Industry Trends Archives – Ensemble Health Partners

Where LLMs Make Sense — and Where They Don’t

Jim Gaffney, Chief Strategy Officer — Wed, 03 Dec 2025 20:17:55 +0000

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.

The three lenses: effectiveness, efficiency and cost

Lens

Effectiveness

Efficiency

Cost

Core Question

Does it improve the outcome quality?

Does it reduce cycle time or human effort?

Does it justify the compute, integration and error cost?

Example Metric

Accuracy, recall, relevance

Task completion time, agent handoff rate

Cost per 1K tokens, rework time, supervision hours

If it’s high-value but low-tolerance for error (like financial reconciliation), deterministic systems win. If it’s ambiguous, language-based or multi-factorial (like summarizing clinical notes or writing appeals), reasoning models add value. If it’s highly repetitive, rule-bound and measurable (like claim edits), predictive or deterministic systems outperform reasoning models on cost and reliability.

The framework: "R.E.A.L."

Step

R — Reasoning needed?

E — Error tolerance defined?

A — Available data type?

L — Latency vs. learning tradeoff

Description

Does the problem require contextual synthesis, judgment, or multi-variable reasoning?

How much error can the system absorb before cost or compliance risk outweighs speed?

Do you have structured, labeled data or mostly unstructured narratives?

Is it more important to get to an output quickly or to improve over time?

Example

Interpreting denial letters or coding documentation.

Appeals generation can tolerate 10% edits; payment posting cannot.

Eligibility checks use structured data; prior auth notes do not.

A chatbot can iterate; a claims router must decide instantly.

If three of the four lean toward “Reasoning / Context,” use an LLM or open reasoning model. If three lean toward “Control / Determinism,” stay with algorithmic or predictive logic.

Practical use cases in revenue cycle management

Revenue cycle example: Denial prevention vs. Denial appeals

Denial prevention: Rules-based, deterministic systems are optimal. You know the payer rules, and you can code deterministic edits. Adding a reasoning model increases cost and potential drift without clear benefit. However, you can use reasoning models to explore large datasets and look for potential new rules. You can also use machine learning classification models such as regression, random forest or gradient boosting if the rule set is not easily written as “If X then Y”. These models are still much more efficient than broad-based LLM models.

Denial appeals: Context matters — clinical justification, payer policy and tone. An LLM with reasoning and retrieval capabilities can draft appeal letters 3–4x faster than humans, with a small manual review loop.

Ensemble’s data shows 40%–60% cycle time reduction for appeal generation using Generative AI.

Cost and control: The hidden variables

Model Type

Deterministic

Predictive

Reasoning (LLM)

Unit Cost

Low

Medium

High

Error Cost

Low

Medium

Variable

Control Level

High

Medium

Low-Medium

Ideal Use Case

Compliance, validation, automation at scale

Forecasting, triage, prioritization

Interpretation, communication, synthesis

When evaluating AI in revenue cycle, the total cost equation matters — not just model performance. That equation should include compute, supervision time, correction rework, regulatory or reputational risk and the costs of model retraining or context injection. For example, running GPT‑4 Turbo on 10 million claims would exceed $1 million per month in token cost alone, while deterministic logic could accomplish the same work for <$10K. Overlooking hidden costs like this can turn a promising AI initiative into an unsustainable expense, eroding ROI and slowing adoption.

The decision tree

If the input is structured, use deterministic or predictive models. If it is not, the next question is whether the outcome is binary or open-ended. If binary, use predictive models. If open-ended, use reasoning models. If the error cost is high, a deterministic model is a good fit. If not, use reasoning or hybrid models. Finally, consider if the task requires contextual synthesis or judgment. If yes, use a reasoning model. If not, choose a predictive model.

Bringing it together: Hybrid systems win

The best architectures combine reasoning, predictive and deterministic logic — not as competing models, but as layers of trust and speed.

Layer 1: Deterministic filters — data validation, policy edits.
Layer 2: Predictive triage — probability of denial, next-best action.
Layer 3: Reasoning model — narrative generation, summarization, contextual insight.

Each layer narrows the field, improving both efficiency and controllability. You get the speed of automation without the chaos of unbounded reasoning.

The goal isn’t to use LLMs everywhere — it’s to use them where human reasoning is the bottleneck. And remember: if you can define the outcome with a clear rule, code it. If you can’t, predict it. If you still can’t, reason it.

Ensemble Outperforms in Latest KLAS End-to-End RCM Report

Ensemble Health Partners — Thu, 11 Sep 2025 12:40:09 +0000

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.

I strongly encourage folks to not use the word outsourcing. If you think this type of engagement is outsourcing, you probably ought to just stick with what you have. You are going to need a partnership that feeds the lifeblood of your organization, namely your revenue...If you can’t get your mind around the fact that this is a partnership and that each party is an extension of the other, then I think the experience will be difficult.

C-suite executive, KLAS End-to-End Revenue Cycle Outsourcing September 2025 Report

Key factors driving the choice of a partner in the revenue cycle include a firm’s:

Model or approach
Expertise + regional familiarity
Technology
Partnership
Contract terms/price
Reputation

Research and insights firm KLAS recently released its biannual End-to-End Revenue Cycle Outsourcing Report to assess the market impacts of these decisions, asking the question “Which firms are delivering superior outcomes through innovation and collaboration?”

Ensemble, the 2025 Best in KLAS winner for End-to-End Revenue Cycle Outsourcing and a five-time Best in KLAS winner, also received the highest client satisfaction across all metrics and a top overall performance score of 95.1 on a 100-point scale.

Our clients partner with us because our clients succeed with us.

Ensemble’s approach fuses performance excellence with strong, enduring partnerships, delivering results that matter and relationships that last.

I know every firm in the revenue cycle space, and I know the difference between Ensemble and every other firm. Quite honestly, there is no comparison. Things with Ensemble have been fantastic. From a client perspective and a services perspective, the responsiveness, the expertise, the support, and the performance against KPIs have all been extraordinary since day one.

