Revenue cycle management software vendors are increasingly turning to artificial intelligence to give health systems of all sizes – from regional systems such as West Tennessee Healthcare to multi-state health systems like AdventHealth and giants like Cleveland Clinic – a leg up on improving key performance metrics.
With providers' expenses continuing to rise and lower reimbursements leading to declining margins, they're looking to key revenue drivers, like making full use of operating rooms, appealing denied claims and speeding up and improving coding operations. Several new product and service announcements are aiming to help.
Driving growth, reducing burden
West Tennessee Healthcare, a non-profit health system that serves 500,000 patients in 19 counties in its state and Southeast Missouri, has been able to increase its OR utilization using artificial intelligence scheduling software that matches independent surgical case requests to open spaces on operating room schedules.
The health system increased its orthopedic service line by 9% within the first 100 days of booking priority surgical cases through an algorithm-based scheduling system, which resulted in a fourfold return on its investment, according to an announcement from its software vendor, Qventus.
Like many of its rural peers, the health system's processes for scheduling operations for surgeons were based on a traditional first-come, first-served basis – leaving revenue-generating resources underutilized and preventing the region's surgeons from accessing robotic assets, the company said Thursday.
West Tennessee wanted to make it easy for independent surgeons to bring their cases to its ORs and turned to machine learning tools that enable outside clinical schedulers to book surgical time.
With machine learning analyzing scheduling requests across OR locations, the health system added 61 cases to its schedule in the first 100 days of use, an increase equaling 90% of its investment in AI, according to Qventus.
"Being able to view available room time in seconds while scheduling in minutes is everything for my staff and patients," Dr. Keith Nord, West Tennessee's chairman of orthopedic surgery, said in a statement.
"We’ve achieved impressive ROI with West Tennessee in a short amount of time, and we continue to work together closely to drive even more growth for their team and increase surgical access for their community."
Surfacing reimbursement potential
AdventHealth used Iodine Software’s pre-billing software to analyze and prioritize patient records that AI predicts will have the most significant potential for reimbursement and directs the cases to review teams, the company said in an announcement Thursday about the software's wider availability.
Its algorithms exclude low-value cases and validate codes by identifying missing documentation, recommending more appropriate codes and surfacing alternative principal diagnoses. Qventus said the next-generation software also identifies opportunities for follow-up, flags missing physician support and detects events that may warrant documentation or coding updates.
Iodine said its AwarePre-Bill product aims to help providers address the climbing claims denials trend, which affects their revenue margins. While most of the denied claims are eventually overturned, 80% according to the company, hospitals often do not pursue appeals due to limited resources, leaving money on the table.
With rev cycle automation, Iodine said its customers have experienced an average of 63% reduction in claims review times and, during 2024, achieved a total reimbursement of $2.394 billion across more than 1,000 health systems.
"We’ve seen a meaningful lift in high-impact queries that drive both revenue and quality outcomes," Dr. Christopher Riccard, VP of hospital medicine and CDI at AdventHealth, said in the statement.
"The ability to prioritize the right cases – not just more – has transformed our teams’ productivity and strengthened our financial performance."
Assisting complex coding
The Cleveland Clinic said it is partnering with generative AI developer Akasa to add machine learning processing to its revenue cycle operations across all of its U.S. locations.
The health system said in its April 30 announcement that its staff reviews more than 100 clinical documents per case, including progress notes, discharge summaries and pathology reports, and then selects codes from more than 140,000 options.
Each case, often complex at The Clinic, could take up to an hour per patient encounter.
Through the partnership, the Cleveland Clinic will enable tools from Aksana's platform to intercede on documentation and coding tasks between patient care and billing, the mid-revenue cycle phase, aiming to streamline and improve case review.
"AI can be transformational for healthcare – not only in patient care – but for helping health system operations run more smoothly and efficiently,” said Rohit Chandra, Ph.D., chief digital officer at the Cleveland Clinic.
Coders will be able to utilize a coding AI assistant tool that supports comprehensive, efficient and accurate practices. It can read a clinical document in less than 2 seconds and process more than 100 documents in 1.5 minutes, according to the health system's announcement.
"Because we treat some of the highest acuity patients in the country, our revenue cycle activities are incredibly complex," added Dennis Laraway, The Clinic's executive vice president and chief financial officer. "Through autonomous coding, we aim to bring greater efficiency and accuracy to these complicated and time-consuming tasks, something that AI is ideally suited to address."
The two partners are also collaborating on a clinical documentation integrity tool to further improve the health system's revenue cycle management operations.
Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.
