The arguments many startups make for automating the healthcare revenue cycle are quite simple. Claims follow rules, payers adhere to guidelines, and most of this work is repetitive enough that an algorithm can handle it.
Todd Manion, President of Revenue Cycle at Mayo Clinicagrees with parts of this argument – but he puts a stop to complete automation.
Clinical complexity doesn’t neatly boil down to the structured data required by automated systems, Manion said this month in an interview at HFMAannual conference in National Harbor, Maryland.
For example, he described a scenario he said he has witnessed many times in his career: a doctor uses precise clinical language that does not translate directly into billing codes. A patient may receive all the medications and treatments associated with pneumonia, but if the doctor documents the illness as a “pulmonary infiltrate” rather than pneumonia, the coder’s hands are tied, Manion explained.
Even if payers can see the evidence, they can’t really act on it, he emphasized. Only an explicit diagnosis, signed by a clinician, recorded in a specific part of the medical file, can actually appear on a claim.
“Sometimes I think there’s a misunderstanding that the entire medical record can be used to, yes, treat the patient — but unless that diagnosis is in a specific location, we can’t apply it to the claim without then going back to the provider and questioning,” Manion said.
However, he did not shy away from what AI can do. At Mayo, he said technology is already beginning to prove its value in the revenue cycle, particularly in areas where workflows are repetitive, such as checking claims status, reporting delinquent payouts and tracking payments that run longer than contractual deadlines allow.
Tasks that once required a staff member to wait on hold at a payer can now be processed automatically, allowing that staff member to work on other tasks that actually require their judgment, Manion noted.
“I don’t need people waiting to find out where the status of a claim is with the payer. There are simplistic, repetitive tasks that we’ve simplified with AI so we can elevate our people to more complex patient issues,” he noted.
In general, Manion said he doesn’t think the revenue cycle is about pursuing claims or closing payment gaps. For him, his goal is to faithfully reflect the care actually provided.
“If we can do it and do it accurately, everything else will fall into place,” he said.
Photo: metamorworks, Getty Images
