Bobby Guelich’s Post

Denials are a major pain point for provider orgs: • 15% of claims are denied • The cost to rework or appeal is $25 for practices and $181 for hospitals • 65% of denied claims are never re-submitted • 35% of hospitals report >$50M in annual lost revenue from denied claims. But where there’s a big pain point, there’s also a huge opportunity for vendors who can solve it. JUMPING THROUGH HOOPS After submitting a claim, it is bucketed into: • Claims with no response yet • Claims with a non-payment response • Rejected claims Denials management is focused on claims with a non-payment response. Teams typically work on denials by looking at the specific reason for denial (i.e. lack of eligibility, lack of authorization, lack of provider credentialing, duplicate claims, coverage status, medical necessity, etc.) and take action based on those specific reasons. The legacy workflow looks something like: 1. Review denial notification 2. Perform “root cause analysis” to identify the specific cause of denial 3. Gather additional information & correct errors 4. Submit an appeal package and detailed letter 5. Follow up with the payer until resolved THE PROMISE OF AI AI offers potential optimizations across each step of the denials management process. Products in this category perform functions including: • Automating administrative steps, like checking status, syncing updates to the EHR, and document submission. (e.g. Rivet Claims Resolution, Crosby Health) • Prioritizing rework that needs to be done by a human based on a number of factors including likelihood of being overturned and paid. (e.g. Sift Healthcare Denials) • Using GenAI to make corrections to the denied claims, such as updating coding, providing additional documentation, or correcting patient information. (e.g. Crosby Health) • Using GenAI to find underpayments even for claims that are paid (e.g. MD Clarity Revfind, Rivet Payer Performance) Additionally, there are a number of end-to-end RCM providers who also offer AI-enabled denial management modules that can be used both as part of the end-to-end platform, or used in conjunction with other products. Examples include Change Healthcare Denial and Appeal Management, Datavant Denial Management, Experian Health Denial Management, Medmetrix Denials Recovery, and Waystar Denial and Appeal Management. A substantial portion of effective denial management is process-based: finding the systematic reasons for denials and fixing them before they become an issue. As such, there is significant potential for symbiosis between AI tools across the revenue cycle. We believe the future for AI in RCM will be predicting which claims will be denied before they are submitted—even as early as the point of care. To do this, vendors need to start thinking longitudinally about how each step affects the probability of payment, and optimizing backwards. We see this developing substantially over the next few years.

Here’s your recap of last week’s health IT news 🗞️ 👇 🤖 AI Clinician Assistant • Oracle Health announced the release of its AI-powered clinical digital assistant, which integrates “clinical automation, conversation-based note generation, and proposed clinical follow ups” directly within the EHR. • NextGen Healthcare released a version of their Ambient Assist designed for small practices, which includes Spanish support and specialty-specific workflows.    • Community Health Network has begun a multiyear Microsoft implementation including Nuance Communications Dragon Medical One and DAX Copilot. 🧑💻 Virtual and At-Home Care • Hackensack Meridian Health partnered with Medically Home to implement their hospital at home program. • Cleveland Clinic is integrating Masimo’s wearables in a new partnership focused on hospital-based RPM. • eVisit acquired UPMC Enterprises' inpatient teleconsult technology and an investment from UPMC’s innovation and investments arm as part of their $45M Series B funding. • PatchRx released an API-based tool allowing providers to sync data directly into their existing care platforms. 📊 Data & Analytics • Atropos Health added two new partners and a data scoring system to allow users to select the most appropriate datasets for their queries. • Xealth launched a metrics tool that allows customers to measure and track patient engagement with their digital health programs. 📋 Patient Administration • Fabric acquired MeMD from Walmart. 🔄 RCM • Inovalon joined MEDITECH’s interoperable product marketplace. • RevSpring released an update that integrates a lockbox solution for check processing within its existing payment platform. • Solventum Revenue Integrity (fka 3M Health Care) released its new AI CDI software powered by Sift Healthcare, Solventum Revenue Integrity System, which uses machine learning to predict denials before they happen. 🍎 VBC Data & Analytics • Arcadia acquired CareJourney leveraging their cost, quality, and benchmark data to enhance Arcadia’s data, analytics, and workflow tools. • Adventist Health selected The Garage In's population health management platform to support its VBC operation. 🧠 Food For Thought •  Coalition for Health AI (CHAI) released its draft standards guide for public comment. https://lnkd.in/eMUXGfvz • We really appreciated Daniel Yang, MD’s post about a recent article on the emergence of a new leadership role: the Chief Health AI Officer (CHAIO) https://lnkd.in/ejZxnJCj --- Reminder: you can sign up for the Elion Briefing to get the latest healthcare tech news delivered to your inbox each week 📬 👉 https://lnkd.in/e2UJ3ckP

