Predicting Denials to Improve the Healthcare Revenue Cycle and Maximize Operating Margins

Healthcare financial leaders are constantly brainstorming ways to increase operating margins through better revenue cycle performance. These efforts often lead revenue cycle leaders to denied claims—when a payer doesn’t reimburse a health system for a service rendered. Although denials are a common reason for lost revenue, experts deem nearly 90 percent avoidable. Effective denials management starts with prevention. Organizations can use revenue cycle performance data, combined with artificial intelligence, to predict areas within each claim’s lifecycle that are likely to result in a denial. With denial insight, health systems can optimize revenue cycle processes to prevent denials and increase operating margins.

The Right Way to Build Predictive Models for the Most Vulnerable Patient Populations

Predictive artificial intelligence (AI) models can help health systems manage population health initiatives by identifying the organization’s most vulnerable patient populations. With these patients identified, organizations can perform outreach and interventions to maximize the quality of patient care and further enhance the AI model's effectiveness. The most successful models leverage a mix of technology, data, and human intervention. However, assembling the appropriate resources can be challenging. Barriers include multiple technology solutions that don’t share information, hundreds of possible, often disparate, data points, and the need to appropriately allocate resources and plan the correct interventions. When it comes to predictive AI for population health, simple models may harness the most predictive power, which allows for more informed risk stratification and identifies opportunities for patient engagement.

Expanding AI in Healthcare: Introducing the New Healthcare.AI™ by Health Catalyst

As healthcare leaders continue to face unprecedented decisions around revenue, cost, and quality, they turn to augmented intelligence (AI) to maximize their analytics. However, leaders struggle to implement AI into existing business intelligence workflows, demonstrate ROI, and move AI efforts beyond predictive models. Health systems can overcome AI’s implementation challenges with the New Healthcare.AI™ offering by Health Catalyst. As a suite of AI products and expert services, Heatlhcare.AI integrates transparent, cutting-edge technology into existing workflows, allowing analysts to produce high-quality insights in minutes. The AI offering dramatically broadens the use and use cases of AI for any healthcare organization with a mix of self-service products and expert services:

1. Analytics integration.
2. Choosing/building predictive models.
3. Optimizing predictive models.
4. Retrospective comparisons.
5. Prescriptive optimization.

The Key to Better Healthcare Decision Making

When healthcare leaders make data-driven decisions, they often think they see the same thing in the data and assume they’re drawing the same conclusions. However, decision makers often discover later that they were looking at the data differently and didn’t derive the same insights, leading to ineffective and unsustainable choices. Healthcare leaders can manage differing data interpretations by using statistical process control (SPC) methodology to find focus, avoid divergent data interpretations, make better decisions, and monitor change for a sustainable future. By deriving concise insights, SPC separates the signal from the noise, augmenting leaders’ decision-making capabilities.

Artificial Intelligence and Machine Learning in Healthcare: Four Real-World Improvements

As COVID-19 has strained health systems clinically, operationally, and financially, advanced data science capabilities have emerged as highly valuable pandemic resources. Organizations use artificial intelligence (AI) and machine learning (ML) to better understand COVID-19 and other health conditions, patient populations, operational and financial challenges, and more—insights that are supporting pandemic response and recovery as well as ongoing healthcare delivery. Meanwhile, improved data science adoption guidelines are making implementation of capabilities such as AI and ML more accessible and actionable, allowing organizations to achieve meaningful short-term improvements and prepare for an emergency-ready future.

Safeguarding the Ethics of AI in Healthcare: Three Best Practices

As artificial intelligence (AI) permeates the healthcare industry, analytics leaders must ensure that AI remains ethical and beneficial to all patient populations. In absence of a formal regulatory or governing body to enforce AI standards, it’s up to healthcare professionals to safeguard ethics in healthcare AI. The potential for AI’s use in support of the pandemic response can have enormous payoffs. However, ensuring its ethical implementation may prove challenging if healthcare professionals are not familiar with the accuracy and limitations of AI-generated recommendations. Understanding how data scientists calculate algorithms, what data they use, and how to interpret it is critical to using AI in a meaningful and ethical manner to improve care delivery. By adhering to best practices for healthcare AI, health systems can guard against bias, ensure patient privacy, and maximize efficiencies while assisting humanity.

Three Keys to Improving Hospital Patient Flow with Machine Learning

Health systems alike struggle to effectively manage hospital patient flow. With machine learning and predictive models, health systems can improve patient flow for different departments throughout the system like the emergency department. Health systems should focus on three key areas to foster successful data science that will lead to improved hospital patient flow: Key 1. Build a data science team. Key 2. Create a ML pipeline to aggregate all data sources. Key 3. Form a comprehensive leadership team to govern data. Improving hospital patient flow through predictive models results in reduced patient wait times, reduced staff overtime, improved patient outcomes, and improved patient and clinician satisfaction.

A Roadmap for Optimizing Clinical Decision Support

Compared to industries such as aerospace and automotive, healthcare lags behind in decision support innovation. Following the aerospace and automotive arenas, healthcare can learn critical lessons about improving its clinical decision support capabilities to help clinicians make more efficient, data-informed decisions:

1. Achieve widespread digitization: Healthcare must digitize its assets and operations (patient registration, scheduling, encounters, diagnosis, orders, billings, and claims) for effective CDS similarly to how aerospace digitized the aircraft, air traffic control, baggage handling, ticketing, maintenance, and manufacturing.
2. Build data volume and scope: Healthcare must collect socioeconomic, genomic, patient-reported outcomes, claims data, and more to truly understand the patient at the center of the human health data ecosystem.

