Artificial intelligence (AI) has become a fixture in healthcare revenue cycle management (RCM), an area where finance leaders are desperate for ways to relieve understaffed departments struggling under unprecedented volumes of third-party audit demands and rising denial rates without sacrificing accuracy or precision.
At a time when RCM staffing shortages are high, AI provides a critical productivity boost. By investing in data, AI, and technology platforms, compliance and revenue integrity departments have been able to reduce their necessary team size by a third while performing 10 percent more in audit activities, compared to 2022, according to the 2023 Benchmark Report.
Here is where AI shines. Arguably its greatest asset is assisting in uncovering outliers and needles in the haystack across millions of data points.
While AI has enabled the automation of many RCM tasks, however, the promise of fully autonomous systems remains unfulfilled. This is partially due to software vendors’ propensity to focus on technology without first taking the time to fully understand the targeted workflows and the human touchpoints within them. It’s a practice that leads to ineffective AI integration and end-user adoption.
For AI to function appropriately in a complex RCM environment, humans must be in the loop. Human intervention helps overcome deficits in accuracy and precision – the toughest challenges with autonomous AI – and enhances outcomes, helping avoid the repercussions of poorly designed solutions.
Financial impacts are the most obvious repercussion for healthcare organizations. Poorly trained AI tools being used to conduct prospective claim audits might miss instances of undercoding, which means missed revenue opportunities. For one MDaudit customer, an incorrect rule within their “autonomous” coding system was improperly coding drug units administered, resulting in $25 million in lost revenues. The error would never have been caught and corrected if not for a human in the loop uncovering the flaw.
AI can also fall short by overcoding results with false positives, an area under specific scrutiny due to the government’s mission of fighting fraud, abuse, and waste in the healthcare system.
Even individual providers can be impacted by poorly designed AI, for example, if the tool has not been properly trained on the concept of “at-risk providers” in the revenue cycle sense. Physicians could find themselves unfairly targeted for additional scrutiny and training if they are included in sweeps for at-risk providers with high denial rates – wasting time that should be spent seeing patients, slowing cash flow by delaying claims for prospective reviews, and potentially harming their reputation by slapping them with a “problematic” label.
Again, keeping humans in the loop is the best strategy for preventing these types of negative outcomes. In fact, there are three specific areas of AI that will always require human involvement to achieve optimal outcomes.
A robust data foundation is crucial, because the underlying data model, including proper metadata, data quality, and governance, is key to enabling AI to function at peak efficiency. This requires developers to get into the trenches with billing compliance, coding, and revenue cycle teams to fully understand their workflows and data needed to perform their duties.
Effective anomaly detection requires billing, denial, and other claims data, as well as an understanding of the complex interplay between providers, coders, billers, payors, etc. This ensures the technology can continuously assess risks in real time and deliver to users the information needed to focus their actions and activities in ways that drive measurable outcomes. If the data foundation is skipped in favor of accelerating deployment of the AI models and other shiny tools, the result will be hallucinations and false positives that will cause noise and hinder adoption.
AI-enabled RCM tools require ongoing education in the same way professionals do, to understand the latest regulations, trends, and priorities in an evolving healthcare RCM environment. Reinforcement learning allows AI to expand its knowledge base and increase its accuracy. User input is critical to refinement and updates, to ensure AI tools are meeting current and future needs.
AI should be trainable in real time. End users should be able to support continuous learning by immediately providing input and feedback on the results of information searches and/or analysis. Users should also be able to mark data as unsafe, when warranted, to prevent its amplification at scale. For example, this could involve attributing financial loss or compliance risk to specific entities or individuals without properly explaining why it’s appropriate to do so.
Human validation is required to ensure that AI’s output is safe. For example, for autonomous coding to work properly, a coding professional must ensure AI has properly “learned” how to apply updated code sets or deal with new regulatory requirements. Excluding humans from the governance loop leaves healthcare organizations wide open to revenue leakage, negative audit outcomes, reputational loss, and much more.
Without question, AI can transform healthcare RCM. But doing so requires that healthcare organizations augment their technology investments with human and workforce training to optimize accuracy, productivity, and business value.
Continuing with our look at areas of coding confusion, let’s today examine pain. According to Medline Plus Magazine from the National Institutes of Health (NIH),
Clinical documentation integrity, or CDI, represents the systematic process of enhancing medical documentation accuracy, completeness, and specificity within healthcare settings. Far from being merely administrative
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Copyright © 2025 ICD10monitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