CEO/President, KLAS Research Interview, March 2025

This isn’t lip service — the proof comes directly from our clients. When surveyed by KLAS:

100% would buy again
94% say Ensemble exceeds expectations

That’s because we don’t just make promises. We deliver proven results across critical performance metrics.

In the KLAS report, nearly 88% of clients report being satisfied or highly satisfied with Ensemble’s impact across all key areas surveyed:

• 83% AR days
• 92% cash collections
• 92% denial rates
• 83% patient experience

We’re investing heavily in AI so our clients don’t have to.

We’ve repeatedly proven that we can deliver top results for our clients, but we’re determined to stay one step ahead of the market. This is just one of the reasons why we’re leading the industry in AI innovation and investment in RCM.

No E2E RCM firm is investing more in AI than Ensemble — it’s that simple. Respondents to the KLAS report expressed excitement about our significant investment in AI and expansion into payer strategy.

We see Ensemble as a pioneer in AI. Ensemble really has embraced AI from day one. They use it a lot in current technology, and they are always exploring new ways to use AI to help improve efficiency.

CEO/President, Klas Research Interview, May 2025

When it comes to RCM market growth, Ensemble has no peers.

The numbers don’t lie. Ensemble has experienced unrivaled growth in the end-to-end revenue cycle outsourcing space. Since the last KLAS report, Ensemble was selected in more validated new end-to-end RCM partnerships than any other firm in the sample.

This rapid growth is a vote of confidence from the organizations that sit at the heart of the revenue cycle, the providers on the frontlines with patient care. The ready expansion of Ensemble’s client base solidifies our position as the partner of choice for healthcare organizations seeking transformative RCM solutions.

The bottom line

Throughout the KLAS survey and in repeated testimonials, clients consistently highlight their deep, trust-based partnerships with Ensemble. These are built on:

Transparent expectations set early in the sales process
Structured governance and collaborative leadership post-implementation
Frequent, purposeful communication

At Ensemble, it’s our partnerships with incredible hospitals and health systems that power our performance.

…Anytime we have a fire, such as a patient experience issue, Ensemble is willing to jump in and help solve the problems for us. If I call with a facility issue, they will have somebody on the ground the next week working with that facility. Ensemble has been very engaged and responsive. Ensemble has our long-term interests at heart…

CFO, KLAS Research Interview, May 2025

The right end-to-end partnership is not just helpful or a “nice to have” option; it is an essential support mechanism for the lifeblood of a health system — its revenue cycle.

By grounding our efforts in measurable outcomes, offering comprehensive operational support and relying on a seasoned team backed by top talent, technology and transformation, Ensemble has proven repeatedly why we’re the top choice of healthcare organizations nationwide.

Read the full KLAS End-to-End Revenue Cycle Outsourcing 2025 Report.

Ensemble’s Always-On Management of Uninsured + Underinsured Populations

Shannon White, Chief Operating Officer — Thu, 14 Aug 2025 19:36:09 +0000

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.

Why the industry is buzzing about OBBA

OBBA will bring significant impacts in the near future, including:

Medicaid cuts + work requirements: OBBA introduces nationwide work verification and tightens eligibility redeterminations. States that exceed the 3% limit on eligibility errors face fiscal penalties such as a reduction in matching federal funds.
Provider payment constraints: New caps on supplemental payments and limits on provider taxes intensify margin pressure for safety-net hospitals.
Timeline shock: Major provisions phase in beginning January 1, 2026, giving hospitals less than 18 months to prepare before these provisions are effective.

OBBA magnifies an already-underway shift from insured to self-pay. Success hinges on proactively qualifying patients for coverage and crafting frictionless payment pathways.

Coverage + conversations at every step

At Ensemble, we provide always-on management of uninsured and underinsured populations , another benefit of our end-to-end approach. Our interactions with patients at every stage enable us to have a greater impact and to keep sight of coverage issues throughout the entire process. By engaging with patients from scheduling all the way to post-service billing and payment, we also have the ability to handle challenges that arise at many different stages, rather than just one based on a single point solution deployment.

Our approach is:

Comprehensive, not episodic: Our model addresses every coverage disruption (e.g., policy change, life event or data error) through continuous analytics and advocacy.
Patient equity- and advocacy-first: Financial conversations emphasize benefits eligibility before payment collection, preserving community trust.
Digital by default, human by design: Tailored agentic AI automation handles routine eligibility and coverage checks as well as estimate creation. Trained financial advocates intervene where human judgment and care for the patients matter most.

Ensemble’s end-to-end patient-financial flow is already ready for OBBA, continually screening for coverage and centering the patient’s experience at every step.

Pre-service auto-screening

At scheduling, every patient record runs through Ensemble’s rules engine and 200+ data feeds to check Medicaid/Marketplace eligibility, commercial coordination of benefits, local charity and a propensity-to-pay score after an estimate is generated.

Digital estimate + financial clearance information

The patient receives a consolidated packet via preferred channel (text, email, portal) containing:

Accurate cost estimate
Real time coverage status and gaps
Simple task list (e-sign forms, document uploads, prompt-pay discount window)

Arrival + Point-of-Service advocacy

Fast-track check-in exists for financially cleared patients. If coverage or payment is pending, financial advocates engage pre-service. Emergency department or unscheduled inpatients get bedside assistance (where allowed by policy) to secure coverage and set up liability arrangements before discharge.

Continuous eligibility search + auto-populated applications

The platform keeps scanning for new coverage and can auto-qualify for charity. Our comprehensive database and connections not only look at Medicaid options but also COBRA, exchange plan options, local funding and special programs such as crime victim funds, searching all avenues for coverage so patients aren’t left to bear the financial burden on their own. If additional data is needed, it triggers pre-filled forms sent to the patient. They simply review and e-sign or snap photos of proofs of income/ID.

