Key Insights for Improving Healthcare Billing

After a few candid conversations with health-system CFOs who collectively oversee billions in physician revenue, one theme rang loud and clear: revenue integrity only scales when clinicians can forget about billing. Here are the takeaways reshaping my roadmap: - Stop mopping—fix the pipe. Physician billing is high-volume, low-dollar. Every avoidable touch destroys margin. Accurate clinical context at the point of care is slashing denials before they happen. - Beware the DRG mirage. A $10 M coding lift can quietly blow up population-health costs if diagnosis creep inflates risk scores. Accuracy beats after-the-fact optimization every time. - 72-hour adjudication is coming. Medicare already pays 80 % of claims within seven days when the data are clean. Shared rails plus real-time records unlock a win–win for providers and payers. - Data as triage coach. Moving an ortho service from a 12:1 to 7:1 consult-to-surgery ratio freed OR time and lifted patient satisfaction, powered by feedback loops to PCPs. - Small practices = single-point-of-failure risk. One vacationing biller shouldn’t freeze cash flow. Submission logic must live in the platform, not in someone’s head. The future RCM stack won’t be a black box bolted onto the EMR. It will be a real-time, rules-aware copilot that flags payer changes before claims queue, adjudicates in hours, and lets clinicians focus on care, not CPT codes. Building toward that future now. If you’re experimenting in the same space, let’s chat. #HealthcareFinance #RevenueCycle #Automation #ValueBasedCare

We’re riding a horse and buggy through a world full of bullet trains — and calling it “healthcare.” Today’s healthcare payment system isn’t just slow. It’s deliberately inefficient. The financial “rails” we use in healthcare — fax machines, batch files, third-party claims processors — are a relic of another era. In a standard transaction, over 25 entities can be involved between the point of care and final payment. Like a horse and buggy, the journey involves frequent, expensive stops: ▪️ Feed the horse (consultants, claims administrators) ▪️ Repair the wheel (manual audits, outdated adjudication engines, retrospective reviews, claim renegotiation) ▪️ Feed and house the passengers on the long journey - (brokers, data warehouse vendors, actuarial modelers, legal reviewers, out-of-network negotiators, audit contractors) Meanwhile, the bullet train — modern financial infrastructure — is literally right next to our bumpy antiquated road, ready to move money and data instantly, transparently, and securely. But we refuse to board. Imagine checking into a hotel on a business trip. You hand over your credit card. All parties know what the room costs (you, your boss, the hotel, etc.) — that’s transparent and pre-agreed. But what if you decide to raid the minibar at midnight or you aren't sure if you're going to need room service? No problem. Your card handles it: ✔️ Places a hold for estimated charges ✔️ Allows charges only in approved categories ✔️ Releases unused funds upon checkout ✔️ Issues an instantaneous itemized receipt ✔️ Provides a fully auditable trail — down to the peanuts and chocolate In healthcare: No pricing No employer visibility No itemized receipts Boss gets billed $5,000 for one night hotel stay, but can't ask questions. This is not a technology problem. It’s a willingness problem. The rails for real-time, rules-based healthcare payments already exist — in banking, fintech, retail, even logistics. But we continue to route healthcare through a bloated, opaque detour that rewards friction. And the ones footing the bill — employers and taxpayers — are kept in the dark. The path from here to there isn’t abstract — it’s operational and its doable: ▪️ Leverage existing financial technology: rails already used in fintech and travel can support pre-authorized, rules-based healthcare payments. ▪️ Define standard pricing logic and integrate it into claims systems before care is delivered. ▪️ Require payers to support real-time adjudication and payment APIs — not batch file delays. ▪️ Give employers direct access to itemized, auditable claims data at the time of payment. ▪️ Align provider contracts around payment velocity and pricing clarity, not opacity and float. ▪️ Use Advanced EOBs and smart payment holds (like in hospitality or retail) to reduce overpayments and eliminate “surprise” billing. The rails are there. The tech exists. The cost of delay is compounding.

