Modernizing the health care payer system: A prescription for alleviating physician workload and burnout

Steve Rowe: ©3Pillar Global

Physicians spend countless hours on their feet each day, working to provide the best possible care to their patients. However, they face significant challenges and heavier-than-needed workloads due to sub-optimized revenue cycle processes. These inefficiencies not only hinder clinicians’ ability to provide seamless patient care, but create unnecessary administrative burdens, undermining their work in three distinct ways.

First, because of poor documentation and a lack of understanding around the claims acceptance process, clinicians are forced to devote additional hours on clinical documentation, submitting claims, and reworking denials. This leads directly to clinician burnout and less time spent on patient care. Second, when clinical discussions are separated from financial considerations, physicians are unable to achieve the best outcomes for their patients. Lastly, when claims get denied, medical practices aren’t fully reimbursed, making it challenging to run a sustainable business.

Here are three ways physicians and medical practices can leverage artificial intelligence, robotic process automation (RPA), and low-code/no-code tools to maximize revenue, reduce physicians’ workload, and create better patient experiences.

1. Minimizing claim denials 

Each payer operates under unique rules and medical policies when it comes to accepting or denying claims – and understanding the complexities of claim acceptance and denials amongst these different payers is key for operational efficiency.

Currently, many physician practices rely heavily on manual reviews conducted by billing office staff, resulting in an over reliance on the human eye to catch errors. Additionally, practices expose themselves to the risk of these employees taking all their knowledge with them when they leave the company. The solution to this? Harnessing the power of generative AI.

By leveraging AI and machine learning, providers can analyze historical claim submissions data and health plan medical policies to better understand why claims get denied, streamline the submission process, and reduce denials. The same process can be applied to understand the different formatting requirements for sending and receiving information to various health plans, enhancing efficiency across these administrative tasks.

2. Simplifying clinical documentation and paperwork

Physicians play a key role in revenue cycle management by ensuring precise and timely documentation of patient encounters, diagnoses, and procedures. This documentation is essential for coding, billing, and reimbursement. By providing comprehensive details, physicians enable medical coders to accurately assign codes for diagnoses and procedures, facilitating correct claims submissions and reducing the likelihood of denials or underpayments.

Given the heavy administrative burden on physicians, there is understandable excitement around ambient listening tools for clinical documentation to help simplify this process and reduce the documentation and paperwork workload. However, the effectiveness of these tools is reliant on integration with software that correctly extracts the right clinical information to populate claims. Additionally, intelligent coding processes can be used to mitigate denials by utilizing rules engines to flag expected issues at the point of documentation and coding.

3.Enhancing the patient billing experience

Physicians are at the forefront of the patient experience from the moment they walk through the practice’s door. From discussing treatment plans to diagnoses and medications, they set the tone for the entire interaction. However, in today’s U.S. health care system, clinical conversations often occur in a vacuum, completely disconnected from the financial implications of a patient’s care journey. The fastest and most effective way to get people healthy is adherence to care – but the reality is most people cannot afford the care they are prescribed. Also, since physicians are not always conversant in the cost aspect of these insurance plans, it can lead to surprise bills that sour patients’ experience, harm retention, and make collecting patients’ outstanding balances difficult.

Rather than waiting until that initial check-in to collect member ID numbers, modernizing the patient intake and consultation process by implementing digital check-ins can allow physicians to collect this data ahead of the appointment. Additionally, using eligibility data more effectively, increasing price transparency, and facilitating point-of-service payment collections can reduce the administrative load on physicians, resulting in a smoother, more transparent patient experience.

With the adoption of technologies like these, clinicians are empowered to make a care plan recommendation while also being able to have an informed dialogue with patients around important cost ramifications – ultimately leading to better patient adherence to care plans and improved health outcomes.

Modernizing health care payments: A new way for physicians

Physicians already face demanding workloads, and the added burden of administrative tasks can detract from their primary focus: patient care. Modernizing the health care payment ecosystem through the adoption of advanced technologies offers a promising solution.

Automating processes such as billing, claims processing, and payment collection can substantially alleviate physicians' administrative burdens. This not only frees up valuable time but also enables them to engage in informed discussions with patients about the financial implications of their treatment plans. By empowering patients with this knowledge, physicians cultivate informed advocates who play an active role in their health care decisions. This patient-centric approach not only enhances the overall health care experience but also contributes to improved health outcomes. Embracing these innovations is essential for fostering a sustainable health care environment where both clinicians and patients can thrive.

Steve Rowe is the health care lead at 3Pillar Global.