Customized payment solutions

Ensemble’s post-care outreach begins with the patient’s chosen channel (including email, text, agent or human call), then expands based on engagement analytics. Plans include:

Prompt-pay discounts for settlement within 15 days
Interest-free installments over a number of months, depending on the balance
Sliding-scale terms that mirror third-party financing without the 8%-15% merchant fees that siphon revenue from our providers

Auto-reverification + compliance reminders

For benefits subject to work-verification or annual proof-of-income, Ensemble triggers reminders 30/15/5 days before lapse. Patients respond by uploading documents (camera capture in app or web), keeping coverage — and revenue — intact.

Post-cycle analytics + bad debt reclass

If coverage still isn’t found, analytics rerun eligibility logic; newly identified payers prompt rebilling, or accounts convert to presumptive charity, as appropriate, to avoid bad debt write-off.

The bottom line

OBBA may feel like the latest earthquake in health-policy land, but for Ensemble and our clients it is simply another tremor our end-to-end model was built to absorb. Our model:

Mitigates coverage volatility: Automated screens and reverification reminders cut avoidable self-pay conversions triggered by OBBA’s new rules.
Protects hospital margin: Direct payment plans retain every dollar, avoiding fintech “skim” and preserving goodwill.
Elevates patient experience: One digital journey, from estimate to zero balance, reduces anxiety and boosts loyalty in an era of heightened financial sensitivity.

Continuous eligibility analytics, advocacy-centered workflows and fee-free payment flexibility keep patients covered and hospitals financially whole, no matter how the ground shifts next.

Why Patient Care Collections Are a Lifeline for Academic Providers

Andrew Bess, Chief Client Officer — Tue, 22 Apr 2025 13:35:28 +0000

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.

Academic medical centers face unique challenges

Academic medical centers (AMCs) are the backbone of medical innovation and training in the United States, with a three-part mission:

Delivering cutting-edge care
Educating the next generation of healthcare professionals
Conducting groundbreaking research

Compared to their community provider counterparts, AMCs face an even greater and unprecedented challenge: balancing their tripartite mission while grappling with escalating costs and shrinking revenue streams for both operating and non-operating revenue, whereby non-operating revenue can account for up to 35% of total revenues.

2025 is a critical juncture and inflection point for AMCs as they face continued financial suppression. This makes patient care collections not just a revenue source, but a lifeline for sustaining their unique role in the healthcare ecosystem.

The tripartite mission is under threat

According to a 2023 report from the Association of American Medical Colleges (AAMC), AMCs account for just 5% of U.S. hospitals but provide 37% of all charity care, 26% of Medicaid hospitalizations and a disproportionate share of complex cases.

AMCs’ three-part mission of patient care, education and research is expensive, and the commitment comes at a cost. It’s one that is increasingly difficult to bear as traditional revenue streams like government funding, grants and reimbursements face compression. This is demonstrated by operating margin erosion from 2017 to 2023, and anticipated declines into the foreseeable future.

Historically, AMCs have leaned on a mix of clinical revenue, research grants and philanthropy to fund their operations, but these sources are under siege due to changing legislation, shrinking traditional patient care and non-traditional reimbursement sources, rising costs, continuing payer friction and other industry trends. These pressures include:

Payer mix and continuum of care shifts: Despite modest revenue growth, AMCs will feel the squeeze of caring for heavy MCR/MCD/uninsured patients, increases in uncompensated care, and a continued shift to lower cost of care settings.
Reimbursement flattening and contraction: All providers continue to face possible cuts to MCR physician fee schedule, and MCR IPPS and Medicaid rate hikes that lag expense growth.
Increased payer friction: Increased initial and final denials (21% CAGR from 22-24 and growing), plus increased cost to collect while seeing declines in cash collections / NPR.
Accelerating expense growth: The cost to treat, educate, research and innovate is much higher given the patient profile and mission components that go beyond a traditional hospital, and is without immunity from tariff legislation.
Continued workforce challenges: Due to the higher complexity and acuity of AMC patients, the labor needs are typically more specialized and heightened given the need to care for sicker patients, and training and educating providers.
Potential crackdown on supplemental revenue: AMCs are often reliant on patient care dollars and other streams to fund their entire mission; they are also grappling with potential 50% cuts to NIH funding and potential slashes to IME, GME, DSH and other programs.
Increasing complexities: As the population ages, workforce challenges intensify and potential funding streams dry up, the ability to deliver quality patient care while training the next generation of providers will get more difficult.

While certain movements in DC and evolving payer mix dynamics are less controllable, placing an emphasis on collecting patient care dollars is more controllable, and has never been more important in the outlook and long-term sustainability for academic providers.

Partnership serves as a path forward

Uncollected patient balances can account for 6%-8% of total revenue leakage. For a mid-sized AMC, this could mean losing $60-$80 million annually , revenue that could otherwise fund research staff, facility upgrades or scholarships. With high-deductible health plans on the rise, patients are responsible for more costs, but AMCs often lack efficient billing systems, leading to delays and uncollected balances.

AMCs need to prioritize patient care collections by investing in advanced billing technologies and training staff to educate patients about their financial responsibilities. This can significantly increase revenue, help bend the cost curve and allow providers to not only execute on their clinical mission but also support and fund efforts for continued education, research and innovation.

The cost and ability to bend these cost and revenue pressures are difficult, however. While some providers are equipped to navigate difficulties themselves, most of the industry needs a partner to help right the ship in capturing the patient care dollars to enable and cultivate investment back into patients, providers and community as a whole.

Ensemble has a proven track record of being the partner to drive unmatched results for providers with exceptional service, underpinned by cutting-edge technology and innovation. We focus on:

Immediate cost reduction and future risk mitigation through geographic arbitrage and scalability
Seamless and thoughtful transition of a non-core business function to a partner that is best positioned to combat industry disruption
Ability to reallocate financial resources to clinical care and strategic initiatives which benefit your patient population.

Clients see a 5.2% net revenue lift on average and meet 100% of year-one goals. Learn more about the Ensemble end-to-end approach >>>

The bottom line

Academic providers are facing unique pressures given threats not only to traditional revenue streams, but also to the supplemental sources of income that enable successful execution of their tripartite mission.

