For The Love of Revenue Cycle

In this episode of "For the Love of Revenue Cycle," host Vanessa Moldovan welcomes Kane Tomlin, who describes his path to state government work at the Mississippi Department of Health on data modernization and AI. They discuss how decades of point solutions created siloed public health data (e.g., TB and STI systems) that slow decisions such as infant mortality reviews, and how integrated, properly segmented data could automate case-file assembly for review boards and enable faster cause-and-effect learning. 00:00 Welcome 00:38 Meet Kane Tomlin 01:38 Kane's Career Path 03:30 Why Health Data Modernization 06:11 Dotcom Digitization Lessons 08:25 Keeping Humans in Control 08:47 Where to Find Kane's Work 09:30 Silos in Public Health Decisions 09:56 Infant Mortality AI Example 13:16 Blockers Privacy and Ecosystems 16:58 Responsible Integration and De-ID 20:11 What AI Enables in Healthcare 23:31 Pandemic Potential and Risks 25:41 Call to Action for Interoperability 28:47 Revenue Cycle Data Integrity Role 30:32 Closing

In this FTLORC Live Denial Q&A, Vanessa Moldovan shares takeaways from APC's HealthCon in Dallas. The episode focuses on denial/non-payment escalation beyond traditional corrected claims and appeals, tracking trends, using payer policy language in second appeals, and briefly contrasts out-of-network strategies (ERISA, patient/employer involvement, No Surprises Act). 00:00 Welcome and HealthCon Takeaways 00:47 Why Prior Auth Hurts Most 03:45 Traditional Appeals No Longer Enough 08:01 Escalation Step One Contract Review 10:37 Escalation Step Two Payer Relations 13:24 Escalation Step Three Insurance Commission 15:02 Grievances and Legal Options 19:00 Q&A Prior Auth Second Appeal Tips 24:41 Q&A When to Escalate and Trend Tracking 30:34 Wrap Up Community and Out of Network

Vanessa Moldovan hosts a first-time dual interview on revenue cycle leadership in federally qualified health centers (FQHCs) with Kara Onorato, CFO, and Jason Lafayette, Director of Revenue Cycle at MCR Health. They discuss MCR's scope (over 27 sites, three mobile units, extensive specialties, clinical trials, and 14 in-house pharmacies) and the FQHC mission to provide care regardless of ability to pay. They highlight trust, transparency, and data-driven partnership, and close with practical takeaways: stay vigilant, analyze denials and yields, educate teams, and lead adaptively. 00:00 Welcome 01:31 Meet the Guests 03:07 Kara CFO Journey 05:34 Jason Revenue Cycle Path 10:25 What Is MCR Health 11:54 Understanding FQHC Patients 15:52 Finding Community Health Centers 17:09 CFO Challenges in FQHCs 19:29 FQHC Revenue Cycle Differences 22:39 Preventing Revenue Leakage 25:32 CFO and Rev Cycle Partnership 30:11 CFO Role Shift Storytelling 32:48 Practical Takeaways and Wrap 36:22 Episode Closing

In this episode of "For the Love of Revenue Cycle," host Vanessa Moldovan speaks with Dr. Sylvia Owusu-Ansah, associate professor of pediatrics and emergency medicine at the University of Pittsburgh School of Medicine and EMS Medical Director at UPMC Children's Hospital of Pittsburgh, about what community engagement looks like in 2026 and why it's a smart investment for healthcare organizations. Dr. Sylvia (AKA Dr. O) shares examples sparked by the COVID era, including door-to-door outreach, language equity, and school-based pathway programs. They discuss why community initiatives are often treated as cost centers, how to measure impact through evaluation plans, and how community health can reduce costs by improving outcomes. Dr. O highlights measurable wins like CPR training that led to lives saved, emphasizes building trust with community leaders for sustainability, and offers calls to action for both community members and hospital leaders. 00:00 Welcome and Topic 01:28 Meet Dr Sylvia O 02:21 What Engagement Looks Like 03:19 Lessons From COVID 05:52 Why It Gets Ignored 07:19 From Research to Action 09:53 Workforce Pathway Programs 12:32 Measuring Impact 15:49 Data and Funding Sources 17:18 Building Trust Right 20:50 Sustainability and Support 25:46 Common Mistakes to Avoid 30:54 Calls to Action 34:45 Closing Thanks

