The Future of RCM: Artificial Intelligence

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

No doubt the pandemic has shifted the revenue cycle model. However, that model had already started to change with payor contracts and fee schedules, higher patient responsibility and deductibles, and a move towards value-based payments. The Revenue Cycle needs an update to deal with the increase in healthcare technology. We see more A.I. being used in clinical treatment and triage but triaging the revenue cycle is a different manner all together. It’s time for the RCM to go A.I.

Moving from manually tracking claim edits, clearing house rejections, payer rejections, payer denials, ever-changing payer rules, and reporting incentive programs to having an analytics tool that can track and monitor this for a practice, particularly larger practices, is becoming a necessity. This not only increases RCM efficiency but leads to faster reimbursement to keep cash coming in the door regularly.

According to a survey done by the American Medical Association (AMA), 86 percent rate problematic authorizations specifically as high or extremely high. Not only does this tie up staff, it delays treatment while payors review authorization applications and often take their time in responses. However, providers seem hesitant to move to a more automated process for prior authorizations.

Reporting from the Council for Affordable Quality Healthcare (CAQH), indicated that the use of electronic authorizations only rose one percent from 2018 to 2019. Much of this hesitation has to do with inconsistent automated payer systems, trouble with website portals, or inaccurate responses. Until payors can guarantee accurate authorization processes through their web portals, providers will continue to go the manual route.

A.I. has the potential to truly change the healthcare industry once the technology can catch up to the need. This technology is still being developed, but will truly become indispensable once quality, consistent processes are available at an affordable cost to providers of all sizes.


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