Last quarter, I saved a healthcare billing company that couldn't understand its declining margins. Their offshore team in Manila was 40% cheaper on paper than local staff. Yet their overall costs kept climbing. The culprit? Staff turnover. Their offshore provider had replaced their dedicated team members 3 times in 11 months. The company spent weeks re-training, re-explaining processes, and correcting new errors each time. The financial impact was staggering: - $27,000 in direct training costs annually  - 17% increase in error rates requiring costly corrections  - 22% slower processing times affecting client satisfaction When we implemented our managed services solution with guaranteed staff retention, everything changed: - We assigned a consistent team with contractual stability guarantees  - We built comprehensive process documentation independent of individual staff  - We created redundancy through cross-training across team members Within six months, their operations stabilized completely. Error rates dropped by 35%. Processing times improved by 29%. Most importantly, their local team finally stopped playing trainer every few months and refocused on strategic growth initiatives. Frequent staff changes aren't a normal cost of offshore operations. They're a failure of proper managed services design. #cpafirms   #staffturnover  #managedservices

A California father's ambulance bill DOUBLED after he shared his insurance information. $600 without insurance Became $1,300 WITH insurance. He was paying $10k per year in insurance premiums to protect his daughter in emergencies. Instead, the system penalized him for it. The representative's explanation? "The initial $600 was a discounted rate for uninsured patients.  Since you have insurance, you're no longer eligible for that discount." This isn't some bizarre anomaly. It's healthcare billing working EXACTLY as designed. This chaos is intentional: * Healthcare billing is purposely unclear * Regulations meant to protect people often backfire * Complexity hides the actual costs, leaving us powerless * Insured patients subsidize the uninsured * Patients can't "shop around" for ambulances during emergencies A hospital can charge $629 for a Band-Aid (this actually happened at Zuckerberg SF General). While 42% of Americans are drowning in medical debt, health insurance CEOs rake in millions -  UnitedHealth: $22.9M, Cigna: $20.8M, Anthem: $19.3M. However, these systemic problems aren't just frustrations. They're signals pointing to massive opportunities for healthtech innovators: 1. Build transparent billing platforms that provide real-time cost estimates based on insurance status 2. Create advocacy-as-a-service tools that help patients contest unfair charges (think TurboTax for medical billing) 3. Design membership-based emergency service models with guaranteed capped rates 4. Create platforms that track and report unfair billing practices to drive systemic change The system isn't broken — it's designed this way. And that design creates both frustration AND opportunity. What solutions do you think would work here? #healthcare #failures #insurance #startups

🔍 Unlocking the Power of RCM 👀 RCM isn’t just about processing claims—it’s about optimizing every step of the journey to ensure practices thrive. One area that often gets overlooked? Documentation, and documentation is everything. It’s the foundation that supports accurate billing, compliance, and financial stability for practices. Without thorough documentation, even the best processes can fail. Did you know that incomplete or unclear documentation is one of the leading causes of claim denials? 💸 yep have you seen these Denial Codes : 16: Claim/service lacks information or has submission/billing error(s). 17: Requested information was not provided or was insufficient/incomplete. 252: An attachment/other documentation is required to adjudicate this claim/service 50: These are non-covered services because this is not deemed a ‘medical necessity’ by the payer. 57: Payment denied/reduced because the payer deems the information submitted does not support this level of service N115: This decision was based on a Local Coverage Determination (LCD). This is just a few, if you are seeing these codes you have a documentation root cause issue, no amount of appeals will get you paid! Here’s why proper documentation matters: 1️⃣ Accuracy in Coding: Comprehensive notes ensure that coders select the right codes, reducing the risk of rejections. 2️⃣ Detailed documentation protects your practice during audits or appeals, providing the evidence needed to justify claims. 3️⃣ Faster Reimbursement: Clear and precise records eliminate back-and-forth communication with payers, speeding up payment cycles. 🔑 Pro Tip: Train your providers and staff to view documentation as a communication tool—not just a task. 🔑 The clearer the picture they paint, the smoother the revenue cycle operates. Investing in strong documentation practices today paves the way for fewer denials, better cash flow, and long-term success. What strategies do you use to improve documentation in your practice? #RCMExcellence #HealthcareDocumentation #RevenueCycleManagement #PracticeSuccess #MaximizeRCM

Tracking denials isn’t enough. Tracking underpayments isn’t enough. Revenue issues are often buried in your data and revenue cycle leaders need to work smarter and harder than ever to find them. Across the U.S., healthcare providers are seeing a sharp uptick in downcoding, with UHC and BC leading the charge. Payers are reducing claim reimbursement by assigning a lower level of service than what was billed based on their AI algorithms. This trend isn’t isolated. From routine E/M visits to complex surgical procedures, downcoding is becoming a systemic tactic for cost containment. The impact? 🔻 Lost revenue for providers 🕒 Increased administrative burden to appeal 💼 More pressure on documentation standards As payers double down on audits and AI-driven claim reviews, providers need to get proactive: ✅ Audit your top-billed codes for compliance 📈 Strengthen documentation to support higher levels of service 📑 Track line item claim denials and adjustment patterns to spot payer behavior This isn’t just a billing issue—it’s a financial survival issue. #revenuecyclemanagement #healthcarefinance