AI in Healthcare: Finding the Right Answers Faster

Health systems rely on data to make informed decisions—but only if that data leads to the right conclusion. Health systems often use common analytic methods to draw the wrong conclusions that lead to wasted resources and worse outcomes for patients. It is crucial for data leaders to lay the right data foundation before applying AI, select the best data visualization tool, and prepare to overcome five common roadblocks with AI in healthcare:

1. Predictive Analysis Before Diagnostic Analysis Leads to Correlation but Not Causation.
2. Change Management Isn’t Considered Part of the Process.
3. The Wrong Terms to Describe the Work.
4. Trying to Compensate for Low Data Literacy Resulting in Unclear Conclusions.
5. Lack of Agreement on Definitions Causes Confusion.

As AI provides more efficiency and power in healthcare, organizations still need a collaborative approach, deep understanding of data processes, and strong leadership to effect real change.

AI-Assisted Decision Making: Healthcare’s Next Frontier

While many healthcare organizations have implemented Artificial Intelligence (AI) and Machine Learning (ML) tools at the point of care, few have successfully applied them to high-level decision making. A new frontier is expanding AI from artificial intelligence to augmented intelligence; traditional AI focuses on improving analytics efficiency while augmented intelligence is about improving the decision-making ability of healthcare leaders. This article addresses the capabilities health systems should embrace and provides two examples of how AI can assist with leaders with their most important decisions. Healthcare leaders’ biggest needs of from AI are the ability to separate signal from noise and make decisions that impact the future.

Artificial Intelligence in Healthcare: A Change Management Problem

The key to successfully leveraging artificial intelligence (AI) in healthcare rests not wholly in the technical aspects of predictive and prescriptive machines but also in change management within healthcare organizations. Better adoption and results with AI rely on a commitment to the challenge of change, the right tools, and a human-centered perspective. To succeed in change management and get optimal value from predictive and prescriptive models, clinical and operational leaders must use three perspectives:

1. Functional: Does the model make sense?
2. Contextual: Does the model fit into the workflow?
3. Operational: What benefits and risks are traded?

Machine Learning Tools Unlock the Most Critical Insights from Unstructured Health Data

Patient comments such as “I feel dizzy” or “my stomach hurts” can tell clinicians a lot about an individual’s health, as can additional background, including zip code, employment status, access to transportation, and more. This critical information, however, is captured as free text, or unstructured data, making it impossible for traditional analytics to leverage. Machine learning tools (e.g., NLP and text mining) help health systems better understand the patient and their circumstances by unlocking valuable insights residing unstructured data:

1. NLP analyzes large amounts of natural language data for human users.
2. Text mining derives value through the analysis of mass amounts of text (e.g., word frequency, length of words, etc.).

A New Era of Personalized Medicine: The Power of Analytics and AI

Healthcare is looking towards an era of personalized medicine in which providers customize treatments for the individual patient. Realizing this tailored level of care s a new level of data volume and analytics and AI capabilities that, while novel to healthcare, other industries are thriving in. Choosing the right role models as healthcare works towards the analytics- and AI-driven territory of personalized medicine will guide informed strategies and establish best practices. With experience and expertise in these key areas, the military, aerospace, and automotive industries can serve as healthcare’s best examples:

1. The human cognitive processes of complex decision making.
2. The digitization of their industries, with the “health” of their assets as key drivers.
3. Operating in a “big data” ecosystem.

How Artificial Intelligence Can Overcome Healthcare Data Security Challenges and Improve Patient Trust

As healthcare organizations today face more security threats than ever, artificial intelligence (AI) combined with human judgment is emerging as the perfect pair to improve healthcare data security. Together, they power a highly accurate privacy analytics model that allows organizations to review access points to patient data and detect when a system’s EHR is potentially exposed to a privacy violation, attack, or breach. With specific techniques, including supervised and unsupervised machine learning and transparent AI methods, health systems can advance toward more predictive, analytics-based, collaborative privacy analytics infrastructures that safeguard patient privacy.

Healthcare Data Management: Three Principles of Using Data to Its Full Potential

Author Douglas Laney is now tackling the topic of Infonomics: the practice of information economics. In his 2017 book, Infonomics: How to Monetize, Manage, and Measure Information as an asset for competitive advantage, Laney provides detailed rationale as well as a thoughtful framework for treating information as a modern-day organization’s most valuable asset. This article walks through how healthcare organizations can leverage data to its full potential using this framework and the three principles of infonomics:

• Measure - How much data does the organization have? What is it worth?
• Manage - What data does the organization have? Where is it stored?
• Monetize - How does the organization use data?

Healthcare NLP: The Secret to Unstructured Data’s Full Potential

While healthcare data is an ever-growing resource, thanks to broader EHR adoption and new sources (e.g., patient-generated data), many health systems aren’t currently leveraging this information cache to its full potential. Analysts can’t extract and analyze a significant portion of healthcare data (e.g., follow-up appointments, vitals, charges, orders, encounters, and symptoms) because it’s in an unstructured, or text, form, which is bigger and more complex than structured data. Natural language processing (NLP) taps into the potential of unstructured data by using artificial intelligence (AI) to extract and analyze meaningful insights from the estimated 80 percent of health data that exists in text form. Though still an evolving capability, NLP is showing promise in helping organizations get more from their data.