ViVE Replay: Building Better RCM Automation with Agentic AI In this special episode, listen to Vanessa Moldovan present live at ViVE 2026. The talk covers identifying RCM and clinical-adjacent workflows ready for automation, ensuring automation solves rather than shifts problems, building CFO-ready ROI, implementing without disrupting operations, and using a framework to decide what to fix first. You'll learn more about high-impact automation areas (eligibility/benefits, prior auth, coding/claim review, payment integrity/contracts), get a clean explanation of agentic AI vs point solutions, hear about the six vendor-evaluation questions you need to ask, and discover what you should be tracking for ROI. After, you'll hear a panel of experts sharing real implementations and selection experiences, including Beacon's rapid care-gap outreach and MCR Health's focus on prior auth-driven cash flow. 00:00 Welcome and Intro 01:25 Session Goals Overview 03:37 Audience Poll 04:48 Why Change Now 05:56 Denials by the Numbers 07:28 Pain Across Ecosystem 10:30 Root Causes Breakdown 13:10 Path Forward and Panel 14:08 RCM Workflows to Automate 14:35 Standards and EDI Q&A 18:42 Ten Core RCM Steps 20:33 Top Automation Targets 26:36 Upstream Clinical Wins 28:11 Payer Side Opportunities 29:40 Agentic AI Explained 32:36 Vendor Questions Checklist 34:51 ROI Framework That Sells 38:39 KPIs That Prove Value 40:39 Tailored KPI Messaging 41:34 Fixing Workflows First 43:23 Agentic AI Reliability 48:19 Prioritization Framework 50:30 Meet the Panel 54:21 Beacon Care Gap Win 56:17 Choosing First Use Case 57:18 Buy In and Cash Flow 01:00:06 Data Quality and Trust 01:04:45 Compliance and Governance 01:08:35 ROI Metrics That Matter 01:10:20 PHI Learning and Feedback 01:16:12 Vendor Selection and Wrap Up

FTLORC Live Denials Q&A! 03/10/26 *Please note, the connection on the call dropped at the end, which is why there is a sudden cut-off. Vanessa Moldovan hosts a live community Q&A on denials and reimbursement, emphasizing end-to-end operational knowledge and root-cause fixes rather than siloed work. Nicolette shares a Medicare claim-rejection issue traced to offshore staff creating duplicate Medicare payer records with incorrect addresses, prompting new claim-entry guidelines. Participants discuss appeal effectiveness over sheer volume and trends in California denials, including Blue Shield requests for additional information and heightened scrutiny of 99213/99214 tied to fraud concerns and diagnosis ordering. Perva describes Medicare wellness/preventive denials for newly eligible members that required rebilling with 99214 instead of a G code and asks about Medicare crossover failures tied to patients updating secondary coverage with Medicare. Guadalupe details out-of-network underpayments driven by third-party pricing vendors like MultiPlan/Data iSight, ERISA-based appeal strategies, obtaining pricing in writing, NCCI/edit disputes, and escalation up to payer leadership. The group also covers documentation precision for time-based behavioral health codes and an orthopedic prior-authorization scenario where an authorized arthroscopy code was denied after a meniscectomy was coded, raising compliance and documentation questions. 00:00 Live Q&A Kickoff 00:55 Medicare Address Setup Errors 02:12 Root Cause Denial Fixes 04:46 99213 Denial Surge 06:57 Wellness Visit Coding Timing 09:09 Medicare Crossover Issues 10:50 Out of Network Underpayments 13:00 ERISA Appeals Strategy 16:40 Bundling and NCCI Disputes 21:05 Escalating to the CEO 24:53 Community Shoutouts and Teaching 26:28 Out Of Network Gap 28:03 Manual And LLM Help 29:05 Automation And Pricing Games 30:39 Multiplan Data Eyesight 32:32 Specialties And New Markets 33:36 Behavioral Health Denials 34:47 Time Based Documentation 36:42 Ortho Prior Auth Denial 42:15 Coding Billing Compliance 46:16 Wrap Up And Thanks

In this episode of For the Love of Revenue Cycle, Vanessa breaks down why prior authorization and eligibility verification are two of the biggest drivers of preventable denials — and how getting them right is essential to clean claims and healthy cash flow. The discussion covers the foundations of payer requirements, the difference between denials and rejections, and where most revenue leakage actually occurs across the front end of the revenue cycle. Vanessa shares practical best practices for improving accuracy and efficiency in PA and EBV workflows, along with real industry data on denial trends. The episode also explores how modern technology, including agentic AI, is transforming these processes by reducing manual work, closing operational gaps, and shifting organizations from denial resolution to true prevention. 00:00 Welcome and Introduction 03:07 Understanding Clean Claims 06:04 Claim Requirements Explained 10:41 Denials vs Rejections 12:25 Why Prevention Matters 17:05 Front End vs Backend 22:05 Prior Authorization Deep Dive 26:28 PA Process Step by Step 29:34 Prior Authorization Best Practices 32:15 Eligibility and Benefit Verification 35:55 EBV Best Practices 38:52 Technology and AI Overview 42:30 Understanding Agentic AI 44:48 AI in PA and EBV Workflows 48:04 Closing and Call to Action  

In this episode of 'For the Love of Revenue Cycle,' the focus shifts from traditional denial management strategies to understanding the power of denial data. Vanessa discusses the limitations of current systems and common misconceptions in how denial management is practiced. Emphasizing the importance of prevention over mere resolution, the episode explains how analyzing denial data can reveal underlying process flaws and drive meaningful improvements. Key points include distinguishing between denial reasons and root causes, the importance of visibility over precision, and the role of technology in optimizing denial management. A call to action encourages listeners to rethink denial management as a strategic, data-informed approach to enhancing organizational performance.   00:00 Welcome and Introduction 00:15 Understanding Denial Management 00:58 The Role of Denial Data 05:14 Challenges in Using Denial Data 06:48 From Resolution to Prevention 07:49 Practical Steps for Denial Management 08:30 The Importance of Root Cause Analysis 10:07 Impact on Organizational Performance 11:46 Leveraging Technology and Automation 13:39 Conclusion and Final Thoughts  

