you can automate much of the RCM workload, you can save time and eliminate many of the errors that delay reimbursement. And with fewer manual RCM processes, private practices can dedicate more resources to patient care, resulting in higher patient satisfaction and better outcomes.
But the benefits of revenue cycle automation don’t apply only to private practices and providers — health tech companies, like electronic health record (EHR) platforms, can profit from this technology, too. Employing automation within existing RCM tools reduces employee workload and eliminates the need to hire additional staff to manage the claims process.
Types of Revenue Cycle Automation
There are a few ways to approach revenue cycle automation. The type of automation you use will depend on the tasks you need to automate. In some cases, you can combine more than one type of automation.
Robotic Process Automation (RPA)
Robotic process automation, or RPA, is an older form of automation that can handle relatively simple, repetitive tasks. RPA automation uses scripting to pull information from various connected sources — something that would normally be tedious and time-consuming for a human to do. For example, you might use RPA to automatically pull claim statuses or post payment amounts from an electronic remittance advice (ERA).
RPA can be helpful for some basic, repetitive tasks, but it still needs some human intervention to create a script and make adjustments if that script breaks. While it may alleviate some of the pain points around RCM, other, more advanced forms of automation can be more effective.
Artificial Intelligence (AI)
Artificial intelligence (AI) isn’t just a buzzword — it’s the present and future of revenue cycle management automation.
Unlike RPA, AI is more adaptable and can adjust processes as information and payer rules evolve. Machine learning (a type of AI) can digest and analyze large amounts of information and provide recommendations or insights. So, instead of a human sifting through detailed insurance or claim data, the AI can analyze the information and find trends.
There are also potential use cases for natural language processing (NLP), another form of AI that can analyze both written and spoken words.
Identifying trends helps us improve RCM processes. And in some cases, AI can learn, adapt and make those improvements without human intervention, further reducing the RCM workload.
Applications for Revenue Cycle Management Automation
Healthcare revenue cycle management automation sounds great in theory. But how can we apply it to those daily, tedious RCM tasks?
Here are some ways automation can improve various RCM and billing process steps.
Prior Authorization
Although several insurers have vowed to eliminate some prior authorization requirements, they’re still a reality in many medical specialties today. And, unfortunately, it’s often a barrier to efficient care and an administrative burden for physicians and practices.
But AI-driven revenue cycle automation can ease the strain of handling prior authorizations. Using ML and NLP, AI can process and analyze all the data required for prior authorization — including patient demographic information, clinical notes, plan details, etc. Then, the AI can either decide for the payer or provide crucial information that will make it easier for a physician to determine whether to approve the prior authorization.
Insurance Eligibility
Patient insurance eligibility is the first and most crucial step of the RCM process. Skipping an eligibility check may mean the claim is a loss from the beginning — if the patient doesn’t have active insurance, a provider won’t be able to receive reimbursement for the care they provide.
Despite its importance, eligibility checks can be a large burden. Automating checks on a daily or weekly basis can save time and efficiently catch errors and invalid insurance, which will minimize claim denials and reduce time to reimbursement.
Patient Estimates
Providing upfront estimates is an excellent way to improve the revenue cycle. And according to a 2018 HIMSS survey, 68% of patients would be more likely to return to practice for future care if it provided cost estimates before the appointment or procedure.
Providing good faith estimates can also keep you compliant with the No Surprises Act.
Automating estimates can improve revenue without taking time away from patients or other important administrative tasks. Plus, it can improve customer satisfaction and patient retention.
Claim Processing and Scrubbing
One of the most impactful use cases of revenue cycle automation is claim processing and scrubbing. Billers, revenue cycle managers and practices can all use tools that automatically submit claims, eliminating the need for manual submission.
Automation can also reduce the time spent editing or scrubbing claims. Whether using RPA scripts or AI-powered ML, creating specific edit rules can help avoid rejections and denials.
We can use CPT code modifiers as an example for RCM automation, like when telehealth claims should have the “95” or “GT” (Medicare) modifier attached to the CPT code. With a revenue cycle management automation, you can create a workflow that automatically adds this modifier to claims based on the rendering provider. Or, you could automatically add this modifier to specific CPT codes.
The automation reduces the time it takes to check these code modifiers. It also reduces the chance of a denial due to a missing modifier — and fewer denials mean faster reimbursement.
Patient Collections
Processing statements for patient responsibility is another laborious process within the revenue cycle. But automating patient billing statements and collections will save time and headaches. Some revenue cycle automation software can recognize a patient balance after the insurance processes and then create and send an invoice without human intervention.
Adding Automation to Your Revenue Cycle Processes
As we’ve outlined, there are ample benefits to RCM automation. But automating every part of the revenue cycle may not be the easiest first step.
Instead, consider the biggest problems disrupting your revenue cycle process today. Where is your team spending the most time and resources? Prioritize finding an automation solution that solves those pain points. Eventually, you may automate every piece of the revenue cycle. But it’s more critical that you find the best solution for your business today to build a solid foundation for the future.
Gentem is on a mission to help private practices and health tech companies thrive by improving the reimbursement process. We use AI-powered automation to optimize the revenue cycle, minimize administrative workload and reduce time-to-reimbursement. Learn more today with a quick intro call.
