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It's hard to align incentives in the way healthcare is paid for in our country. You know, fundamentally, one side wants to get paid and one side doesn't want to pay so it's almost like a zero sum game. Welcome

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to off the chart,

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a business of medicine podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians. Practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, managing editor Todd schryock sat down with Roshan Patel, founder and CEO of Arrow, a healthcare payments company. They're talking about why getting paid by insurance has become so complicated, and why it's unlikely to get simpler anytime soon. Patel explains the three routes the practices typically take when payment processing gets out of hand, where AI is actually making a difference in revenue cycle management, and where it still falls short. Rosh and Patel, thank you for joining us. Let's get into the episode.

1:42
You

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I'm here with Roshan Patel, founder and CEO of healthcare payments company arrow, to discuss trends in medical payments. Thanks for joining me.

1:57
Yeah, thanks for having me.

1:59
So what are the biggest pain points right now in payment processing for medical practices?

2:06
Yeah, I think it's always a challenge to get paid by insurance, and especially nowadays, it's becoming more and more complicated. The pay rules are constantly changing. There's more prior auth requirements. There's more denials happening. Claims are getting rejected. Systems are more fragmented, so it's just harder to get paid by insurance for the services that you've already rendered. And there's a lot of reasons why that is, but I think we're just seeing mass frustration across the board, from from most physicians and providers in the industry,

2:42
why do these pain points exist? Why? Why haven't they been fixed? Isn't it in everybody's best interest to have a smooth payment processing system? I

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think it's a complicated question, because I think it's it's hard to align incentives in the way healthcare is paid for in our country. You know, fundamentally, one side wants to get paid and one side doesn't want to pay. So it's almost like a zero sum game. I think the way healthcare payments has come about from when, you know, insurance as a model originated, systems are so fragmented, it's just hard to even get the correct data right. Even knowing if some patients insurance plan requires prior auth for a certain procedure, it's hard to just get that information right. Oftentimes it's not easily accessible in your EMR clearing house. You have to call the insurance company, oftentimes they don't know they're so large, and their systems are so fragmented, so it's just kind of a mess. And this problem is compounded because there's so many different payers, so many different rules, plans are becoming more complicated, and there's just so much manual work that has to get done. And when there's that amount of manual work. You need specialized, trained staff, and that staff is hard to find. They're constantly getting burnt out and leaving, and it's hard to replace them. So the whole system is kind of a mess right now.

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So what's the solution? How do we fix this?

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Yeah, I think if there was an easy answer, we wouldn't be here today, like this would have been solved, but typically I see providers go one of three routes. One is they just hire more people in house. Just throw more people at the problem, because it is a ton of work, and that usually can help. Second is try and outsource it. There's obviously a lot of medical billing companies, both in the US and abroad, that are specialized to handle this, and a lot of practices that just don't have the ability to spend time hiring, or maybe they're growing and so they don't want to deal with hiring staff like that's a great option. And then lastly is. Is use technology. I think technology has really accelerated in the past decade, and especially in the past few years with AI. So there's a ton of tools out there which practices can take advantage of, but it's also hard to know which tools to use, which ones actually work. Has, you know, in any new technology that comes about, there's going to be a ton of noise, so it's really hard to make sense of what actually works.

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So how will AI and automation kind of solve these pain points? How will they how will it make it better for physicians?

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Yeah, I think a lot of ways. There's sort of two models that I see right now. One is using AI to automate work, and so you're sort of taking a workflow or a job or a function and getting AI to do that completely, like end to end. So one great example we've seen is scribing. That used to be something that doctors had to manually type, and now that whole workflow is pretty much automated, and that's been a huge time saver. The other approach that I see is using AI more as a co pilot or collaborator, where maybe for more complex workflows or higher stakes workflows. You don't really want to outsource it completely to AI. You want to have more control and visibility over things. And that's a lot of what I see in revenue cycle and billing. Just because it's so important, the stakes are very high. You're dealing with money. You're dealing with the financial health of a practice, and so, you know, think about like chat GPT. It's more of like a back and forth conversation. You're not just, you know, sort of outsourcing an entire task to chat GPT.

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So what would this look like to the end user? Is this something like, you know, the AI system will flag a certain insurer and say, Hey, insurer x always wants to see this data. Make sure you include that. Or, I guess what? What does it look like in the end?

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Yeah, absolutely, it's, it's hard to say, because revenue cycle and billing encompasses so many different tasks, right? Like insurance, verification, coding, preparing claims, submitting them, denials, payment, posting, patient billing, but you bring up a great example, like especially before claims go out, so much can be done with technology and AI to ensure those claims are clean. We're adhering to payer rules. We're flagging any abnormalities or things that would result in a denial. A lot of those tend to be more rules based. So it doesn't really even need AI. You can just make sense of the data. You already have a case that may be a little bit more take advantage of AI would be like writing appeal letters once you've gotten a denial that can take a biller, you know, several hours to do all of the research, compile the information, write a compelling letter and submit it. But now with ai, ai is very good at producing content, assembling data and writing and so we see Tasks that used to take hours now take minutes.