In this special episode of 'For the Love of Revenue Cycle,' Vanessa Moldovan presents a recording of a recent webinar focused on the topic of Agentic AI. Approved by AAPC for one CEU, this episode dives into the reality of Agentic AI in revenue cycle operations. It explains what Agentic AI is, its difference from traditional automation or RPA, and how it addresses core issues like human error, payer complexity, and inadequate legacy technology. Practical, real-world applications in prior authorizations, eligibility verification, and document management are discussed, alongside the benefits of this technology. The importance of cautious and controlled adoption is emphasized, providing listeners with essential questions to evaluate vendors and ensure effective integration of Agentic AI into their workflows.   To claim your CEU, please submit the form here: https://forms.gle/J76NCbeXiyy6B5rC6   00:00 Introduction and Webinar Overview 00:49 The Reality of Agentic AI 01:56 Understanding Agentic AI 03:08 Challenges in Revenue Cycle 07:40 The Role of Agentic AI in Revenue Cycle 19:03 Evaluating Agentic AI Vendors 25:45 Implementing Agentic AI Safely 27:26 Conclusion and Next Steps  

In this episode of 'For the Love of Revenue Cycle,' host Vanessa Moldovan delves into the complex and pressing topics of audits, compliance, and documentation. Joined by expert Brenda Edwards, who has extensive experience in healthcare revenue cycle, they discuss the rising frequency and importance of audits, sharing insights and real-world examples, including metadata and audit trails. Brenda emphasizes the need for thorough documentation to support services billed and advises on how to handle audit letters without panic. Practical advice is given to ensure that organizations remain compliant and prepared for inevitable audits. The episode also highlights the need for internal and external audits, the importance of having a compliance plan, and the potential benefits of integrating thoughtful automation into the audit process.                                                              00:38 Meet Brenda Edwards: Background and Expertise 00:52 Understanding Audits: Who, Why, and How 00:58 Real-World Example: Incident Two and Split Shared Services 01:16 Practical Takeaways: Responding to Audits 01:26 Disclaimer and Scope of Discussion 01:59 Starting the Conversation with Brenda 02:09 The Growing Importance of Audits 03:03 Brenda's Journey in Auditing 09:54 Compliance and Documentation: Best Practices 10:58 Cardiology Audit Case Study 11:44 The Role of Metadata in Audits 16:18 The Consequences of Improper Access 26:02 The Long-Term Impact of Audits 26:52 First Offense Penalties and Compliance Plans 28:43 Case Study: EHR Upgrade Issues 30:09 Legal Implications and Repeat Offenders 31:57 Handling Sanctioned Providers 34:04 Responding to Audit Notifications 34:33 Educational vs. Recoupment Letters 42:07 The Importance of Documentation 46:39 Final Thoughts and Takeaways

In this webinar replay, host Vanessa Moldovan leads a discussion on the current state of the revenue cycle management (RCM). The episode kicks off the 'Drive to ViVE' webinar series, focusing on the lead-up to the event next year in Los Angeles, which will feature industry leaders discussing healthcare IT, business, and more. Vanessa addresses the major challenges in RCM, such as rising denial rates, fragmented workflows, and the dynamic changes in regulations and policies. She shares insights on denial prevention, education, and the adoption of smart technology, specifically Agentic AI, to improve RCM processes. The episode also highlights the importance of leadership accountability, continuous learning, and genuine industry collaboration to drive significant change while preparing for the future of healthcare reimbursement.  00:00 Welcome and Introduction to Drive to ViVE 00:53 Current Challenges in Revenue Cycle Management 02:53 What's Broken in Revenue Cycle Management 07:30 What's Working in Revenue Cycle Management 11:32 Strategies for Future Improvements 25:02 The Role of Technology in Revenue Cycle Management 28:44 Involving Users in the Process 29:48 The Role of Technology in Revenue Cycles 31:03 Understanding Agentic AI 31:28 The Evolution of Navigation Technology 32:38 Agentic AI in Revenue Cycle Management 36:49 Q&A Session Begins 37:28 Addressing Denial Prevention 40:39 The Importance of Front-End Processes 42:04 Skills for Future RCM Teams 43:56 Networking and Education in RCM 46:35 Supporting Frontline Teams 49:30 Final Thoughts and Future Directions  