Most academic providers, however, are incapable of bending these pressures themselves. The right end-to-end revenue cycle management partner can help support by leading with an innovative, AI-forward approach and exceptional service, leading to unmatched results that can help AMCs stay solvent under intense headwinds.

How Strategic Partnerships Create a Competitive Advantage for Regional Health Systems

Andrew Bess, Chief Client Officer — Wed, 12 Feb 2025 19:24:39 +0000

Despite industry-wide headwinds, large health systems are performing better — in both financial and quality metrics. Regional hospitals often struggle to compete, providing services on a smaller scale in a specific area, and with fewer resources at their disposal.

It’s not just that these smaller systems struggle to keep pace — they simply can’t get ahead. Regional systems often operate with thin margins, making it difficult to invest in necessary innovations. By contrast, larger health systems benefit from economies of scale and higher profitability. For example, Tenet Healthcare reported an operating margin of 12.2% in 2023, while many regional hospitals struggle to break even.

Strategic partnerships can help bridge this gap by providing access to resources and expertise that regional hospitals cannot afford independently. Hospitals with strategic partnerships often see improved financial performance and stability. To create value and remain competitive, regional health systems should seek outside expertise in areas where they lack resources and capabilities.

Regional hospitals face systemic challenges

Due to their limited scale and resourcing, regional hospitals often struggle with:

Limited ability to recruit top talent: Attracting and retaining skilled professionals, especially in specialized areas like revenue cycle management, is challenging for regional hospitals. According to a report by the Commonwealth Fund, regional hospitals often lack the resources to compete with larger systems in attracting top talent. Moreover, multi-stakeholder collaboration and effective partnerships among healthcare providers and third parties were crucial in achieving health system goals.
Constraints on innovation and technology investments: Thin margins and limited capital make it difficult for regional hospitals to invest in cutting-edge technology and innovation. McKinsey’s report on the future of US healthcare highlights that many regional hospitals are unable to allocate sufficient funds to technology initiatives due to financial constraints.
Lack of integrated health networks: Unlike larger health systems, regional hospitals do not benefit from economies of scale, deeper reach, and better purchasing power. McKinsey’s analysis on regional health system strategies emphasizes the competitive disadvantage faced by smaller hospitals due to their limited scale.

An end-to-end RCM partnership can help regional systems get ahead

Partnering with specialized revenue cycle management experts can help regional health systems not only shore up their revenue cycle but also gain a competitive edge.

An end-to-end partnership allows hospitals to leverage external expertise and resources, letting providers focus on core operations and clinical outcomes.

Access to top talent: Alignment with an RCM partner brings access to a large, skilled workforce. Ensemble employs an extensive workforce of industry-certified associates, enabling regional health systems to tap into talent and expertise that they would not normally be able to acquire on their own.
Cutting-edge technology: Investing in advanced technologies is crucial for maintaining a competitive edge in healthcare. Ensemble invests millions into technology and innovation to benefit our entire client base, providing access to generative AI, automation and EHR standardization that can help regional hospitals stay competitive.
Economies of scale: Similar to the advantages of participating in a group purchasing organization, partnering with an end-to-end RCM provider unlocks economies of scale. Ensemble leverages its size representing nearly $40 billion in annual net patient revenue to help change payer behavior and negotiate favorable contract rates and terms for its clients. Insights gained from transactional data across hundreds of hospitals also enables process optimization and technology development to solve issues at scale across organizations.

Partnership in practice

An RCM partner brings unique resources and expertise to the table, allowing for a more efficient and effective use of a hospital’s own capabilities. The right strategic partnership can drive results that improve performance system-wide, by:

Improving patient experience: Our clients have seen a 27% reduction in patient registration wait times through streamlined patient communications, the delivery of comprehensive training and accelerated pre-service processes. Read more.
Preventing lost revenue: Health systems partnering with Ensemble have prevented $80 million in revenue loss by addressing pre-billing errors and inaccuracies through our revenue cycle intelligence engine, EIQ^®. Read more.
Improving payer performance: A large health system resolved unpaid claims and achieved a 20% rate increase with a major payer through an effective out-of-network strategy and a robust approach to addressing contact language, payer performance and dispute resolution of outstanding AR. Read more.
Reinvesting in patient care: By reducing first pass denial rates by 84% in just six months for a department within a large non-profit health system, Ensemble enabled the department to double patient treatment capacity. Read more.

These improvements — including reduced patient wait times, recovered revenue and enhanced payer performance — ultimately lead to a more efficient and profitable healthcare facility, regardless of size or location.

The bottom line

By partnering on the revenue cycle, regional health systems can achieve economies of scale, access top talent and implement cutting-edge technology. These partnerships enable regional hospitals to create strong market advantages and improve patient outcomes.

Because of this, regional health systems should consider strategic partnerships as a key component of their long-term efforts to remain competitive while facing challenging headwinds.

Recent ACA Plan Growth Holds Risks + Opportunities for Providers

Brad Gingerich, VP, Payer Strategy — Tue, 01 Oct 2024 18:05:54 +0000

What you need to know

Subsidies have made health insurance more affordable, with the added benefit of bringing favorable commercial reimbursement rates and contracting leverage to providers. However, these same subsidies are set to expire at the end of 2025. Now is the time for action — providers must advocate for the extension of subsidies to protect tenuous financial margins.

The Affordable Care Act (ACA) has expanded coverage for patients while bringing surprising benefits for providers nationwide. In 2024, 21 million people enrolled in the ACA Marketplace, a record level that’s nearly double the 11 million enrolled in 2020.

A large portion of this growth can be attributed to the enhanced subsidies introduced during the COVID pandemic by ARPA in 2021 and renewed under the IRA in 2022. These subsidies made health insurance more affordable for all enrollees, but particularly for low- and middle-income individuals who were previously priced out of coverage. In fact, 91% of beneficiaries now receive some form of subsidy, while 74% of beneficiaries are below 250% of the Federal Poverty Level.