I recently had the pleasure of speaking with Deepa Sheth, former Chief Corporate Development Officer at SCAN and former SVP at Oak Street Health. Deepa has an incredible background having led M&A and partnerships (among many other responsibilities) at two of the most interesting VBC organizations of the last decade. It was a great conversation, with a ton of hard-won insight. I've dropped an excerpt below and you can catch part 2 of the interview in Elion's newsletter next week. --- 🟩 Q: From your experience at SCAN and Oak Street Health, where do you see VBC organizations focused when it comes to technology? 𝗗𝗲𝗲𝗽𝗮: With their technology investments, it’s all about how VBC organizations make sure their tech is driving better patient outcomes, while managing increasingly complex P&L headwinds. Medical cost pressure has always been challenging, and is something health tech has played a big hand in helping manage. Now, health tech partners will be affected by the question of how VBC companies will weather the effects of recent rulings and policy changes that will create significant revenue compression and rising costs for payers with a Medicare Advantage book of business (e.g. V28 model changes, Final Rule and Quality program changes, etc.) From the perspective of a health tech vendor, long gone are the days of selling a sliver solution that solves one problem for one small population or demographic within the health plan membership. Vendors need to be thinking about platform solutions that are designed for a whole population. 🟩 Q: As you see these increasing pressures, I'd be curious if there are specific categories or vendors that are of particular interest to payers. 𝗗𝗲𝗲𝗽𝗮: Many areas, particularly where the solutions are addressing stubborn pain points in a VBC model. One example for any payer that has Medicare Advantage products or risk-based contracts is accessing high quality specialists. The red tape (and time) to get authorization and a referral to see a specialist has always been a pain point, but with continued importance on not only the access to specialists, but patients' perception of access to specialists, this is one of many areas health tech vendors can provide immense value. There are savvy vendors working on solving parts of the specialist challenge: Ribbon Health, for example, is really smart about cutting through the noise and quality checking provider data, including infrastructure to ensure that the network of providers a VBC company interacts with is actually accurate. RubiconMD has made huge strides in their VBC partnerships, among other lines of business, for connecting patients and primary care providers to specialists through e-consults within minutes, instead of weeks and months. Dina is another innovative company working with payers and providers to close the time (and frustration) gaps for getting patients connected with post-acute care.

The stats on patient payments aren't good: • Almost 70% of patients' hospital bills don't get paid in full • Over 40% of U.S. adults have medical or dental debt • Nearly 20% of U.S. adults have medical bills that are in collections With the rise of high deductible health plans putting increasing financial responsibility on patients, hospitals can't afford 𝘯𝘰𝘵 to make their payment processes as simple and seamless as possible. We recently dug into the patient payments space, with a particular focus on how AI is being applied to this problem. THE CURRENT PATIENT PAYMENTS MARKET In the legacy fee-for-service patient payment model, the hospital revenue department (or an outsourced firm) sends out bills, tries to take payment, and, after 60-120 days, sells them to collections. In the last five years, tech entrants in this space have focused on one of the hardest parts of this problem: engaging with the patient throughout the journey so that when the bill is due, the patient understands it and sees a clear path to payment. Despite improvements, however, we're still seeing underpayment across the majority of patient bills. AI FOR PATIENT PAYMENTS AI is rapidly being applied to the patient payment process in a number of ways: 📄 AI-generated patient bills or explanations, minimizing errors and helping patients better understand their bills. 🤖 Billing inquiry chatbots that help patients handle routine billing questions and workflows 📅 Optimized payment schedules that help determine the optimal times and channels for reminders, messaging, etc. 💸 Integration of relevant data and prediction of ability to pay in order to provide discounts, payment schedules, and other financial support for patients. In the new AI-enabled model, there are essentially two main market segments that echo their legacy counterparts:  patient financial engagement solutions & companies that model and take on financial risk. PATIENT FINANCIAL ENGAGEMENT Like their predecessors, these digital front-door technologies focus on creating easy consumer payment experiences. They differentiate from prior solutions by using machine learning to optimize messaging, delivery time, and message channels. They also often include billing inquiry chatbots and AI-generated explanations for bills. Examples include: • Cedar • Decoda Health • Flywire • Raxia • VantageHealth.ai PATIENT FINANCIAL RISK These tools leverage AI to predict whether patients will pay and how much they can pay over time, creating payment plans to help them pay off bills. In some cases, vendors also automatically pay health systems and take on financial risk to collect from patients. Flywire PayZen Sift Healthcare Our team is betting the future for patient payments will be hospital systems getting paid immediately, and AI-enabled patient payment platforms taking on the responsibility for collecting payment. Where do you see the patient payments category going?

