Denials by commercial health plans rose 56 percent in 2023. Hospitals are spending nearly $20 billion annually in appealing said denials, resulting in many being overturned. Attendees at XCHANGE, a collaborative conference among payers and providers in Nashville, Tenn. from Sept. 29-Oct. 2, are tackling this conundrum head-on.
Health system executives and end users convened with health plan attendees across a variety of disciplines – revenue cycle, utilization management, physician advisor, and case management. Their common vocabulary was one of hope – “evangelists” that are collectively chipping away to earn their organizations a piece of a $360 billion dollar pie. That’s the projected amount that could be saved annually when artificial intelligence solutions are adopted more broadly in healthcare.
When health systems and health plans are able to collaborate using real-time data, automation, and objective insights, the odds of alignment increase. But that’s not to say the journey is an easy one.
“Change is hard” was a recurring comment during panel sessions. But change is a worthy pursuit for a variety of reasons that emerged as themes throughout the conference:
(1) Trust and collaboration: Both health systems and health plans recognize the opportunity to improve processes and relationships. For example, reducing unnecessary administrative work (faxing in particular) is a shared pain point for both parties.
Dr. Kathryn Lueken, the vice president of clinical utilization management at Humana, said up to 85 percent of medical necessity decisions are stalled or denied due to a lack of information.
“For example, with concurrent authorization, we have up to 72 hours to make a decision,” she said, “and a lot of the key pieces are held up in the EMR because it requires physician sign-off. (Xsolis’) scoring is instrumental in removing noise for either end of the spectrum and fine-tuning conversations.”
Building trust takes time. Some conversations are still tough to navigate. But many presenters agreed that AI can be used as a way to align decision making and minimize avoidable denials and unnecessary friction, thus improving collaboration and easing contract negotiations.
(2) Employee satisfaction: Burnout is a sweeping industry concern that affects revenue cycle and utilization management roles uniquely. This is due to the high amount of manual work that traditional, criteria-based utilization management solutions and even EMR workflows still perpetuate, according to Dr. Debbie Schardt, assistant vice president of revenue cycle and utilization management with MultiCare Health System.
“What we do every day plays on our emotions,” Schardt said, “because we are fighting these cases that are so obviously inpatient or OBS (observation).”
A shared AI platform such as Xsolis’ not only reduces manual work (and the emotional toll) to increase job satisfaction but puts the patient data to support appropriate care status at the clinician’s fingertips – more defensible positions when appeals arise.
(3) Operational efficiency: In a financial leaders panel and poll, workforce optimization ranked as the top challenge that keeps leaders up at night, closely followed by staffing shortages, burnout, and cost of labor. The good news? Workforce optimization is the only one of those contributors that leaders can control, as one panelist pointed out. In fact, leaders already have proven AI tools at their disposal that can drive efficiency.
Providers mentioned leveraging tools such as Xsolis’ Care Level Score to support decision-making, especially to guide clinicians toward the right cases, saving around two hours a day per user. The technology also helps predict discharge dates to reduce length of stay, which has become a growing priority.
(4) Ongoing value: XCHANGE attendees emphasized that new technology should be seen as a support tool.
“AI complements, not competes,” said Humana’s Angie Frame, who serves the Gulf South region as director of health services.
The ongoing success of tools is also contingent on having the right people and processes in place, which requires a high level of consultative customer service.
(5) Future opportunities: There is potential for deeper collaboration with real-time information across the continuum of care. AI could play a role in enhancing this further.
While it’s clear generative AI solutions will continue to take hold, event attendees remain cautiously optimistic about its untested capabilities in healthcare.
The regulatory landscape evolves constantly. Presidential election years pose an additional layer of uncertainty around the future, said Shawn Stack, director of perspectives and analysis, Healthcare Financial Management Association.
Stack encouraged the use of educational resources and collaborative forums such as the HFMA Executive Revenue Integrity Council for collective problem-solving as leaders look toward the future.