Intelligent Revenue for Healthcare Providers

By Kamesh Raghavendra | Aug 01, 2019, 4:45 pm EST

Our country’s healthcare systems have gone through sweeping changes over the course of this decade and are still in flux with more changes coming. While there is much coverage of the impact of these changes on patients, they have equally impacted hospitals and healthcare systems. Across the country, hospitals are facing downward pressures on reimbursements and cash collections. Frequent changes in regulations are heaping large administrative burdens on collecting revenues from payers. In such a fast-changing vertical, revenue can no longer be a disconnected silo in the providers’ finance departments. Revenue needs to become a cross-functional intelligence across the providers’ patient engagement, managed care, clinical practice and back-office functions. In this blog, we describe The Hive’s venture co-creation exploration in building a cross-functional intelligent revenue product for specialty healthcare providers.

Revenue cycle management (RCM) has traditionally been a back-office business process led by healthcare providers to recover revenue from the payers through the claims’ reimbursement process. This structure is being challenged by the following sweeping changes in patient engagement, managed care, clinical care and business processes:

Patient Engagement: While the Affordable Care Act (ACA) 2010 has increased the overall insurance coverage in the country, it has also significantly increased the out-of-pocket financial burden on individual patients. Hence traditional RCM needs to be augmented with revenue intelligence that manages the necessary non-clinical interactions with the patients to assess affordability and streamline recovery in the form of patient engagement. The payers have also significantly increased prior authorizations needed before submitting claims. All these require revenue intelligence to be an integral part of a provider’s front office integrated with patient relationship management and engagement.

Managed Care: Another significant consequence of ACA is the rapid shift towards managed care portfolios away from the traditional government health insurance plans (Medicare and Medicaid). Managed care plans are very diverse, non-standard and vary wildly in terms of claims review & payment periods. Hence traditional RCM needs to be augmented with revenue intelligence to deal with varying terms of the large number of plans right from the point of admission of the patient.

Clinical Care: Advancements in medical sciences and pharma are making clinical care extremely personalized. Doctors have a great deal of discretion in structuring the in-hospital treatment and drug administration to suit the specific patient’s genetic, lifestyle and personal conditions. This has opened up the opportunity of turning revenue intelligence into another lever for personalizing healthcare. Specialty healthcare (especially oncology and cardiology) is the fastest-growing personalized care and medicine segment. Revenue intelligence will be a key necessity for sustainable clinical care in this segment.

Business Process Operations: New administrative burdens, driven by changes like the new coding system ICD-10 (which included ~140,000 codes instead of the previous ~17,000 codes) and stricter enforcement of medical policies, demand specialized automation to cut down the increasing costs of back-office operations. Backoffice automation needs to be informed by near real-time revenue intelligence gathered from across the functions of managed care, patient engagement and clinical care. Furthermore, the increasingly more complex claims review processes need conversational intelligence to automate responses to the objections raised by payers.

In response to the above trends in healthcare RCM, The Hive sees a market opportunity for a product that delivers actionable cross-functional AI-based revenue intelligence to healthcare providers and specialty pharma through the patient engagement, practice management and back-office processes. Oncology would be a great initial area of focus for addressing revenue leakage & collection challenges of cancer care units within providers, specialty pharma and clinic networks. The Hive’s market assessment has indicated strong demand for intelligent recommendations across multiple functions of the provider, right from automating verification of requisite pre-authorizations at the time of patient’s admission at the front-office in the context of specific payers and plans. There is also great value to be created in guiding the patient’s clinical care through practice management systems by scoring equivalent options with probabilities of payment. There is also an opportunity to create specialized back-office automation services including claims prioritization, form enrichment and responses to objects from payers. The breadth of data accessed by such a product can also be used to optimize employers’ healthcare costs by recommending optimal plans to managed care organization and third-party administrators (TPAs) in the field of oncology.

The Hive is in early engagements with clinic networks and specialty pharma as a part of the co-creation process. The venture will be based in Palo Alto with a team comprising of experts in healthcare IT, clinical care and AI/data science.