By Matt Bridge, senior vice president – Strategy and Solutions, AGS Health.
Optimizing financial clearance and other patient access operations is an important aspect of any strategy to offset revenue cycle issues that are behind more than half of all claim denials. Healthcare organizations struggle to do so, however, thanks to staffing and technology limitations that impede efficient operational processes and increase front-end authorization errors.
Those barriers are starting to crumble as artificial intelligence (AI) and automation become more deeply embedded in healthcare revenue cycle management (RCM). Of particular note is the emerging subset of tools designed to streamline and expedite aspects of financial clearance operations, including eligibility and benefits determination and prior authorization processes. Early adopters of these intelligent authorization tools are reporting rapid return on investment (ROI), including 70% to 85% faster eligibility and benefit determination and 85%-90% improvement in authorization determination time.
Also being reported are 65% to 80% less time on authorization initiation and authorization follow-up times that are up to 85% shorter, as well as 80% faster price estimating. The result of these improvements is not only higher revenue growth and employee retention, but an improved overall patient financial experience.
Challenges to Financial Clearance
Operational inefficiencies, outdated technology, and staffing limitations are among the main contributors to rising denial rates, which were up to nearly 12% in the first half of 2022. More than 41% of those denials are the result of front-end RCM issues, including eligibility, authorization, and other financial clearance activities, which also contribute to higher net revenue leakage via avoidable write-offs.
Breakdowns in the financial clearance process can also drive down patient experience scores, with one survey reporting that 93% of patient respondents indicated provider loyalties hinge on their financial experience and more than half said it also impacts their decision to refer a friend or family member. Forty-one percent said they’re unhappy with their overall medical billing experience, with many pointing to a lack of pricing transparency or certainty despite the No Surprises Act mandate to provide them with both.
One cause is the critical shortage of RCM professionals. More than 60% of providers face RCM staff shortages, and nearly half of CFOs and revenue cycle vice presidents from large health systems and physician groups say their labor shortages are severe, with four in 10 reporting vacancy rates between 51%-75%.
The opportunity to resolve these challenges while also eliminating error-prone manual processes from financial clearance is why nearly 80% of healthcare organizations surveyed are turning to AI and automation. Financial clearance and its redundant and time-consuming tasks is a prime candidate for AI and automation, with 42% of respondents to one survey saying their organization would benefit most if eligibility checks and prior authorizations were automated.
By Eric McGuire, senior vice president, Medical Coding and CDI Service Lines and Corporate Strategy, AGS Health.
Traditional fee-for-service reimbursements are falling by the wayside as healthcare continues its transition toward value-based reimbursement models. This is evidenced by data from the Health Care Payment & Learning Action Network (LAN), which shows more than half of healthcare payments in 2022 were made under value-based care models. Additionally, nearly 75% of health plan leaders surveyed by LAN believe value-based care model activity will continue to rise.
Integral to this transition – which requires providers to better manage patient costs based on a clear, concise, and comprehensive picture of patients’ health and medical conditions – are Hierarchical Condition Category (HCC) codes. Used by the Centers for Medicare and Medicaid Services (CMS) and commercial payers to forecast medical costs for patients with more complex healthcare needs, the HCC risk adjustment model measures relative risk due to health status to determine reimbursement levels. The more complex the patient’s medical needs, the higher the provider’s payment.
In fact, HCCs are the preferred method of risk adjustment for the Medicare population, which includes nearly 60 million people on both Part A and Part B, CMS reports. As such, accurate HCC management is critical for appropriate reimbursement of the care provided to Medicare patients and beneficiaries.
Accuracy is Key
The highly complex HCC model includes approximately 10,000 diagnosis codes that map to HCC codes and 189 different HCC categories with 87 CMS-HCCs, each of which represents diagnoses with similar clinical complexity and expected annual costs of care. Any error can significantly impact reimbursements, which under HCC is determined by mapping a patient’s diagnoses to these codes to create a Risk Adjustment Factor (RAF) score.