This expansion of accessible coverage has had a substantial impact, particularly at a regional level. States with the highest growth in ACA enrollment, such as Texas, Mississippi and Georgia, initially had high uninsured rates and have not expanded Medicaid. This has direct, positive repercussions for healthcare providers and their bottom lines, since many individuals enrolled in ACA plans were uninsured prior to the Affordable Care Act, often because of Medicaid restrictions within their state.

With the introduction of enhanced subsidies, these individuals were able to gain access to insurance plans — and not just any insurance plans, but those with the highest hospital reimbursements. The transition from uninsured to ACA plan enrollment, rather than Medicaid coverage to coverage by an ACA plans, represents the maximum revenue impact on hospitals that can be achieved via payer mix change.

Subsidies drive ACA plan membership — but they’re set to expire.

Subsidies have played a crucial role in making ACA plans affordable. There are two main types of subsidies:

Premium tax credits: These reduce the monthly premiums for eligible individuals and families.
Cost-sharing reductions (CSR): These lower out-of-pocket costs for eligible enrollees.

The enhanced subsidies under ARPA and IRA have expanded eligibility and increased the amount of financial assistance available. For example, households with incomes up to 400% of the federal poverty level — $103,280 for a family of three in 2024 — can receive premium tax credits. Those with incomes below 150% of the poverty level can have zero-dollar premiums for silver plans.

Not extending ACA plan subsidies brings clear risks

The enhanced subsidies are set to expire at the end of 2025. If not extended, the following risks may arise, impacting patients, providers, payers and employers alike:

Loss of coverage

Millions of individuals could lose their health insurance coverage, leading to a potential increase in uninsured rates.

Increase in self-funded employer costs

With the subsidies factored in, ACA plans are less expensive than some employer-sponsored plans. If individuals don’t have that option, they will need to move back into the employer-sponsored plans, bringing added to financial burden to those employers.

Revenue impact

Providers could face a significant revenue impact due to the loss of commercially insured patients and a potential increase in uninsured or Medicaid patients.

Market instability

The uncertainty around the extension of subsidies could lead to market instability, affecting both insurers and providers.

Contracting leverage: an overlooked opportunity of ACA plans

The risk of not extending these subsidies is underscored by the opportunities brought to providers by the rapid growth of ACA plan membership. Chief among these is the potential for ACA plans to serve as a means of leverage during contracting.

Providers can take proactive action to capitalize on the recent proliferation of ACA plan enrollments:

Lean on direct-to-consumer education during open enrollment
The ACA opens new opportunities for contracting leverage through direct-to-consumer marketing during open enrollment. Put simply, during open enrollment, and just like with Medicare Advantage, ACA members can choose their desired plan from a level playing field — a practice distinct from employer-sponsored plans, where coverage options are determined by the employer, not the healthcare consumer.

By aligning the term of the contract with the open enrollment window, providers can leverage the relevance of the contract negotiation against the open enrollment window, communicating with the public the potential reality that their provider will not be participating with a specific payer in the following year and asking them to consider this when making a plan selection.

When dealing with payers that offers both Medicare Advantage and ACA products, both of which have overlapping open enrollment windows, we see a unique opportunity to challenge the payer’s membership at scale while also educating the public on their access options.
Ensure contract rates for ACA are equivalent to the commercial rates
Providers must take inventory of their current ACA contracted rates. Ensure that they are equivalent to that payer’s commercial rates.

This creates a significant revenue opportunity for individuals that were previously uninsured or underinsured and avoids the revenue leakage due to migration from an existing employer-sponsored plan to ACA plans since the ACA plans will be the same contracted rate.
Support lobbying efforts to renew + extend subsidies
Providers hold industry expertise and influence, enabling them to effectively lobby policymakers to recognize the importance of making healthcare more accessible and affordable. Executives should collaborate with advocacy groups, participate in policy discussions and provide data-driven insights that highlight the positive impact of expanded subsidies on public health outcomes and economic stability.

Education is key. Providers can contact their representatives in Congress, invite them to tour the healthcare facilities and show them what has been made possible from the revenue associated with these enhanced subsidies. Care innovations, community impact and other tangible improvements all support a platform that would be easy for politicians to get behind if they are educated on it.

Additionally, providers can mobilize their networks to amplify the message, ensuring that the voices of patients and providers are heard. By actively supporting these lobbying efforts, healthcare leaders can help create a more equitable healthcare system that benefits all stakeholders.

The bottom line

The proliferation of ACA plan membership, driven by enhanced subsidies, has created substantial opportunities for healthcare providers. It has opened new contracting leverage opportunities in the struggle to negotiate fair and adequate reimbursement with payers. However, the potential expiration of these subsidies poses significant risks industry-wide that cannot be overstated.

Stakeholders — including both insurers and providers — must advocate for the extension of these subsidies. The goal is not only to expand care, but to support comparable fee-for-service rates, appropriate reimbursements and the hard-earned margins keeping organizations afloat in an industry facing numerous pressures.

An End-to-End RCM Partner Is Not a Traditional Vendor

Amy Summers, SVP, Marketing + Commercial Operations — Thu, 29 Aug 2024 14:33:29 +0000

What you need to know

While many health systems work with RCM vendors to handle financial transactions at a task level, the true benefits to the revenue cycle lie in forming one strategic, end-to-end RCM partnership. With careful management at every stage of the revenue cycle, this type of partnership can drive sustainable growth, improve patient satisfaction and help to ensure the long-term success of an organization.

Healthcare CFOs must ensure the financial health of a health system, not only through meticulous oversight but through strategic foresight. The choices they make around revenue cycle management (RCM) can have a significant impact on the current and future health of their organization.

The first and most major question many face is how to properly implement RCM processes. Management options have traditionally included:

Keeping management in house, driven by staff who are primarily focused on care
Contracting out with RCM vendors, ensuring revenue-related tasks are completed
Establishing a strategic RCM partnership to drive tech and talent in service of long-term goals

Each of these options can address revenue cycle needs, but only one helps focus and shape the efforts and outcomes that matter the most to a particular health system. Let’s take a closer look.