Having spent a lot of time digging into the RCM space recently, it's been fascinating to see how little visibility many health systems and providers have into the underlying drivers of their revenue cycle performance. A clear and accurate picture of the revenue cycle can literally mean the difference between profitability and losing millions of dollars. However, once you start to realize how many different systems are involved in the end-to-end RCM process, its understandable why getting a comprehensive picture is so hard. It's no wonder then that revenue intelligence is becoming a key priority for more and more provider orgs. 📊 ONE DASHBOARD TO RULE THEM ALL The greatest hurdle to having a well-modeled version of the full revenue cycle is data integration: pulling in claims data, clinical data and codes, and data from other billing systems. Once accomplished, it’s much easier to not only get a comprehensive view of the state of revenue and accounts receivable, but to run modeling and see where improvements can be made. For example, visibility into the revenue cycle can enable workflows like: • Understanding common sources of revenue leakage across the system—denials, audits, takebacks, concurrent denials, patient payments, etc.     • Monitoring and identifying changes in performance across service codes, practice sites, providers, and denial reasons.    • Evaluating collection strategies and patient segmentation.    • Reviewing contract performance to identify trends in underpayment or inform re-negotiations.    • Forecasting and understanding the financial health of the system. 💸 CATCHING REVENUE LEAKAGE WITH AI Going a step further, we’re seeing some vendors focus on specific tools to improve denial management and other sources of revenue leakage. This is where machine learning (ML) often comes into play. When payers change their adjudication engines, impacting claims denials, ML is effective at spotting patterns and identifying potential process changes. We’re also seeing some vendors start to use LLMs to produce action reports for specific stakeholders based on intelligence derived from the data. 💡 ➡️ 🏃♀️ STREAMLINING INSIGHT TO ACTION While we see substantial value in having the high-level view and feedback mechanism to improve aspects of the revenue cycle, we're most excited about the potential for solutions that are “self-tuning”—uncovering and acting on the insights in a single self-contained workflow. We think the future of revenue cycle management is intelligent, integrated, end-to-end systems that can reason along the longitudinal journey of a claim, ultimately enabling more efficient issue identification and resolution. --- Current vendors in our revenue intelligence category include: • MedeAnalytics • VisiQuate • adonis • Anomaly • Deloitte Revenue Intellect • Rivet Revenue Diagnostics • Etyon • RevOps Health • Sift Healthcare Rev/Track   

In the face of soaring denial rates that are keeping hospital financial executives up at night, one AI-powered solution is turning the tide and transforming despair into hope. A recent survey conducted by the Healthcare Financial Management Association (HFMA) has shed light on the pressing issues faced by health system finance leaders. According to the "HFMA Health System CFO Pain Points 2024: Margin Challenges and Opportunities for Vendors" report, an overwhelming 90% of respondents identified denials as the top hurdle in revenue cycle management. It's a stark reminder of the complexities and inefficiencies that plague our systems. The statistics paint a concerning picture: 82% of health systems have seen an increase in denial rates compared to 2019. This uptick not only strains resources but also diverts attention from patient care to administrative battles. Moreover, with 62% of leaders pointing out that Medicare Advantage is significantly more challenging to work with compared to commercial or traditional Medicare plans, the path to revenue optimization seems fraught with obstacles. The disparities in clinical policies between these plans result in an increased volume of denials, pushing some health systems to the brink of discontinuing services for certain Medicare Advantage plans. However, amidst these challenges, a beacon of hope shines brightly: AI-powered, autonomous medical coding by CodaMetrix. Leading health systems, including Mass General Brigham, have witnessed a groundbreaking transformation by integrating CodaMetrix's AI solutions into their revenue cycle management. The results speak volumes: a reduction in coding-related denials by at least 60%. This remarkable achievement is not just a number; it's a testament to the power of innovation in overcoming the hurdles of traditional coding practices. CodaMetrix leverages advanced AI to ensure accuracy, consistency, and efficiency in medical coding, directly addressing the root cause of many denials. By automating the coding process, health systems can reduce immediate and ongoing costs, avoid lost revenue, and significantly decrease denials. This shift towards autonomous medical coding is not just about improving financial outcomes; it's about redefining the approach to revenue cycle management in the age of digital transformation. As we look towards the future, the message is clear: embracing technology, particularly AI, in healthcare finance is no longer an option but a necessity. Let us join hands in transforming our revenue cycle management processes, reducing the burden of denials, and paving the way for a more efficient, accurate, and financially healthy healthcare system. #HealthcareFinance #RevenueCycleManagement #MedicalCoding #AI #CodaMetrix #Innovation #HealthSystemLeaders