Conference Season Recap: Maximizing Value from Industry Events In this episode of 'For the Love of Revenue Cycle,' host Vanessa Malon offers a comprehensive review of the conferences she attended this season, including Becker's, HBMA, MGMA, the Medical Cost Containment Series in Chicago, and the Invest Behavioral Health Conference. Vanessa discusses the key takeaways, the value of attending these events, and provides practical advice on how to maximize ROI, whether you're a leader or frontline worker. She emphasizes the importance of choosing the right conferences based on your goals, whether it's for education, networking, or vendor evaluation. Vanessa also shares tips on how to prepare, what questions to ask, and the benefits of small group sessions, making this episode a must-listen for revenue cycle professionals planning their conference schedules. 00:00 Introduction and Podcast Overview 00:40 Season Review: Conferences Attended 02:11 The Value of Conferences 04:10 Becker's Conferences Insights 06:49 Medical Cost Containment Series 08:00 HBMA and MGMA Conferences 10:00 Networking and Practical Tips 16:15 Final Thoughts and Recommendations 17:30 Conclusion and Contact Information

In this episode of 'For the Love of Revenue Cycle,' host Vanessa Moldovan engages the community in a live Q&A session. The discussion covers the pressing issue of denials and reimbursement challenges in the healthcare industry. Key topics include recent policy changes by Cigna on automatic downcoding, the implications of DRG downgrades, and strategies for identifying downcoded claims. The episode also addresses how to measure denial rates, manage medical necessity denials, and successfully overturn denied claims. Expert insights and community contributions make this episode a valuable resource for anyone involved in the revenue cycle. 00:00 Introduction and Welcome 00:12 Open Q&A: Community Challenges 01:10 Discussion on Cigna's Downcoding Policy 03:01 Identifying and Handling Downcoding 07:33 Measuring Denial Rates and Overturns 12:00 Government Shutdown Impact on Telehealth 12:57 Combating Medical Necessity Denials 17:25 Escalating Denial Issues with Payers 22:20 Conclusion and Community Engagement

In this episode of 'For the Love of Revenue Cycle,' we delve into the unique aspects of the orthopedic revenue cycle compared to general Revenue Cycle Management (RCM). The discussion covers four key themes: prior authorization and payer policy awareness, global surgical rules, care settings, and payer types. Practical tips are provided for various stages including scheduling, registration, coding, claims review, payment posting, and AR management. The episode also offers management takeaways and highlights common denials in orthopedics and strategies for avoiding them. The insights are valuable for employees, managers, consultants, and technology partners working within the orthopedic realm.   00:00 Welcome and Introduction 00:50 Orthopedic Revenue Cycle Overview 01:30 Patient Intake and Scheduling 03:16 Registration and Check-In 04:04 Prior Authorization and Payer Policies 05:52 Encounter and Coding 08:27 Claims Creation and Review 09:25 Denials and Resolutions 10:50 Settings of Care 11:57 Workers' Compensation 13:17 Accounts Receivable Follow-Up 16:23 Leadership and Management Tips 17:56 Common Denials and Prevention 19:17 Conclusion and Final Thoughts

In this webinar replay, Vanessa Moldovan tackles a critical healthcare challenge: bridging the gap between innovation and operations in the revenue cycle. She explores the disconnect between RCM leaders and technology innovators, revealing how resistance to change, staffing shortages, and fragmented systems fuel inefficiencies and reimbursement setbacks. Vanessa explores root causes such as human error, denial management breakdowns, and rising costs to collect, while offering practical solutions to close the divide. By emphasizing knowledge, empathy, and a shared understanding of the full revenue cycle, she outlines how leaders and innovators can work together more effectively. Listeners will walk away with actionable insights on clean claims, leveraging technology for accuracy, and building more productive conversations between RCM teams and tech partners, ultimately paving the way for stronger collaboration and better financial outcomes. 00:00 Introduction and Disclaimers 01:31 Understanding the Gap Between Innovation and Operations 03:02 Challenges in Revenue Cycle Management 08:46 Revenue Cycle 101: Components and Functions 16:47 Key Performance Indicators and Cost to Collect 22:36 The Role of Technology in Revenue Cycle Management 27:31 Common Gaps and Reconciliation Points 40:21 Understanding Eligibility and Benefit Verification Challenges 41:28 The Burden of Documentation Requests 41:57 How Technology Can Help in Revenue Cycle Management 44:41 Tech Solutions for Front-End Processes 46:52 Mid-Cycle and Back-End Tech Solutions 49:45 Preparing for Successful Tech Implementation 50:00 Bridging the Gap Between RCM Leaders and Tech Innovators 52:55 Effective Sales Conversations for Tech Solutions 01:01:53 Key Steps for Successful Product Demos 01:13:59 Final Thoughts and Next Steps    

In this first My Take episode, Vanessa reflects on her conversation with Felix Segre and dives deeper into the topic of payment integrity. She breaks down the difference between pre- and post-payment review, the growing role of technology, and why payment integrity looks different for providers, payers, and vendors. Tune in for perspective, encouragement, and practical insights on how to advocate for yourself, know your motivators, and never underestimate your role in the revenue cycle. 00:03 Welcome to My Take 00:21 Defining Payment Integrity 01:14 Manual Work to Technology 01:25 Pre- & Post-Payment Review 03:57 Payment Integrity is About People 04:32 Vanessa's Homegrown Perspective 06:26 Know Your Motivators 07:46 Key Takeaway: Every Role Matters  