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Hey there. Keith Reynolds here, and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack, an employee engagement win or a lesson learned the hard way. I want to be true. Shoot me an email at K Reynolds at mjh life sciences.com with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute

9:26
about for patient payments. You know, practices are dealing with insurance companies, but they also have some patients that are paying cash or, you know, through a health savings account. Is that a separate system, or does that need to be integrated so that all the payments are in kind of one system within the medical practice?

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Yeah, I think a huge problem right now is that there really is no one system of record or source of truth. I. Think the EMR tries to do that, but fundamentally, the EMR is really built as more of a clinical tool, not really focusing on billing and payments. So oftentimes, when I ask providers, you know, how much are you collecting, or what's your denial rate, they just don't know. The data is not very easily accessible, because there is no one source of truth in an ideal world. Yes, everything is in one place, and it should be all connected. But I think I see most physicians and practices use their EMRs patient billing functionality as the way to collect the patient responsibility, whether that's their balance after insurance is paid, or they're just paying private pay.

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So if a practice wanted to modernize its payment systems and do everything it could to streamline the process, what steps should they take? What questions should they be asking?

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Yeah, I think the best place to start is just ask your peers, what are they using? What are they seeing that's working? Because if you just Google, you know revenue cycle technology or AI tools in billing, you're going to see dozens, hundreds of companies, and it's impossible to do your research, because all the websites say the same thing. They all look great. They all promise the world. So I would just get trusted information from peers that have actually tried it. I think depending on the size of the practice, usually the smaller you are, you don't really want too many tools that are separate. You kind of want like one or two that do most of the work. But the larger you get, it tends to make more sense to look for point solutions that do one thing really well and really customize that to your practice, because you're much larger and you may have a different way of doing things. And I also think conferences and events are a great way to learn about tools. You can go to booths and see the vendors right there and get conversations going. You don't have to wait to, like, do your research and book a sales demo.

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Are there any metrics that practices could use to kind of measure the impact that these systems would have, or metrics they should be asking about to a vendor?

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Yeah, I think it's a great question to ask the vendor, like, what metrics are you going to measure and improve? For me, but I think it kind of comes back to the system of record problem where no one really knows their metrics. The metrics are also hard to measure, so there's just a lot of inability to know what works. But I think if you're on top of your numbers, you can, you know, come to the vendor and say, you know, here's my collection rate, or here's how long it takes me to get paid by insurance on average. How does that stack up to what you see in the market? And what are you going to do to those metrics to get them to where they need to be? Think, the more informed you are as a physician or practice owner, the more you can discern like what's real and what's not, because the vendors are always going to promise that you're not doing well and the vendor is going to make you do well.

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Is there one particular area where these systems really make the biggest difference?

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Yeah, I would say it's a lot of when there's a lot of manual work required. I would say that's probably in most places in revenue cycle and billing, but the one that I see the most is when you're dealing with denials or claims that have not been paid. That's typically the most labor intensive part of revenue cycle, because it's not as simple as just clicking a button to verify patients insurance. You have to do a lot of digging to understand why something was denied, oftentimes, the reason that comes back from the insurance company is often not the right reason, or the reason is very vague, and you have to call them and figure out what's going on, and you have to write appeal letters, and you have to, you know, even when you submit that appeal, you have to follow up on it and make sure it gets paid out. So it just creates a lot of work, and that's a great area where I see use of technology,

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looking out five to 10 years, where do you see these systems, you know, what pain points do you think they will solve in the long run?

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Yeah, I think it'll mostly be the same pain points. I think there's an argument whether AI is going to replace medical billers or not? I think a lot of people industry think that it will, just like most types of knowledge, work could be completely automated, but I don't think that's the case. I think there's a lot of specialized knowledge within a practice of you know, billers have decades. Of experience, of like, oh, this payer always requires this certain little quirk when we submit the claim that it's just hard for AI to pick up on, because it's not going to have all of the context and data that comes with years of billing experience. So I personally think we'll still have medical billers around, but they'll be strongly empowered and more efficient and more productive by the tools that we have. I don't think healthcare payments is ever really going to be solved the way the current system set up. There's always going to be denials, there's always going to be friction in the process. We're probably not going to have some sort of like real time payments in healthcare for a very long time. So I think this, this job is going to be required, but just made a lot more less frustrating, I suppose,

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very good. Well, thanks for joining me.

15:51
Yes, thanks for having me.

15:55
Once again. That was Roshan Patel, founder and CEO of Arrow, speaking with medical economics Managing Editor, Todd Shryock, on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts, and if you'd like the best stories that medical economics and physicians practice published delivered straight published delivered straight to your email six days of the week. Subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Latrell. Medical economics and physicians practice are both members of the MGH Life Sciences family. Thank you.