Hospitals and health systems face constant pressure to balance innovation with financial stewardship. Relying on the right revenue cycle management partner to pilot and validate emerging technologies allows hospitals to sidestep the high costs, operational risks and distraction of building in-house “start-up” capabilities.

An end-to-end RCM partner like Ensemble brings specialized expertise, proven frameworks and the ability to absorb early-stage errors, so hospitals don’t have to invest in expensive infrastructure or retraining. This approach protects capital and reduces the risk of unsustainable expenses while keeping the organization’s focus on delivering high-quality clinical care.

But what are the tools that are being assessed?

Every technology shift in the healthcare industry creates a temptation to apply the new tool to every problem. That’s what we’re seeing with large language models (LLMs) today. The truth is, not every workflow benefits from a model that “reasons.” Some problems need prediction; others need precision. Some need exploration; others need control.

Understanding when to use an open reasoning model versus a deterministic or predictive system is the new systems-thinking challenge. Let’s break that down.

November 10 update: Since this article was published, CMS has shared key details of the WISeR Model that were previously pending. On the evening of Nov. 6, CMS revealed the technology companies selected as Model Participants — companies that will use enhanced technology like artificial intelligence to support medical necessity coverage determinations. These companies include Cohere Health, Inc., Genzeon Corporation, Humata Health, Inc., Innovaccer Inc., Virtix Health LLC and Zyter Inc. The following day, Democrats in the U.S. House of Representatives introduced legislation to repeal the model. With the January 1 effective date approaching, Ensemble will continue to monitor these developments as our operators prepare our clients for success under the model.

Facing limitations in internal expertise, resources and technology, many healthcare organizations have turned to end-to-end revenue cycle outsourcing (RCO) firms for support. Most are looking for a true partner, one who can provide more than just third-party vendor aid.

Congress’ newly enacted One Big Beautiful Bill Act (OBBA) introduces work requirements, caps on state-directed payments and other measures that will slash roughly $1 trillion from Medicaid over ten years, leaving millions more patients potentially uninsured or under-insured according to the American Hospital Association.

While this has generated headlines, coverage churn is not new. State “Medicaid unwinding” began in April 2023 when unenrollments and reverification that had been suspended due to the Covid pandemic were lifted, and people fell off the rolls more quickly than they would have historically. This has already led to approximately 25 million disenrollments.

Ensemble has long treated under-insurance as a perpetual and complex challenge, not a one-off crisis. The same end-to-end operating model we deployed for the Medicaid unwinding easily scales to the OBBA era — protecting hospital revenue, safeguarding patient coverage and continuing to deliver a consumer-grade experience.

Referral leakage, also occasionally referred to as network leakage, occurs when a healthcare provider directs a patient to receive care outside of their affiliated hospital network.
This phenomenon can detract from the patient’s overall care experience in numerous ways:

• Medical records may not transfer seamlessly, leading to gaps in information
• Patients may not schedule appointments due to confusion about who initiates the process
• Duplicate tests may be ordered if the new provider doesn’t have access to prior results
• Out-of-network care can lead to higher out-of-pocket costs for patients
• Lack of follow-up and coordination can result in worsened health conditions

In addition to being detrimental to the patient experience, patient referral leakage can also result in substantial financial losses for healthcare organizations and disrupt the continuity of patient care. Consider this:

• The average cost per claim for MRI, CT, PET, mammogram, ultrasound and cardiac testing is approximately $1,500.
• If one provider refers these tests externally four times per month, it could result in an annual revenue loss of $72,000.
• When this figure is multiplied by a group of 100 providers, it increases to a potential loss of $7.2 million in revenue.

By comprehensively understanding the causes and consequences of referral leakage, we can develop and implement strategies to mitigate it, thereby ensuring that patients receive coordinated and efficient care within our network.

The registration process is far more than a routine step — it’s the first moment a patient connects with a facility, setting the tone for their entire visit. A smooth and welcoming registration process can calm a patient’s nerves and build trust, while a disorganized or indifferent one can increase their anxiety and result in patient distrust.

Patient access teams, as the frontline providers of this experience, hold the power to shape these moments. By focusing on key registration-specific questions from patient satisfaction surveys — three from outpatient and three from ambulatory surgery — we can turn this critical touchpoint into a source of comfort and trust.

The stakes to optimize core clinical revenue and cash have never been higher for academic providers. Although providers as a whole experienced an uptick in performance in 2024, celebration across the industry has been subdued throughout Q1 of 2025, as several headwinds continue to brew that are expected to hinder bottom-line performance.

While inflation has stabilized over the first three months under the new administration and providers have experienced 5%-6% top-line growth, reimbursement headaches continue.

These include:

• Continued payer mix deterioration
• Increased payer friction
• Reimbursement rates for commercial, Medicare and Medicaid that lag expected expense growth
• Increased competition within the hospital sector and across the care continuum

Exacerbating the top-line challenges are continued increases in expenses (7%-10%+), as well as ongoing workforce challenges attributed to increased patient acuity and complexity.

Healthcare is deeply personal for patients. It’s the most important financial transactions we have as American consumers. If fine dining, high-end hotels and VIP concerts can exchange goods and services for money without discomfort, surely, healthcare can too.

But healthcare must learn a thing or two from the industries that have mastered customer service. That’s why ensuring a quality patient experience is so critical, even and especially in the healthcare revenue cycle. Providers don’t have to avoid talking about money. In fact, effective revenue cycle management and effective patient conversations can enhance the patient experience rather than detracting from it, as many organizations fear.

Imagine going to a restaurant. The patient experience is akin to the entire dining experience, from making a reservation to enjoying the meal and paying the bill. The healthcare revenue cycle is like the restaurant’s operations, ensuring that the reservation is confirmed, the meal is prepared and served correctly and the payment process is smooth and transparent.

Now, imagine if your dining bill arrived at the table with completely different pricing than you’d seen on the menu, or that the restaurant’s own coupon was declined at the register with no explanation. Imagine your meal could only be paid for by check, or required you to stamp and post a physical stub with your payment for the night’s dining.

Just as a positive dining experience encourages repeat visits, a positive patient experience in healthcare encourages patient loyalty and timely payments — and a negative experience can build distrust and resentment, even among formerly satisfied patients.