In this episode of 'For the Love of Revenue Cycle', host Vanessa Moldovan and guest Felix Segre, Director of Revenue Integrity, delve into the crucial topic of revenue integrity. With nearly 30 years of experience in revenue cycle management, Vanessa explores Felix's two decades of expertise spanning front, middle, and backend operations. They discuss the significance of revenue integrity, why it should be everyone's responsibility, and share actionable steps for fostering a culture of recognition and support within an organization.  The episode also offers practical advice for leaders on using data to guide decision-making and creating a culture of open communication. It highlights how every role in the revenue cycle plays a critical part, underscoring the interconnected nature of the process and the need for both individual accountability and collective ownership to ensure accurate reimbursement and an optimal patient experience. Bonus: This episode is also available in video format at youtube.com/@FTLORC! 00:00 Introduction and Host Background 00:34 Guest Introduction: Felix Segre 01:34 The Importance of Revenue Integrity 03:38 Personal Stories and Realizations 07:29 Defining Revenue Integrity 17:36 Challenges and Solutions in Revenue Cycle 21:32 Advice for Frontline Workers and Leaders 30:26 Closing Thoughts and Takeaways 35:00 Conclusion and Listener Engagement  

FTLORC Live Returns with Vanessa Moldovan In this episode of 'For the Love of Revenue Cycle,' host Vanessa Moldovan shares her extensive industry experience and the mission behind the podcast. Listeners are introduced to Vanessa's background in revenue cycle management, her current role at Agentic AI company Magical, and the goals of the podcast, which include offering practical guidance and fostering community discussions. The open Q&A session features real-world challenges such as AI-driven rejections, anesthesia reimbursement nuances, and payer dynamics. Vanessa and participants discuss issues like increasing denials due to AI, leveraging provider contracts for claim escalation, and strategies for dealing with payer resistance. The episode emphasizes the importance of community, the need for technology to ease revenue cycle management, and the value of sharing knowledge among professionals.  00:00 Introduction to Vanessa and the Podcast 00:36 Today's Episode Overview 01:33 Community and Facebook Group 02:16 Vanessa's Career and Focus on Denials 03:08 Participant Introductions 03:20 Nicolette's Experience and Challenges 04:37 Angie's Experience in Anesthesia Billing 09:16 Discussion on AI and Claim Rejections 21:23 Escalating Denied Claims 21:41 Challenges in Claim Resolution 23:04 Strategies for Effective Escalation 27:16 Dealing with Overseas Call Centers 28:45 Leveraging Contracts and Technology 37:00 Community and Continuous Learning 39:15 Conclusion and Next Steps  

In this episode of 'For The Love of Revenue Cycle,' host Vanessa Moldovan and expert Doug Hires discuss crucial strategies for revenue cycle management (RCM) leaders in their first 90 days. Doug, with decades of healthcare operations experience, provides actionable guidance on assessing priorities, making a case for technology investments, and achieving quick wins to build credibility. The episode emphasizes the importance of communication, transparency, and keeping a business-focused perspective. Vanessa and Doug also delve into change management and how to address resistance in staff. The conversation provides a comprehensive framework for new leaders to navigate their roles effectively and make meaningful impacts quickly. 00:00 Introduction to the Podcast and Host 00:40 Today's Episode Overview: Prioritizing the First 90 Days 02:20 Guest Introduction: Doug Hires 02:37 Doug's Career Journey and Experience 03:40 Challenges for New Revenue Cycle Leaders 05:27 The Importance of Observation and Feedback 08:42 Triage and Prioritization in Revenue Cycle Management 14:08 Quick Wins and Business Impact 16:49 Justifying Technology Investments to Leadership 17:42 Understanding the Impact of Technology Changes 21:01 Change Management and Communication Strategies 23:22 Addressing Fears and Resistance to Change 27:53 Final Thoughts and Key Takeaways  

Preparing for Tech Downtime in Healthcare: Key Strategies and Insights with Darlene Vendittelli In this episode of 'For The Love of Revenue Cycle,' host Vanessa Muldoon and guest Darlene Vendittelli, Director of Digital Revenue Management at South Coast Health, discuss crucial strategies to prepare for technology downtime in healthcare settings. The conversation covers the inevitability of system outages and emphasizes the importance of having a well-crafted downtime plan. Darlene shares five key steps, including inventorying systems, creating paper processes, developing a recovery plan, and establishing a strong communication strategy. They also talk about the necessity of rehearsals and regular reviews to ensure readiness. With practical tips and real-world examples, this episode provides valuable insights for healthcare professionals to maintain operational continuity during tech downtimes. Additional Episode Resources: The SAFER Guides (Safety Assurance Factors for EHR Resilience) — government-published checklists and self-assessment tools for contingency planning and downtime preparedness: https://www.healthit.gov/topic/safety/safer-guides A one-page tip sheet Darlene created summarizing her five-step downtime framework: Please email [email protected] to receive your free copy. 00:00 Introduction and Host Background 00:33 Episode Overview and Guest Introduction 02:38 Importance of Downtime Preparation 06:10 Steps to Build a Downtime Strategy 16:34 Communication and Recovery Plans 26:56 Practical Tips and Resources 30:20 Conclusion and Call to Action  