The RAF score represents the estimated cost of caring for that patient based on their disease burden and demographic information. It is then multiplied by a base rate to set the provider’s per-member-per-month (PMPM) reimbursement amount. The sicker the patient, the higher the RAF score and, subsequently, the provider’s reimbursement.
Each year, CMS publishes a list of diagnosis codes and corresponding HCC category. Hierarchies (or ‘Families’ of categories) are listed among related condition categories, which set values based on the severity of illnesses. Improperly documenting HCC codes, or failing to document the highest appropriate specificity, results in lower reimbursement rates. For example, HCC 19 (diabetes with no complications) might pay an $894.40 premium bonus compared to a bonus of $1,273.60 for diabetes with ESRD, which requires two HCC codes mapping to 18 and 136.
Conversely, properly documenting HCCs at the highest appropriate specificity can boost reimbursements. For example, if CMS has set a $1,000 PMPM for a patient with an RAF of 2.234 who has diabetes with complications reimbursement would be just $673 per month if the condition is not coded. However, if the case was properly coded as E11.9 Type 2 diabetes mellitus without complications under HCC19 Diabetes without complications, the RAF increases to 2.366, resulting in reimbursement of $1,062 per month. If properly coded as E11.41 Type 2 diabetes mellitus w/diabetic mononeuropathy under HCC18 Diabetes w/ chronic complications, the RAF increases to 2.513 for a reimbursement of $1,312.5.
Autonomous coding enjoys a high level of trust among healthcare finance professionals who use or plan to use the technology, with 45 percent indicating it often works well and 16 percent placing complete trust in it. Yet despite its emergence as a powerful tool for streamlining and improving error-prone manual coding processes, autonomous coding suffers from an awareness problem, with 52 percent saying they do not know what it is.
Those are the findings of a new survey from the Healthcare Financial Management Association (HFMA) on behalf of AGS Health, a leading provider of tech-enabled revenue cycle management (RCM) solutions and strategic growth partner to healthcare providers across the U.S. More than 450 healthcare finance professionals were surveyed during the 2023 HFMA Annual Conference on their knowledge of and value expectations for autonomous coding, including 60 percent that use or plan to use autonomous coding.
More than half (52%) of respondents said they don’t know what autonomous coding is and 30 percent either did not or were unsure if it could be trusted.
Thomas Thatapudi
“Despite high expectations around its potential to increase coder productivity and coding accuracy, reduction in denials, missed charges and low-risk scores, and accelerated provider decision-making, autonomous coding suffers from a knowledge gap that must be closed if we are to see broader adoption,” said Thomas Thatapudi, CIO of AGS Health. “Until we can fully educate finance leadership on the potential autonomous coding holds for improving the healthcare revenue cycle, we are unlikely to see an acceleration in use cases for AI-powered technology which includes autonomous coding.”
Among the key benefits of autonomous coding is its ability to eliminate the potential for human errors that result in missed reimbursement opportunities, backlogs, delays, and claims errors, and its ability to push accuracy levels to near perfect percentages. All of which can be achieved in near real time with the right integration pipelines. Autonomous coding is also faster than its human counterparts – it can complete charts in seconds – yet it also understands what it does not know, flagging it for human review.
AGS Health, a leading provider of tech-enabled revenue cycle management (RCM) solutions and strategic growth partner to healthcare providers across the U.S., announced today the release of Intelligent Authorization, a single-source solution that automates and optimizes the financial clearance process and avoids prior authorization-related denials.
Part of AGS Health’s AI Platform, Intelligent Authorization streamlines and expedites processes by up to 90% through a variety of configurable automation solutions that improve operational efficiency, reduce costs, and enhance the patient experience.
“Half of all denials can be traced back to prior authorization and other front-end revenue cycle issues, jeopardizing provider organizations’ financial health and negatively impacting the patient experience by limiting transparency and delaying access to care,” said Matt Bridge, senior vice president of RCM Services, AGS Health. “Intelligent Authorization addresses the underlying issues causing prior authorization-related denials while streamlining and accelerating financial clearance processes. Customers report doubling production volumes and tripling the number of days in advance their patient access teams can secure authorizations, which in turn expedites appointments to better support patient needs and fill open time slots – resulting in improved revenue growth and an enhanced patient financial experience.”