Here’s your recap of last week’s health IT news 🗞️ 👇 🤖 AI Products • Emergency Services, Inc. + Augmedix Go ED: The emergency medicine group adopted the new ED-specific AI ambient scribe solution.    • Color + OpenAI: The cancer care tech company partnered with the GenAI giant to build a AI clinical decision support copilot.    • AKASA Medical Coding: The AI RCM vendor known for its AI prior auth tool AKASA Authorization Advisor released a new GenAI medical coding solution.    • Humata Health: The AI prior auth for providers vendor closed a $25M funding round led by healthcare org-backed funds The Blue Venture Fund and LRVHealth.    • Wellsheet + Concord Hospital Health System: The AI-enabled Smart EHR UI solution announced a client-reported 16.3% reduction in length of stay and 40% decrease in time spent in the EHR via its partnership with Concord Health, as well as the release of its new LLM-generated handoff summary feature. 🍎 VBC • BSIM Healthcare Services + Innovaccer: The healthcare provider—embarking on its first VBC contract—adopted the pop health data platform for analytics. 🩼 Durable Medical Equipment • Parachute Health: The DME e-prescribing and ordering solution released an update that integrates prior authorization. ⚕️Clinical Staffing • Matchwell + Indiana Hospital Association: The clinical staffing service partnered with the hospital member org to create the first state-wide resource pool for temp staffing. 🧑💻 Virtual and At-Home Care • Deaconess Health System + KeyCare: The Indiana-based health system adopted the Epic-based virtual care provider for around-the-clock virtual urgent care.    • UC Davis Health + Current Health: The health system launched a new RPM program for high blood pressure in partnership with Best Buy Health’s care-at-home platform. 🧠 Food for Thought: We came across a couple of good resources this past week on the current state of healthcare data information exchange: • This article in Health Affairs from Deven McGraw and Tina Grande provides a comprehensive overview of some of the patient health data abuses we've seen come to light in recent months, as well as a number of policy recommendations to improve the health information exchange landscape for all participants. https://lnkd.in/e_GEQ-JJ  (h/t Alya Sulaiman)    • This episode of Health Gorilla's InteropTalk gives a helpful update on the current state of affairs, with a particular focus on the state of trust across the health data exchange community and how the definition of "Treatment" may evolve. https://lnkd.in/e96AJG-5 (h/t Brendan Keeler) --- Reminder: you can sign up for the Elion Briefing to get the latest healthcare tech news delivered to your inbox each week 📬 👉 https://lnkd.in/e2UJ3ckP

Last spring, Brendan Keeler and I started digging into what it meant to be a Certified EHR and the implications for provider organizations of using one (or not). Little did we realize the epic journey we were embarking on. Today, Brendan's post marks the culmination of this quest. Highly recommended reading if for no other reason than Brendan's stellar meme game.

This past week I interviewed Dale Gold, MD of NerdMDs and ACMIO for CommonSpirit Health’s Mountain Region. I wanted to share a quick excerpt that I found interesting given Epic's role in the healthcare AI landscape (note: you can get the full Q&A in Elion's weekly newsletter) 🟩 Epic has been very public about the many AI-first products they’re building. How do you think about when to go with an Epic-native product vs. looking at other solutions (either internally built or externally purchased)? 𝗗𝗮𝗹𝗲: The best strategic approach for health systems historically is to have an Epic-first mentality — meaning to understand their roadmap, where it's going, and try your best to align with that direction. This is important both in terms of your operational workflows — doing things the way that Epic is built so that you function within those frameworks — and in terms of reducing customization and personalization, which requires long-term maintenance and takes bandwidth away from your IT teams to innovate. At the same time, I believe it’s really important to build some of your own expertise and capabilities in this new area. Having it fully outsourced limits what you can learn and how you can innovate. So I think that there's a balance of doing some yourself — maybe not designing your own custom AI models, but having some expertise with editing them, prompting them, integrating them — so you're not fully reliant on external solutions. 🟩 Is there any whitespace you see today when it comes to building AI solutions? 𝗗𝗮𝗹𝗲: I think it's in-basket. I know people are working in that space, but it's such a hard problem to solve. An ideal solution would understand my preferences as a provider, the patient’s context, and how they like to be cared for, and then surface a set of decisions for me to make and help communicate next steps in a way that is clear, translated to a patient, and empathetic. 🟩 I agree with you. I’m curious if you think it’s because Epic has been vocal about the in-basket solution they’re building, or if there’s another reason we haven't seen more solutions. 𝗗𝗮𝗹𝗲: I think it’s just a hard problem to solve. Honestly, I don't know that Epic being involved scared people away, though I think Epic has an advantage in this space because they have access to the full chart. But I think that their true advantage is that they really put a lot of time and money into physician wellness and understanding what provider’s pain points are. They know more than anyone what a burden the in-basket is for providers. I suspect part of the challenge is finding the ROI in fixing the inbox. Where does the money come from? Solving the inbox impacts the patient experience, the provider experience, the wellness piece, and the quality piece. But finding the dollar signs takes a little bit more effort and takes organizations that are really motivated to do what's right by their providers and patients.