Navigating Automation in Revenue Cycle Management with Michael Laukaitis In this episode of 'For The Love of Revenue Cycle', host Vanessa Moldovan dives into the world of automation with healthcare IT expert Michael Laukaitis. With over two decades of experience, Mike shares his journey from rural Montana to UT Southwestern, highlighting the evolution of automation in healthcare. The discussion covers the importance of evaluating processes before automation, the differences between RPA and agentic AI, and the need for human oversight in automated systems. Mike emphasizes the necessity of stable, high-volume processes for successful automation and warns against over-promising vendors. Mike and Vanessa provide practical advice for healthcare leaders on selecting and implementing automation tools, ensuring measurable outcomes, and maintaining system integrity. 00:00 Introduction to the Episode 00:36  Meet Mike Laukaitis  01:00 Early Automation Experiences 02:05 Current Automation Projects 03:53 Challenges and Considerations in Automation 04:47 When Not to Automate 07:15 Human Element in Automation 09:58 Technical Aspects of Automation 17:54 Evaluating Automation Vendors 25:39 Best Practices and Lessons Learned 33:37 Conclusion and Final Thoughts What makes a process a good candidate for automation? Use this quick scorecard (1=low, 5=high). Aim for 24+ out of 35. Volume and frequency: high, daily work. Rule clarity: clear decision rules or prompts a model can follow. Input quality: structured data, stable forms, reliable sources. System stability: few UI changes, APIs available, or predictable portals. Exception rate: historically under 15% and well-defined. Impact: measurable time saved, faster cash, fewer denials, fewer clicks. Risk profile: errors are detectable and reversible. Questions leaders should ask before building or buying automation tools What is the exact business outcome and how will we measure it monthly? Where is the waste today: rework, wait time, over-processing, or motion? Is the process stable and documented, or do we need to fix it first? What is the current exception rate and why do exceptions happen? What data sources are required and who owns their quality? What are the failure modes and how will we detect, alert, and roll back? What access, audit, and compliance controls are required end-to-end? Build vs buy: which option reduces time to value and long-term maintenance risk? What's the realistic total cost of ownership, including rebuilds after system or payer changes? How will staff be trained, and what tasks will they do when the bot takes over the boring parts? Who is the named process owner and who shuts it off if metrics slip? What is the decommission plan if the upstream system adds a native feature? Implementation guardrails that save pain later Fix the process first. Map it, remove steps, standardize inputs, then automate. Start in "shadow mode." Let the bot run in parallel for 2 weeks and compare outcomes. Instrument everything. Log starts, stops, exceptions, and outcomes. Alert on drift. Keep humans in the loop for edge cases and approvals above risk thresholds. Review quarterly. If payer or EHR changes make it brittle, redesign or retire it.  

Mastering Payment Analysis: Best Practices with Stacy Calvaruso In this episode of 'For The Love of Revenue Cycle,' host Vanessa Moldovan and expert Stacy Calvaruso discuss the often-overlooked yet crucial topic of payment analysis. The episode differentiates between contract modeling and payment analysis, addressing common issues like underpayments and silent downcoding. They share actionable steps for ensuring proper payment using both advanced technologies and spreadsheets. The discussion also covers the importance of data in running a revenue cycle, triggers for payment analysis, and strategies for contract negotiation. Practical advice on identifying and rectifying underpayments is provided, emphasizing the need for regular review and collaboration within the organization. Whether you're a large hospital or a smaller clinic, this episode offers valuable insights into maintaining revenue integrity.  Here is the link to the analysis sheet referenced in the call: Payment Analysis Lost Revenue Tracker 00:00 Introduction and Episode Overview 00:56 Meet Stacy Calvarusso: Revenue Cycle Expert 02:49 The Importance of Data in Revenue Cycle Management 03:52 Contract Modeling vs. Payment Analysis 05:50 Understanding Payment Variances and Underpayments 08:53 Contract Negotiation Strategies 14:51 Triggers and Tools for Payment Analysis 18:47 Practical Tips for Payment Analysis 32:14 Conclusion and Final Thoughts

In this inaugural live Q&A episode, Vanessa Moldovan, CEO of For the Love of Revenue Cycle, answers real-time questions on denials, RCM technology gaps, billing strategies, and more. Tune in for practical insights on tech adoption, denial resolution, and how to evaluate in-house vs. outsourced billing. [00:03:00] – Where do you think the biggest gaps are between what technology promises and what it actually delivers in revenue cycle? [00:07:45] – What makes a revenue cycle leader actually adopt a new product or tool? [00:13:20] – What is the number one mistake you see practices or companies make when it comes to denials? [00:22:30] – Who should be handling your billing—in-house or outsourced?

