While everyone is talking about how impactful AI will be in healthcare, I’ve been emphasizing that the long-term impact of this powerful technology will be beyond our wildest imagination but the rollout will be slower than expected. I’ve also been talking about the fact that each use cases needs to be stood up with great effort. Given the cost and complexity of launching each application for a specific use case, the customers of health AI solutions will prioritize applications that will result in immediate and meaningful ROI in terms of increased revenues, lower costs, improved staff efficiency, address staff shortages, etc. Some of the use cases that meet that criteria involve the administrative and operational use cases for AI. For example, ambient scribe, where a microphone listens to the conversation between the doctor, nurse, or the medical assistant and the patient and AI creates a concise and accurate note of the encounter seems to have crossed a threshold in terms of the proficiency of the technology. Given the increasing burnout of the medical staff and shortages, and how much of each day is spent creating documentation for medical encounters, this use case is ripe for rapid adoption.
Another use case that will lessen the workload of the staff and provide financial benefits to the organization is autonomous coding. Medical care is for the most part paid for by insurance. This could be government insurance, as is the case in US and all other advanced nations, or private insurance. Regardless of the insurance company, the payment process is convoluted and more complex than most other industries. That’s because the care we receive from healthcare providers is not usually paid for on the spot, like buying a consumer item in a store or online. That means there is a third party involved with this transaction. Yes, the beloved insurance company that receives a bill for the care you received and will (or will not) pay it. Insurance companies are businesses and they make more money when they pay out for less care received. If the amount of care they pay for exceeds the premiums they charge each member every month, they won’t be able to stay in business for very long. As such, they carefully evaluate whether the bill submitted is accurate, in line with the type of care received, not duplicative, proper documentation has been submitted to support it, and more.
All of this adds up to a game of cat and mouse that is going on everyday. How do you mean, you might ask? Well, on the other side of that transaction are the healthcare providers. Their business does better when they can collect more for the care they receive. As such, they have every incentive to charge the maximum amount possible and submit the bill in a way that is advantageous to them so they get paid and within a short amount of time. So, each one of these organizations has people, technology, and processes in place to win this game. Healthcare providers need to document the care they provide, devices and instruments they use to provide that care, and other costs, and submit it to get paid. In order to make sure that the charges are accepted, they employ armies of people who review the documentation and the billing codes to ensure accuracy and completeness before they’re submitted. On the other side, insurance companies have armies of people who review the charges and the supporting documentation and find issues that can allow them to not pay or pay less. Many of the submitted charges are denied or paid at a lower rate and then the provider will need to appeal those decisions if they want to get paid.
All of this has been going on for a long time and for the most part, this is a manual process. That means the care providers manually document their care, then they or a professional coder chooses the right codes for the care documented, and then the organization submits those codes. The codes are ICD-10 or CPT codes for the most part and there is also a level of care indicated. For a simple quick visit, the codes submitted will receive lower reimbursement than a complex visit that requires time or office procedures. Since this is subjective, it leaves a lot of room for dispute between the provider and the payer. This is already a loser for the care providers. Because they have a business to run and the delay means that they’re not getting paid on-time. If you have ever run a business, you know that having money going out of the door faster than it comes in is a recipe for disaster. Most businesses fail because they run out of cash. As such, ensuring that the codes submitted result in the highest appropriate reimbursement and well-supported by the documentation of that care is vital for healthcare organizations. This means serious investment in this area. This has taken the form of having well-trained staff for their coding function and using the technologies available, which until recently hasn’t been much.
In the next post in this series, we will take a look at the technologies that have been used to date and start getting into some of the recent developments.