An RCM partner frees up in-house resources

Effective revenue cycle management ensures that healthcare providers are paid for their services in a timely and accurate manner, critical for maintaining financial stability and supporting care initiatives. However, hospitals and health systems already have a primary mission in place that does not address revenue cycle needs. That mission: providing the best care for patients.

As payers increase their expenditures around artificial intelligence technology meant to assist in denying claims, health systems struggle to keep up with these focused investments, given limited funds and staff available in-house to put toward the latest revenue cycle advancements.

For many, outsourcing revenue cycle management emerges as the best answer — but how a system goes about implementing this process can drastically shift the outcome. There are critical differences between simply signing with third-party RCM vendors versus crafting a robust relationship with an end-to-end RCM partner.

The best revenue cycle management companies are those that understand how to balance proactive management of all aspects of staff and systems with long-term strategic planning to ensure providers continue to be supported at every stage of the revenue cycle.

Traditional outsourced revenue cycle management has limitations

Hiring RCM vendors to handle tasks might seem like a straightforward solution to manage the revenue cycle. After all, most health systems already contract with vendors for a variety of services, including food, janitorial and even pharmaceutical offerings.

It’s critical to note, however, that the aforementioned services don’t require regular interfacing at the executive level, nor are they intertwined with long-term strategies that can make or break a health system’s stability.

Without the integration of a strategic revenue cycle partnership, simply outsourcing on a task level in RCM can fall short in several key areas:

Transactional relationship: Vendors typically operate on a transactional basis, focusing on the completion of specific tasks rather than the overall financial health of the organization. An efficient and effective RCM partnership will ensure that operators are always marching toward the most critical KPIs in line with an agreed-upon strategy.
Limited customization: One-size-fits-all vendors may offer standardized solutions that do not fully align with the unique needs and goals of a particular health system. A true RCM partner will customize scope and carefully consider what success looks like on a system-wide basis, ensuring that each organization measures the outcomes that matter to them.
Minimal executive involvement: Traditional RCM vendors often lack the high-level executive engagement necessary to drive strategic improvements and align RCM processes with broader organizational objectives. An RCM partner should be a partner in more than just name; make sure there’s someone to reach out to when challenges arise.

A true RCM partnership brings numerous benefits

In contrast to the traditional vendor outsourcing dynamic, an end-to-end RCM partnership offers a collaborative approach that extends throughout the revenue cycle. Since a strategic partner plays a role at every stage, it can readily manage any interdependencies that arise, in a way that a vendor operating on a task-by-task basis simply cannot.

This holistic approach unlocks numerous areas of value, including:

Strategic alignment

An RCM partner works closely with the health system to understand its strategic goals and align RCM processes accordingly. This ensures that every aspect of the revenue cycle supports the organization’s broader objectives, from improving patient satisfaction to optimizing financial performance.

Customized solutions

Unlike task-oriented vendors, the right RCM partner will provide tailored solutions that address the specific challenges and opportunities of a particular health system. This customization leads to more effective and efficient RCM processes, ultimately resulting in better financial outcomes.

Regular executive involvement

One standout feature of an RCM partnership is the regular involvement of senior executives. This high-level engagement ensures that strategic decisions are informed by deep industry expertise and a comprehensive understanding of the health system’s needs. Executive involvement also facilitates continuous improvement and innovation in RCM processes.

Enhanced data analytics

An innovative RCM partner can leverage advanced data analytics to provide actionable insights into the health system’s financial performance. These insights enable CFOs to make informed decisions, identify areas for improvement and implement strategies that drive revenue growth and operational efficiency.

Improved compliance and risk management

Navigating the complex regulatory landscape of healthcare requires a proactive approach to compliance and risk management. Because of its strategic orientation, an RCM partner brings specialized knowledge and expertise to help a health system remain compliant with relevant regulations.

Scalability and flexibility

As health systems grow and evolve, their RCM needs may change. An RCM partner offers the scalability and flexibility to adapt to these changes, ensuring that the health system’s revenue cycle processes remain effective and efficient over time.

Each of these factors can significantly enhance the financial performance and operational efficiency of a health system.

The right RCM partner offers a measurable impact

A robust RCM partnership can also provide a significant competitive advantage. By leveraging the expertise and resources of an RCM partner, health systems can differentiate themselves through superior financial performance and patient care. In fact, the benefits of a true RCM partnership often extend beyond financial performance. These include:

Enhanced patient experience: Efficient RCM processes lead to faster and more accurate billing, reducing patient frustration and improving overall satisfaction. A positive patient experience is crucial for building trust and loyalty, which can drive patient retention and referrals.
Financial stability: By optimizing revenue cycle processes, an RCM partnership helps health systems achieve greater financial stability. This stability enables the organization to invest in new technologies, expand services and improve facilities, all of which contribute to better patient care.
Operational efficiency: Streamlined RCM processes reduce administrative burdens and free up staff to focus on more strategic initiatives. This operational efficiency leads to cost savings and improved productivity across the organization.
Data-driven decision-making: Access to advanced analytics and insights empowers CFOs to make data-driven decisions that enhance financial performance and operational efficiency. This strategic approach ensures that the health system is well-positioned to navigate industry challenges and capitalize on opportunities.

The bottom line

For health system CFOs, the choice between simply hiring RCM vendors and forming an actual RCM partnership is clear. An RCM partnership offers a strategic, collaborative and customized approach that delivers superior results.

Moreover, by partnering with an RCM expert, health systems can focus on their own core competencies — delivering high-quality patient care. This allows healthcare providers to allocate more resources and attention to clinical operations, ultimately enhancing patient outcomes and satisfaction.

With benefits like regular executive involvement and enhanced data analytics, the right RCM partnership can transform the financial and operational performance of a health system. By embracing this partnership model, a health system can drive sustainable growth, improve patient satisfaction and help to ensure the long-term success of their organization.