In this episode of 'For the Love of Revenue Cycle,' host Vanessa welcomes Dr. Greg Hobbs, the Chief Medical Officer and co-founder of Milagro, a provider of autonomous coding solutions for healthcare. Dr. Hobbs discusses his background as an emergency physician, his journey through the academic and IT sectors, and his subsequent focus on healthcare technology. The conversation delves into the challenges and benefits of adopting technology in healthcare, particularly autonomous coding. They explore physicians' skepticism towards AI, the need for transparency in automated systems, and the importance of finding the right vendor for technology solutions. Dr. Hobbs highlights the necessity of real-time coding to avoid preauthorization mismatches and enhance efficiency. Emphasizing a partnership approach with technology providers, the discussion underscores the value of integrating smart software with human expertise to optimize healthcare workflows. 00:00 Introduction and Guest Introduction 00:20 Dr. Greg Hobbs' Background and Experience 01:37 Challenges with Technology Adoption in Healthcare 03:54 Importance of Accurate Coding 04:37 Addressing Skepticism and Legal Responsibilities 08:30 Autonomous vs Automated Coding 11:35 Real-Time Coding and Preauthorization 15:55 Integration and Implementation Challenges 19:03 Vendor Selection and Partnership 22:35 Conclusion and Final Thoughts

In this episode, Vanessa is joined by Dugan Winkie with Cedar to explore the integration of innovation within the revenue cycle. The discussion focuses on patient accounts receivable (AR) and the transformative role of technology in making patient financial experiences more efficient and personalized. Dugan shares insights from his career and Cedar's approach to bridging the gap between technology and revenue cycle management. The conversation touches on the need for simpler payment processes, the impact of AI in answering billing questions, and the importance of finding healthcare solutions that balance operational efficiency with patient care.  For further information go to https://www.cedar.com/ 00:00 Introduction and Guest Introduction 02:44 The Importance of Patient AR 06:30 Challenges and Innovations in Patient Financial Experience 10:09 Leveraging AI and Technology for Efficiency 15:59 Strategies for Improving Patient Engagement 19:19 Choosing the Right Partner for Revenue Cycle Management 20:58 Conclusion and Final Thoughts

Episode Summary: Conferences can be a game-changer for your career, whether you attend in person or virtually. In this episode, we dive into how to maximize your return on investment (ROI) from industry conferences, choose the right events, and make the most of opportunities—even if you can't attend in person. 🔥 What You'll Learn in This Episode: • The tangible and intangible benefits of attending conferences. • How to calculate your ROI to determine if a conference is worth it. • Key differences between in-person and virtual attendance. • Alternative ways to gain value if you can't attend in person. • How to select the right conference for your career or business goals. • Two major conference announcements where Vanessa will be speaking! ✈️ Upcoming Conferences & Speaking Engagements 🏥 RCM Summit – Nashville (February 5-7, 2024) 📍 Speaking Session: 🔹 Panel: "Creating Common Ground – Strategies for Payer-Provider Synergy" 🕑 February 6th at 3:45 PM Eastern 💡 Why Attend? • A must-attend for revenue cycle professionals. • The only event uniting RCM professionals from healthcare and insurers. • Features 25+ senior-led sessions, networking, and exclusive discussions. • FREE for healthcare providers and those who work for healthcare organizations! 🔗 Register Here 🌐 ViVE – Nashville (February 16-19, 2024)   📍 Speaking Sessions: 🔹 February 16 – Bridging the Gap Between RCM & Technology 🔹 February 19 – First Ever RCM Summit at ViVE 💡 Why Attend? • Premier event for digital health transformation. • Unmatched networking with tech innovators, revenue cycle experts, and healthcare leaders. • Exclusive RCM Summit featuring the top minds in the space. 🔗 Register Here 💰 Save $250 on Registration! Use promo code: v25p_FTLRC250 📌 If you found this episode valuable, please share it with a friend or colleague! 💡 Join the conversation: Follow Vanessa on LinkedIn for more industry insights. 🎤 For the Love of Revenue Cycle – Helping you navigate RCM with clarity, strategy, and innovation.  

Navigating Denial Management and Best Practices in Medical Billing   In this episode, our host addresses common issues and questions related to claims denial in the healthcare industry. The session kicks off with a briefing about the recording process and the host's recent absence due to business commitments in Europe. The conversation delves into topics such as the upcoming conferences in Nashville, including the RCM Summit and Vive, and moderating panels on collaboration between providers and payers. The Q&A covers detailed discussions on claims denied for timely filing, challenges faced with behavioral health billing, the importance of accurate reason codes, and the complexities of dealing with authorization denials. Specific case studies are examined, including issues with Blue Cross of Massachusetts and UnitedHealthcare denials. The episode emphasizes the need for resilience, thorough research, and the use of technology in managing billing processes effectively.   00:00 Introduction and Housekeeping 02:34 Welcome and Updates 03:45 Upcoming Conferences 04:41 Panel Discussion Preparation 09:54 Q&A: Denial Management 15:28 Common Denial Issues 25:41 Behavioral Health Billing Challenges 31:06 Challenges with Authorization Denials 31:59 Manual vs. Technological Solutions 32:54 Dealing with Out-of-Network Denials 34:54 Frustrations and Resilience in Billing 35:50 Escalating Appeals and Insurance Company Tactics 38:22 Utilizing Support Networks 41:47 Specific Case Discussions and Policies 01:00:04 Conclusion and Final Thoughts

