Article - AI-driven approach to optimize Revenue Cycle Management

Artificial Intelligence (AI) and automation have a pivotal role to play for improved revenue cycle performance. AI is making big waves across many industries, and healthcare organizations are exploring ways to harness AI's transformative power.

Healthcare leaders think that AI should be a priority and there are many use cases of AI in healthcare out of which prior authorization is one of the best use cases. However, prior authorizations are just one of the burdensome processes in a transaction-heavy part of healthcare i.e. the revenue cycle.

Revenue cycle management in today's healthcare market faces numerous challenges such as insurance denials, rising costs faster than reimbursements. Hospitals and health systems see a potential solution to some of these issues using AI technology in the revenue cycle management.

Let’s look at the benefits of AI for modernization revenue cycle management, and adoption such disruptive technology in hospitals and health systems:

 Automation of various tasks to optimize Revenue Cycle Management

  • Various high-volume, repetitive, and mundane tasks can be addressed accurately with the help of automation allowing hospitals to expand production at a much lower cost. Hospitals can then re-invest these freed up resources into those tasks that require a more human touch such as empathy, creativity, and complex thought.
  • According to a survey, Providers could save USD 9.8 billion by automating key revenue cycle functions.
  • Organizations can do few things differently with their revenue cycle staffing and strategy with the help of AI.
  • AI enables organizations to address workforce shortages.
  • Talent retention is important in competitive markets which can be done with the help of AI, as hospitals can reward loyal employees with more consequential roles as they are no longer needed for tasks that can be completed with automation.
  • AI enables healthcare organizations to be more strategic with the work they outsource.

Prediction of claim denial rate

AI-driven approach for revenue cycle management enables predicting claim denials. Constantly changing payer guidelines and human error are among the reasons hospitals and other provider organizations struggle with high claim denial rates. It's estimated that hospitals lose more than $260 billion annually from insurance denials.

Identify trends of claim denials

Adoption of AI technology-empowered hospitals and health systems to pinpoint the reasons payers denied claims in the past and uncover denial trends. Analytics of claims denials enables a healthcare organization to predict denials and resolve problems before claims are submitted, leading to lower denial rates and higher revenue.


AI and automation can optimize costs for hospitals and health systems by streamlining and optimizing manual processes. Another aspect of AI natural language processing in healthcare shows promise for transforming the revenue cycle. NLP enables computer programs to process and analyze unstructured data, such as free-text physician notes written in an EHR. Application of NLP can improve coding and clinical documentation in RCM.

After knowing about the benefits of AI, one should have the question in mind “potential of AI for optimizing RCM?” Let’s look at this aspect in detail now:

Potential of AI for optimizing RCM 

Various healthcare providers are leveraging the AI technology to deliver better care for patients with everything from sleep disorders, eye disease, cancer, and even COVID-19.

The revenue cycle contains an abundance of tagged data, which means values are codified to data points to indicate certain events. For instance, attributes of a patient’s diagnosis. AI is efficient at evaluating those variables and coming up with an ever-improving success rate of getting to the right outcome against any of those process steps.

AI can imitate intelligent human behavior through various algorithms that find patterns and plan future actions to produce a positive outcome. Hence AI can effectively address various revenue cycle management issues, such as prior authorizations, claim status checks, and out-of-pocket cost estimates while getting the information that needs human intervention at the right time.

In the revenue cycle, some of these processes include checking the status of claims, working denials, or reviewing eligibility are time-consuming and copy-and-paste intensive by automating such a task, a healthcare organization can address every patient account, regardless of the dollar amount attached to it.

AI helps in keeping the privacy and security of patient’s information by controlling the sending of sensitive patient information. It eliminates the need for at least one set of eyes on the data and enables information to be securely sent and accessed, meaning hospitals have greater control over who accesses patient data and where it goes.

AI in the revenue cycle mainly deals with revenue integrity, compliance, and optimal reimbursement. The technology allows hospitals to repurpose employees and mitigate revenue leakage in ways that require more critical thinking.

AI for healthcare staff 

AI helps hospitals operate in smart ways. With the help of automation, hospitals can offer a productive environment to its employees in which employees are empowered to focus solely on work that requires the human touch.

AI system helps staff in a couple of important ways:

  • Completes nearly 100 percent of eligibility checks on the front-end of the revenue cycle
  • Highlight changes in payers' reimbursement policies, which helps employees act sooner to reduce AR days or notice variations in accounts much earlier.

However, justifying spending thousands of dollars on new technology such as AI will be difficult for instance, consider the EHR system, a single hospital stands to spend millions of dollars on a new system. But this is the wrong way to think about automation. Hospital leaders shouldn't think about AI and automation as another price tag, but as a path to savings. These leaders should carefully examine the business case for AI-driven revenue cycle management and explore small-scale innovations with the potential for a strong return.

AI-based RCM is a necessity for a healthcare organization to address the challenges and opportunities of the modern revenue cycle. We have a team of experts who understand the technology and its benefits. We offer RCM services keeping in mind the latest advancement in it. Contact us to know more.

Published By - Medical Billers and Coders
Published Date - Jul-28-2020 Back

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