Finance executives address the three big challenges for revenue

From left: Jim Bohnsack, chief strategy officer of Aspirion moderates a panel discussion that includes Edna Buffington, vice president of revenue cycle at Community Health Services, Spencer Allee, chief AI officer at Aspirion. Bradley Tinnermon, senior vice president of finance shared services for Kaiser Permanente, and Ted Syverson, vice president of revenue cycle for King's Daughters Medical Center.

Photo: Susan Morse/HFN

LAS VEGAS - A panel of revenue cycle experts spelled out their biggest challenges during the HFMA Annual Conference in Las Vegas on Tuesday.  

The big three are staffing, denials and prior authorization. None likely surprised the standing-room only audience in the Mandalay Bay Conference Center. More than 3,500 people are attending the annual conference of the Healthcare Financial Management Association.

Hospital finance executives have been facing these issues for some time, with claims denials and prior authorization becoming such an increasing threat for provider finances that some have stopped taking Medicare Advantage reimbursement, where denials have reportedly been rampant.

A bipartisan group of over 50 representatives and senators sent a letter on June 25 asking Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure for increased oversight of Medicare Advantage coverage decisions. Plans use AI to erroneously deny care, the lawmakers said.

The panelists said they use AI and automation in all of the problem areas, where practical.

"A Practical Approach to Using AI, ML and Automation in Revenue Cycle," moderated by Jim Bohnsack, chief strategy officer of Aspirion, included panelists Edna Buffington, vice president of revenue cycle at Community Health Services; Spencer Allee, chief AI officer at Aspirion, Bradley Tinnermon, senior vice president for finance shared services for Kaiser Permanente, and Ted Syverson, vice president of revenue cycle for King's Daughters Medical Center.

Hospitals have a hard time remaining competitive to attract labor to jobs that pay the lowest wages in the health system, such as registration. Buffington said workers can make $25 at a car wash, compared to $14 an hour as a hospital employee working in registration.

Because of turnover, customer service is another area where hospitals struggle, when registration can be the first point of contact.

CHS is using AI to automate areas such as the phone system, and move staff to other jobs. 

Denials are a top priority for CHS, Buffington said. The health system gets very proactive to get pre-authorization. For instance, colonoscopies are being denied if there is no pre-authorization before a biopsy.

"Those are the main challenges for all of us to improve our reimbursement," Buffington said.

The CHS system automatically corrects variations in what's being paid if the insurance amount differs from what the system has produced.

CHS gets a weekly denial report. It's looking at how to implement systems for more complex denials and whether this is something to build in-house or go out to buy.

All revenue cycle departments are looking at build, buy or partner, Tinnermon said.

A lot of people have tried to automate the pre-authorization space, and that has proved to be more challenging than people think, Tinnermon said.

But Kaiser is doing a lot of analytical work around denial codes and what's needed to get those fixed. 

"That's something we're really looking into," Tinnerman said, "to see what we can automate."

Denials mean money is being spent on legal resources. In the past seven years, there's been more legal expenses spent over complex claims and contract-related issues, said Syverson, of King's Daughters Medical Center.

Kaiser Permanente is taking a deep look at automation to eliminate variation across systems, Tinnermon said. Some ideas for AI and tech improvements die on the drawing board because of the lack of connection with existing systems.

Kaiser is an integrated system that runs a risk-adjusted health plan that is expected to get bigger, Tinnermon said. And it runs three revenue cycles: a value-based revenue cycle, a revenue cycle for self-funded plans and a typical fee-for-service revenue cycle.

On AI and automation, the first thing Kaiser looks for is the stability of the core technology. The second is the cost to collect, and the next step is whether to have systems do real-time automation or to have an overnight approach.

"I'd say there's not a lot of places we're not looking," Tinnermon said.

Email the writer: SMorse@himss.org

The HIMSS AI in Healthcare Forum is scheduled to take place September 5-6 in Boston. Learn more and register.