Your revenue cycle is too important to be left to chance.

Contact Ensemble Health Partners to find out how an end-to-end partner with proven results can help secure your organization’s financial future.

The post An End-to-End RCM Partner Is Not a Traditional Vendor appeared first on Ensemble Health Partners.

AI in Action: Revenue Cycle Management

Devdatta Halbe, SVP, Engineering — Thu, 11 Apr 2024 18:54:18 +0000

What you need to know

Artificial intelligence (AI) holds great opportunity for the healthcare revenue cycle, and organizations are taking notice. One recent survey found that nearly 60% of healthcare organizations are considering using generative AI for revenue cycle management (RCM) operations. AI models can be fine-tuned to reduce friction across the revenue cycle and more accurately predict outcomes. For patients and staff, AI can help automate tasks, enhance accuracy and promote compliance.

The healthcare revenue cycle offers a labyrinth of processes, each with its own intricacies. Coding complexities, billing inaccuracies, claim denials and reimbursement delays can often create bottlenecks. These inefficiencies not only impact financial health but also directly affect patient care, causing delays and frustrations in the healthcare journey.

Optimizing the healthcare revenue cycle with AI

Luckily, artificial intelligence can lend support in these areas by:

Automating administrative tasks: AI-driven solutions streamline coding and billing processes, significantly reducing manual efforts and error rates. By automating these tasks, institutions can expedite the revenue cycle and minimize discrepancies.
Enhancing accuracy in claims processing: AI’s analytical capabilities can help minimize errors in claims processing, reducing denials and rework. This precision ensures smoother revenue flow and quicker reimbursements.
Optimizing revenue with predictive analytics: AI algorithms can analyze historical data to predict and prevent barriers to efficient, complete revenue collection. This proactive approach aids in strategic planning and resource allocation, ensuring optimal financial outcomes.
Engaging patients with AI-driven communications: By leveraging AI-powered platforms, institutions can provide patients with transparent billing information and promote compliance. This not only fosters trust but also reduces payment delays.

Here at Ensemble Health Partners, AI is deployed in ways both big and small in support of our partners. The Ensemble data lake maps over 25 billion transactions to outcomes, providing a continuous and growing stream of feedback and insights across our partners. Over the past decade, more than 5,500 AI models have been deployed, informed by 25,000+ variables.

This enables our partners to benefit from things like predictive analytics, intelligent prioritization of operator work queues and zero-touch automation to streamline processes and ensure providers get paid what they are owed.

A bright future for AI in healthcare RCM

The healthcare revenue cycle, which encompasses the entire lifespan of a patient’s account from appointment scheduling to payment, is a critical process for any organization. Artificial intelligence and generative AI stand to revolutionize not just healthcare’s clinical processes but also those of revenue cycle management.

Today’s AI innovations have the potential to address longstanding challenges and optimize RCM operations — if deployed thoughtfully and with consideration for the current limitations of this technology.

Having specific elements in place can help support AI transformation. These include:

Using aggregated, normalized data to build and train models
Building diverse models representing numerous geographies and perspectives, which can prevent overfitting a model to a limited set of instances
Deploying a clear correlation of inputs to outputs — in the revenue cycle, this might be transactions mapped to outcomes — in order to detect successful patterns
Smoothly integrating AI into RCM operations in order to infuse insights directly into workflows and streamline processes
Ensuring compliance with HIPAA and other security or privacy policies

Due to specialized knowledge, massive processing power and particular tools needed, building AI models and implementing them effectively can be a difficult undertaking for providers attempting to implement on their own. The right end-to-end RCM partner with experience incorporating AI into the revenue cycle can help to make the transition a seamless one.

The bottom line

AI’s integration into the healthcare revenue cycle brings with it the ability to automate tasks, enhance accuracy, provide predictive insights and engage patients. Exploring and strategically adopting AI solutions can redefine the financial landscape of healthcare institutions, paving the way for improved efficiency, accuracy and, most importantly, better patient outcomes.

Explore The Power + Potential of AI in the Healthcare Revenue Cycle to find out more about how artificial intelligence is being applied in RCM today and learn additional best practices for implementation. Get the whitepaper >>>

Opt for Outcomes with End-to-End RCM Vendor Selection

Andrew Bess, Chief Client Officer — Wed, 24 Jan 2024 17:06:29 +0000

What you need to know

When it comes to selecting the right revenue cycle management (RCM) partner, there are crucial factors beyond cost considerations. For 43% of executives, the ability to generate revenue lift is their number one most important criterion in selecting an RCM partner; just 24% of executives would prioritize vendor cost above all else. A majority of executives also think it’s important to partner with a single RCM firm rather than with multiple, reducing duplicative work and allowing for integrated, streamlined efforts. Think of the revenue cycle as a value driver and plan your strategy with growth in mind.

As many healthcare executives opt for a single, comprehensive RCM partnership, the high value of performance and outcomes is becoming clear. The real question isn’t merely about selecting an RCM partner — it’s about choosing the right partner capable of driving tangible and meaningful results.

End-to end RCM by the numbers

In a recent survey of more than 100 executives representing organizations ranging from multi-hospital systems to specialty physician groups, 95% expressed a keen interest in pursuing end-to-end RCM managed services to tackle critical business issues.

One robust, comprehensive RCM partnership allows organizations to address challenges and streamline processes in a way that can be difficult and duplicative when revenue cycle responsibilities are spread out across multiple vendors.

Survey results bear this out; not only did 61% of executives state that managed services provide superior results compared to in-house operations, but 60% of executives also think it’s important to partner with a single firm for RCM services.

The majority of executives, then, are seeking integrated solutions that drive comprehensive value across the revenue cycle. But what does that value look like?

A shifting focus: performance over cost

Leaders are honing in on the factors that drive tangible results. When ranking the most important factors in selecting an RCM partner, healthcare executives named their number one most important criterion:

Concerns about revenue lift were far and away the most important factor for choosing an RCM partner. Customer service was ranked as the second most important factor, critical to 29% of respondents, recognizing the importance of a seamless and patient-centric approach within revenue cycle management.