A platform-agnostic solution, Intelligent Authorization prevents denials, reduces aged A/R, improves net revenue reimbursements, and increases clean claim rates across a variety of specialties, including radiology, oncology, occupational and physical therapy, surgery, and infusion/diagnostics. Compared to manual processes, it enhances productivity and reduces the time required for financial clearance activities, delivering:
75%-85% faster eligibility and benefit determinations
85%-90% improvement in authorization determination time
65%-80% less time spent on authorization initiations
75%-85% shorter authorization follow-up times
Up to 80% faster price estimations
Intelligent Authorization achieves these outcomes by automating eligibility and benefits determination processes, including order entries, scheduling, rescheduling, and monthly and annual re-verification processes. It automates authorization status via robotic process automation (RPA) and generates good faith estimates based on the fee schedule and embedded payer- and client-specific rules, which are then transferred back to the EMR.
Finally, Intelligent Authorization offers insightful and actionable analytics including self-service reports, customized dashboards, and flexible data management that enables users to view insights across different dimensions, create action plans, and make decisions faster.
“Smart workflow tools feature fast, flexible data transfers to the EMR through HL7, simplified task management and automated case assignment, and enhanced document management and accessibility, all of which come together in Intelligent Authorization to eliminate financial clearance issues created by error-prone, time-consuming manual processes,” said Suhas Nair, director of product management, AGS Health. “By leveraging the latest advances in RPA and AI technologies, Intelligent Automation helps healthcare organizations implement the tools needed to strengthen their financial footing and better service their patients.”
AGS Health, a leading provider of tech-enabled revenue cycle management (RCM) solutions and strategic growth partner to healthcare providers across the U.S., has been named a Leader in Revenue Cycle Management (RCM) Operations by Everest Group for the third consecutive year.
Everest Group Revenue Cycle Management (RCM) Operations PEAK Matrix Assessment evaluated 25 RCM providers’ market impact and ability to successfully deliver services based on subdimensions, including market adoption, portfolio mix, value delivered, and strategic vision and capability. Results were then used to determine each organization’s overall market leadership position – Aspirant, Major Contender, or Leader.
More information on Everest Group RCM Operations PEAK Matrix Assessment can be found here.
AGS Health is more than a revenue cycle management company – we’re a strategic partner for growth. With expert services complemented by AI-enabled technologies and high-touch support, AGS Health is the premier revenue cycle partner for leading health systems, physician groups, and academic medical centers in the U.S.
With expert insight into modern revenue cycle practices, the company pairs cutting-edge technology with college-educated, trained RCM experts to help clients achieve a high-performance revenue cycle to optimize workflows, maintain compliance, and prevent revenue leakage. AGS Health employs nearly 12,000 team members globally and partners with more than 130 clients across a variety of care settings, specialties, and billing systems.
Revenue cycle management solutions provider AGS Health announced the launch of operations in Manila, Philippines. Serving as a strategic growth partner to more than 100 major healthcare providers across the U.S., the expansion will offer AGS Health and its customers increased access to global talent.
Identified as one of the most popular outsourcing destinations in the world, the Philippines is known for the quality of skills offered in the business process outsourcing (BPO) sector. With strong medical backgrounds and voice-based skills, AGS Health aims to focus on supporting end-to-end accounts receivable services. “By augmenting our service line with patient calls, responding to patient queries, and timely patient follow-ups, the addition of our Philippines operations represents an exciting added value to our customers,” said Patrice Wolfe, CEO of AGS Health.
As the company continues to grow, AGS Health is diversifying its global operating locations. The Manila office is the second recent global addition for the company, following the opening of its Jaipur, India office in June 2022. With more than 11,000 employees worldwide, AGS Health combines a global pool of expertly trained, college-educated resources with AI-enabled technology to leverage the latest advancements in modern revenue cycle practices.
