Using AI to appeal denials three times faster – and recover lost revenue

EmpowerMe, a healthcare provider services organization to more than 1,000 senior living communities across 38 states, regularly receives denials from its insurance company on procedures or treatments they should cover.

That means staff members have to go through the lengthy process of appealing these denials in order to get money the healthcare organization should be receiving.

THE PROBLEM

This was incredibly time-consuming and required certified clinicians to spend hours understanding each individual case to draft and submit the appropriate appeals. With the industry suffering a labor shortage, the problem was even more challenging.

PROPOSAL

The proposal from Crosby Health, vendor of an artificial intelligence-powered technology called Apollo, was to handle most of the work of drafting appeal letters for EmpowerMe.

“Apollo would analyze each case and draft the appeals, and all our clinicians would have to do is review them instead of starting from scratch,” said Dr. Jody Mitchell, chief medical officer at EmpowerMe. “By leveraging AI, EmpowerMe could target all of our appeals, instead of having to prioritize our bandwidth for the most important ones.

“This would mean getting more appeals submitted and our clinicians not overwhelmed with the workload,” he continued. “It also meant we could apply the AI technology more upstream after we completed appeals.”

For example, staff used to have regional directors who were trained clinicians manually completing chart compliance audits. With the AI, EmpowerMe could tackle denial management first, understanding back-end processes, and then use the same technology to fix the issues on the front-end.

MEETING THE CHALLENGE

The provider organization needed something that could mirror what its practitioners were doing day in and day out. It met with the vendor and things instantly clicked, Mitchell recalled.

“For EmpowerMe, adopting this technology was a no-brainer; it can tap into the same knowledge base as our clinicians and processes denials quicker,” he explained. 

“On the case management side, the vendor has worked very closely with our leadership and the clinicians on our appeals team to ensure our integrations are smooth, now working with two of our EHRs – first with Clinicient and now with NetHealth.

“We started off understanding the technology and mapped out all the different use cases from chart auditing to clinical appeals,” he continued. 

“We decided to start with appeals, but it won’t stop there. With their integrations into our EHR, there are numerous applications that will meaningfully impact our business and automate administrative workflows that would otherwise take up clinical resources.

The vendor worked with the provider’s appeals team for months understanding everything it could to apply its technology in the right areas. It continues to garner feedback from the provider’s team to go further.

RESULTS

The technology has completely revamped EmpowerMe and saved the organization time and team bandwidth, Mitchell reported.

“It’s helping to build our clinician’s trust in AI being used in the healthcare space,” he noted. “Using Apollo has enhanced our appeals team’s efficiency and streamlined our revenue cycle management tasks at hyper-speed.

“By leveraging AI, we’re allowing our doctors to do what they do best: be doctors and manage patient outcomes,” he added. “Specifically, we now are able to write appeals at three times the speed, allowing our team to focus on higher-leverage tasks.”

ADVICE FOR OTHERS

It’s fair to be wary of AI in healthcare but using proven technology to help do easily automatable tasks is a no-brainer, Mitchell advised.

“We’re not using AI for anything patient-facing,” he noted. “We’re using it internally to save our team’s time and effort so they get to do what they are trained to do and what they love, take care of people not paperwork,” he said. “We were able to find an easy-to-use model our clinicians quickly learned, and it helped them do an annoying part of their job at 3 times the speed while recovering lost revenue for our business.

“By opting for solutions with intuitive interfaces that can be quickly integrated into existing workflows, the success of AI implementation largely will depend on the willingness of your team to embrace and use the technology,” he continued. “Providing adequate training and support will facilitate a smooth transition and ensure clinicians can leverage the tool effectively to enhance their productivity.”

Above all, it’s imperative to continuously monitor and evaluate the impact of the technology on both operational efficiency and patient care, he insisted.

“Healthcare organizations must solicit feedback from clinicians and all staff to identify areas for improvement and optimization,” he concluded. “By fostering a culture of innovation and continuous improvement, health systems can harness the power of AI to streamline processes, enhance quality of care and improve patient outcomes.”

Follow Bill’s HIT coverage on LinkedIn: Bill Siwicki
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Healthcare IT News is a HIMSS Media publication.

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