It’s a clear indication that healthcare leaders are placing a premium on partnerships that directly impact the bottom line and an organization’s own customers. This growing reliance on external partnerships signifies a departure from the traditional emphasis on minimizing costs. Now, the focus is on maximizing value.

Reframing the revenue cycle as a value driver

Providers are beginning to shift their perspective from the revenue cycle as a cost center to a value driver. This means changing the viewpoint that a successful RCM strategy is one that simply minimizes costs. More and more, healthcare executives are investing and staffing in order to grow their revenue cycle strategically in a way that improves payment accuracy and reduces revenue leakage.

This might mean investing in patient advocacy efforts, new technology, internally developed capabilities or even commercial opportunities that support the revenue cycle. Nor does investment stop at tools or partnerships. HFMA notes that, for some organizations, having a growth mindset for the revenue cycle may mean funding the professional growth and development of existing staff members. For others, a refocused revenue cycle may call for expanding the talent pool to include those with a laser focus on customer engagement or high critical thinking skills.

Ensuring front-line RCM employees are customer-focused enhances the patient experience — which should be a primary goal for every healthcare organization.

The bottom line

Today’s healthcare executives are selecting vendors based on factors like revenue lift and customer service, emphasizing growth and performance as the true barometers of success.

Now, it’s about what an organization can get out of an RCM relationship, rather than simply what it must put in — and in a competitive healthcare environment where every reclaimed dollar counts, the comprehensive value of a single end-to-end RCM partnership cannot be understated.

Revenue Cycle Managed Services Fill In-House Gaps

Andrew Bess, Chief Client Officer — Wed, 10 Jan 2024 13:56:13 +0000

What you need to know

There’s a growing trend of healthcare organizations investing in revenue cycle managed services, supported by trusted vendors. For many, in-house resourcing is no longer feasible given labor shortages, margin pressure and gaps in internal capabilities; for others, the increasing complexity of payor negotiations and decreasing payor reimbursements is fueling this shift. By partnering externally for revenue cycle management support, healthcare organizations gain efficiency, increase agility and are better able to use limited resources — all critical improvements in a difficult industry and environment.

Financial solvency is a cornerstone of sustainable healthcare operations. Much of an organization’s success or failure comes down to how the healthcare revenue cycle is managed, including activities such as identifying and recovering underpayments, negotiating with payors and ensuring proper denials management to resolve existing issues and prevent future claim denials.

As healthcare CFOs and their organizations navigate these complexities, a clear trend has emerged: the significant rise in investment directed towards revenue cycle managed services.

The shift to RCM managed services is already in motion

No longer content with or capable of keeping revenue management processes in house, many healthcare organizations are choosing instead to partner with a third-party vendor, entrusting them with this critical process.

According to a recent survey of more than 100 executives representing organizations ranging from multi-hospital systems to specialty physician groups, 97% of healthcare organizations are already spending a portion of their RCM budget on managed services. Substantial future reallocation is also on the table, with 25% of organizations planning to spend more than half of their RCM budget on managed services in the next five years.

What’s truly telling is the inclination towards and view of managed services as a viable and effective means of addressing operational challenges. An almost unanimous 95% of healthcare leaders say they would pursue end-to-end-managed services to solve key business issues — that is, one comprehensive RCM partnership, versus managing multiple vendors.

Revenue cycle managed services address in-house challenges

One primary benefit of working with a third-party partner is tackling the many challenges that weigh heavily on in-house healthcare operations, including:

Labor shortage: 56% of healthcare leaders cited labor shortage as a primary driving force. Managing revenue cycles in-house amid staffing deficiencies becomes an uphill battle, leading organizations to seek external expertise.
Margin pressure: The ongoing struggle to maintain margins in an increasingly complex healthcare environment also ranked high, with 49% recognizing margin pressure as a pivotal factor when choosing to work with a vendor.
Gaps in internal capabilities: Another significant concern, flagged by 40% of respondents, revolved around missing skillsets and other gaps in internal capabilities. As the healthcare landscape becomes increasingly complex, managing every facet internally has become unwieldy for many organizations.

Other challenges cited by healthcare executives include the complexity of payor negotiations and decreasing payor reimbursements, difficulty in collecting AR, limited EHR/EMR/HIS functionality and increasing organizational complexity overall.

Looking forward with RCM managed services

The trajectory is clear: healthcare financial leaders are reimagining operational strategies by prioritizing external partnerships for revenue cycle management. This shift isn’t merely a trend but a strategic move towards efficiency, agility and optimal resource utilization.

Forging the right partnerships is pivotal. The right partnership can bring specialized expertise and other advantages that a healthcare organization simply may not have the time or resources to train in house, as providers and staff focus on patient care and other clinical concerns.

Managed services aren’t just a nice-to-have option; in today’s environment, the right partnership can be a critical component for sustainable financial health. As the healthcare landscape continues to evolve, embracing managed services emerges not only as a practical choice but as a strategic imperative for financial stability and growth.

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An End-to-End RCM Partner Is Not a Traditional Vendor

What you need to know

An RCM partner frees up in-house resources

Traditional outsourced revenue cycle management has limitations

A true RCM partnership brings numerous benefits

Strategic alignment

Customized solutions

Regular executive involvement

Enhanced data analytics

Improved compliance and risk management

Scalability and flexibility

The right RCM partner offers a measurable impact

The bottom line

Your revenue cycle is too important to be left to chance.

AI in Action: Revenue Cycle Management

What you need to know

Optimizing the healthcare revenue cycle with AI

A bright future for AI in healthcare RCM

The bottom line

RELATED CONTENT

Opt for Outcomes with End-to-End RCM Vendor Selection

What you need to know

End-to end RCM by the numbers

A shifting focus: performance over cost

Reframing the revenue cycle as a value driver

The bottom line

RELATED CONTENT

Revenue Cycle Managed Services Fill In-House Gaps

What you need to know

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