𝐖𝐡𝐚𝐭 𝐡𝐚𝐩𝐩𝐞𝐧𝐬 𝐰𝐡𝐞𝐧 𝐚 𝐂𝐅𝐎, 𝐚 𝐛𝐢𝐥𝐥𝐞𝐫, 𝐚𝐧𝐝 𝐚 𝐠𝐮𝐲 𝐧𝐚𝐦𝐞𝐝 𝐇𝐚𝐫𝐩𝐚𝐮𝐥 𝐰𝐚𝐥𝐤 𝐢𝐧𝐭𝐨 𝐚 𝐦𝐞𝐞𝐭𝐢𝐧𝐠? It gets awkward fast. The CFO was fed up. His billing costs kept rising, and every time claims volume spiked, so did his invoice. The biller tried to explain: “We charge a percentage. More claims = more people = more cost.” Then the CFO turned and asked a simple question: “𝐖𝐡𝐲 𝐜𝐚𝐧’𝐭 𝐰𝐞 𝐮𝐬𝐞 𝐀𝐈 𝐭𝐨 𝐩𝐫𝐨𝐜𝐞𝐬𝐬 𝐭𝐡𝐞𝐦 𝐢𝐧𝐬𝐭𝐞𝐚𝐝?” That’s why I was in the room. In that moment, something became crystal clear: In 2025, growing headcount isn’t a strategy. It’s a warning sign. We’ve hit a tipping point in healthcare ops. If your model for scaling relies on hiring more people, you’re already behind. An AI employee doesn’t need a desk or a coffee break—it needs a clean data pipeline and the right workflows. And it can process thousands of bills, denials, and appeals simultaneously… while adapting in real time. The future of healthcare billing isn’t “more staff.” It’s zero marginal cost labor at scale. The fastest-growing orgs of the next decade won’t win because they hired better. They’ll win because they rearchitected the org chart—putting AI at the core. So here’s the question every healthcare leader needs to ask right now: 𝐀𝐫𝐞 𝐲𝐨𝐮 𝐬𝐜𝐚𝐥𝐢𝐧𝐠 𝐲𝐨𝐮𝐫 𝐰𝐨𝐫𝐤𝐟𝐨𝐫𝐜𝐞… 𝐨𝐫 𝐚𝐫𝐞 𝐲𝐨𝐮 𝐬𝐜𝐚𝐥𝐢𝐧𝐠 𝐲𝐨𝐮𝐫 𝐯𝐢𝐬𝐢𝐨𝐧?

In today’s healthcare landscape, where every dollar matters , operating margins are under significant pressure (look at the publicly traded payer and hospital system stocks for reference). Rising costs, regulatory challenges, and inefficiencies in both clinical and administrative processes are squeezing margins. Here’s how CFOs can leverage AI platforms to improve margins: 1. Automate Administrative Tasks: Streamlining repetitive processes like claims processing, prior authorizations, and medical coding can significantly reduce labor costs and errors. AI can do these tasks faster and with greater accuracy, freeing up resources and reducing overhead. 2. Enhance Revenue Cycle Management: Especially for providers, Ai can reduce claims denials, expedite payments, and improve billing accuracy, leading to faster collections and better cash flow. We can even forecast which claims are at risk of being denied before they’re submitted. 3. Predict Better: We can identify high-risk members or costly interventions before they escalate, enabling preventative care that reduce unnecessary hospitalizations and expensive treatments. 4. Improve Outcomes: AI driven decision-making can improve everything from patient diagnoses to treatment plans, reducing unnecessary procedures and improving care quality, which in turn, decreases readmissions and penalties. CFOs can lead the charge in creating a more financially resilient healthcare organization while improving overall patient care and operational efficiency by using Ai platforms. But, are healthcare CFOs even thinking about this? Are they aware of the impact Ai can have, or do they think that Ai's another buzz word like Cloud or Data? #HealthcareAI #CFO #HealthcareFinance #OperatingMargins #DigitalTransformation #AIinHealthcare #healthcare #RCM