One of the cool things about building Elion is that the market research we do to create our product also drives lots of great content. Over the last few months, we've channeled this into creating a best in class healthcare tech newsletter.  Each week, we produce a new category-specific market map, health system exec interview, and roundup of the latest healthcare technology news. It's been truly awesome to see the positive response so far. And we're excited to continue making it even better in the weeks and months to come. If you're interested in the world of healthcare technology and haven't signed up, now is a great time: We're giving away a $5k travel upgrade for your next healthcare conference (HLTH, HIMSS, HFMA, etc.) and today is the last day to register. Sign-up link 👇 https://lnkd.in/ecBEEMQW p.s. if you're already a subscriber you can register too! Just follow the same link (and thanks for your support!)

Here’s your recap of last week’s health IT news 🗞️ 👇 🖊️ AI Ambient Scribes • CHRISTUS Health + Abridge: The 15,000 provider Texas health system adopted the ambient scribe enterprise-wide.    • Tampa General Hospital + Nuance Communications DAX Copilot: Over 500 providers at the health system will begin utilizing the AI ambient scribe.    • Texas Oncology + DeepScribe: The statewide oncology practice adopted the AI ambient medical scribe. (ed. note: scribes continue to be hot!) ☎️ AI Contact Center • Clearstep: The AI conversational chat vendor launched a new feature allowing patients to self-schedule specialist visits. 📊 Data & Analytics • InterSystems + CLEAR: The cloud-based patient data service is integrating the identity technology to expedite access to patient records.    • WakeMed + Bamboo Health: The health system is adopting the data interoperability and encounter notification service. 🥼 Clinical Decision Support • University Hospitals + Aidoc: The Cleveland-based health system is implementing the AI clinical decision support platform across 13 of its hospitals and additional outpatient locations. 🧑💻 Virtual and At-Home Care • University of South Carolina School of Medicine + Rimidi: The hospital group and an affiliated multispecialty clinic are adopting the remote patient monitoring platform to reduce complications from postpartum hypertension.    • Mount Sinai Health System + HealthSnap: The medical center announced a new remote patient monitoring and chronic care management program in partnership with the virtual care management platform.    • Wheel: The telehealth company released a new AI-driven virtual care platform designed to enhance the patient experience and offer resources to help partners scale their virtual care services. 💬 Patient Engagement • CipherHealth: The patient engagement solution focused on patient rounding released a new AI summary tool.    • DexCare: The care orchestration platform completed a $75M series C funding round 🩼 Durable Medical Equipment • Better Health: The medical device and peer support network completed a $14M funding round. 🧠 Food for Thought: • Silicon Valley Bank released an interesting report on the state of investment in AI in healthcare, including stats on AI usage at healthcare organizations and the impact of leveraging AI on startup valuation. https://lnkd.in/em7AfivT    • The journal Critical Care Medicine published an editorial on an “in clinico” evaluation of a machine learning-based early warning system to predict in-hospital deterioration. We found it to be an interesting look at the actual impact of a model’s deployment on care processes and patient outcomes in a critical care setting. https://lnkd.in/eQhZbVKu

Last week I spoke with Anuradhika A., System Vice President of Strategic Partnerships and Innovation at CommonSpirit Health, and she really nailed one of the common themes I’ve been hearing from health system leaders: Efficiency is about more than productivity “It also includes things like allowing our nurses to operate at the top of their license, helping clinicians spend more time with patients and less on administrative tasks, and eliminating the back-and-forth from processes.” Highlights from the rest our conversation below 👇 ___ 🟩 Q: What’s the biggest impact you've experienced from an innovation initiative over the past year? Our initiative to provide more transparency into the expected care journey for patients in the ED and inpatient areas has had a triple bottom-line impact. It’s improved the patient experience (we’ve literally had patients raving about their experience on Yelp). It’s improved outcomes via better continuity of care and care adherence. And we’ve seen our provider satisfaction increase significantly. The impact has truly been phenomenal. 🟩 Q: When it comes to AI, what areas are you most excited about? Like many health systems, we’re most focused today on the administrative use cases, given the potential to move quickly and drive significant value. We’re also spending a lot of time looking into solutions for ancillary areas that haven’t gotten as much spotlight as care delivery but remain hugely important. A couple of specific areas we’re investigating and bringing innovation to are PBM transparency and supply chain. 🟩 Q: Any areas where you see whitespace to develop new solutions? Expanding behavioral health solutions across the continuum is one. There remains a tremendous need for support, particularly on an ongoing basis across primary care and serious mental illness, and we believe there’s room for much more innovation in this area. There is also a lot of room to further enhance life science and precision medicine innovation with the advent of AI, so we continue to look for ways to harness those opportunities.