The COVID-19 global pandemic and widespread natural disasters have highlighted the importance of business continuity planning. With an already-extensive presence established in India, AGS Health strengthens its infrastructure with this cross-country addition.
“Our expanded footprint reduces the risk of business disruptions to our clients should operations be interrupted in India,” Wolfe said, adding “The Philippines emerged as our top choice for its solid, low-risk infrastructure and its role as a top business center.”
AGS Health, a leading provider for tech-enabled revenue cycle management (RCM) solutions and strategic growth partner to healthcare providers across the U.S., announces the acquisition of the India-based patient access outsourcing business unit of the Florida-based healthcare technology company Availity.
With more than half of U.S. hospitals anticipating a year of negative margins, achieving full and accurate reimbursement for services has never been more critical. With this expansion, AGS Health is positioned to provide faster, more flexible financial clearance solutions at an even greater scale to help increase customers’ first-pass reimbursements rates.
“At AGS Health, our focus is greater financial freedom for healthcare organizations, allowing them to reinvest in their vision for superior patient care,” said Patrice Wolfe, CEO of AGS Health. “With this acquisition, we can better equip our customers with the tools and expert services necessary to help overcome payer complexities, reduce denial rates, mitigate revenue leakage, and accelerate cash flow on the back end.”
The acquisition allows AGS Health to expand the capabilities of the AGS AI Platform with new technology to enhance accuracy and scalability and further streamline patient access operations. The technology platform is capable of automatically determining, submitting, and verifying the status of prior authorization requests. Additionally, estimates of the patient’s out-of-pocket cost can be automatically generated based on payer rules set by the healthcare organization.
The move will also add approximately 200 patient access service team members to AGS Health’s global team of more than 11,000 college-educated, trained RCM experts. With labor shortages devastating all areas of the healthcare system, outsourced services are more critical than ever – particularly as financial clearance performance depends on access to qualified, skilled labor.
“This acquisition is just part of our continued investment in our customers’ success with automation technology and expert teams,” Wolfe adds. “As growth partners, we are committed to equipping our customers with flexible, modern solutions to mitigate risk and adapt to change. This is part of what we call ‘AI with a human touch’.”
Health equity is a focus of providers, regulatory agencies, and payers as they seek ways to eliminate care disparities across race and ethnicity, gender, sexual orientation, and socioeconomic status lines. Its significance is further impacted by new quality-based care models beyond those established by the Patient Protection and Affordable Care Act of 2010.
The challenge for many healthcare organizations participating in these new reimbursement models is how to view health equity and social determinants of health (SDoH) to understand the actual value of this information. Often overlooked is that healthcare organizations’ coding and revenue cycle management (RCM) departments already aggregate information that can help better understand inequities in care delivery and health equity across their patient populations.
A Primer on SDOH Impacts
SDoH impact many health risks and outcomes, which is why this data is vital for clinical care and reimbursements. Defining factors can include anything from geography, race, gender, and age to disability, health plan, or any other shared characteristic. Of increased importance, SDoH issues are most often experienced by the most vulnerable members of society: the poor, less educated, and other disadvantaged groups.
SDoH is linked negatively with outcomes, including higher hospital readmissions, length of stay (LOS), and increased need for post-acute care. Value-based payment programs, therefore, may penalize organizations that disproportionately serve disadvantaged populations if they do not collect and respond to SDoH data.
For example, addressing food insecurity — a key SDoH data point — by connecting patients to programs like Meals on Wheels, Supplemental Nutrition Assistance Programs (SNAP), or food pantries is proven to reduce malnutrition rates and improve short and long-term health outcomes.
In the case of SNAP, which is the primary source of nutrition assistance for more than 42 million low-income Americans, participants are more likely to report excellent or very good health than low-income non-participants. Low-income adults participating in SNAP incur about 25% less medical care costs (~$1,400) per year than low-income non-participants.
AGS Health