Episode Overview: In this episode, we dive into the latest trends and challenges in the world of healthcare denials, focusing on payer-driven issues and solutions. The discussion spans denial trends, specifically around inpatient DRG downgrades, and the nuances of navigating denials and claim processes. We also cover technology gaps, regulatory shifts, and emerging solutions in the revenue cycle, particularly for claims with no response and payer-driven reimbursement barriers.   Key Topics Discussed: • DRG Denials and Humana's Query Compliance: Robin brings up a denial trend where Humana denies inpatient DRG claims based on "non-compliant queries," prompting insights on how other professionals are tackling this issue. • Technology for Claims Without Response: A compelling case is made for creating automation around claims that have not received a denial or payment. This includes potential decision trees for follow-up actions on claims without EDI data to improve efficiency. • Prior Authorization and Payer Challenges: The conversation highlights the industry's struggle with prior authorization, arguing that innovation should focus on reducing the overall burden rather than automating current processes, which only minimally alleviate providers' challenges. • The Telehealth Dilemma Post-2024: With telehealth flexibilities set to expire at the end of 2024, Whitney raises concerns over how practices primarily based on telehealth services, especially those offering behavioral health, will adapt. Regulatory changes are dissected, with possible strategies suggested to navigate this impending change. • Innovations in Denial Management: Attendees discuss tools for denial tracking and payer insights, like Cleopatra Queen of Denial, a software solution developed to trend denial types across categories for better negotiation leverage. • Building Technology That Truly Helps the Revenue Cycle: A call is made for technology that directly addresses payer-driven issues, rather than administrative burdens, suggesting a focus on innovation that simplifies payer policies and medical necessity criteria. • Professional Events and Resources: The episode includes a discussion on upcoming events, like Joe Rivett's denial forum, offering listeners insight into where they can learn more about denial management, payer perspectives, and effective appeals writing. Listeners are encouraged to reach out and share their own experiences with denial management challenges, particularly around DRG downgrades and telehealth changes, fostering a community of shared insights and solutions.

Mastering Payer Defense In this episode, Vanessa Moldovan, CEO and founder of 'For the Love of Revenue Cycle,' dives deep into the complexities of downcoding and mastering payer defense strategies. She discusses essential steps including understanding contracts, interacting effectively with payers, and leveraging legal options and state insurance commissions. Vanessa also shares insights gathered from a healthcare attorney specializing in defending providers against insurance companies. Tune in to learn actionable strategies to safeguard revenue and ensure fair payment while maintaining professional relationships with payers.  00:00 Introduction and Overview 00:13 Understanding Downcoding 00:53 Expert Insights and Strategies 02:20 Importance of Contracts in Payer Defense 03:49 Presenter's Background and Expertise 06:00 Webinar Disclaimer and Initial Questions 07:10 Best Practices for Denial Escalation 11:39 Identifying and Addressing Downcoding 19:58 Effective Payer Conversations 29:22 Navigating Payer Relations and Contracting 31:01 Effective Appeal Strategies 33:40 Documentation and Professionalism 37:43 Leveraging State Insurance Commissions 43:33 Filing Grievances: Medicare and Commercial Plans 48:47 Legal Complaints and Final Steps 52:19 Q&A and Closing Remarks

Transforming Healthcare Revenue Cycle with Technology and Human Expertise Join Vanessa Moldovan, CEO and founder of For the Love of Revenue Cycle as she delves into the intersection of innovative technology and Revenue Cycle Management (RCM). Discover the critical role of technology such as Artificial Intelligence (AI), Large Language Models (LLMs), and Software as a Service (SaaS) in optimizing financial processes and patient data management.  This episode covers essential topics including vendor selection, key technological terms, and the importance of human factors in successful technology adoption. She tackles common objections to new technology, and provides practical strategies for evaluating software solutions and maximizing the benefits of software demos. Learn how to balance human intervention and automation to achieve efficiency and long-term financial success. For more information, contact Vanessa at [email protected] and connect via LinkedIn or Facebook. 00:00 Introduction and Webinar Overview 00:11 About Vanessa Moldovan 00:48 Mission and Services 01:58 Importance of Technology in Revenue Cycle 05:50 Key Terms in Technology 09:37 Understanding Information Technology 11:31 Software as a Service (SaaS) 28:50 Human Factor in Technology 35:49 Challenges in Revenue Cycle Management 36:57 Understanding Common Objections to Technology Adoption 37:55 Overcoming Resistance and Bad Experiences 40:07 Perception of High Costs and Value Challenges 42:34 Preparing for Technology Demos 44:46 Maximizing Demo Effectiveness 50:39 Evaluating Technology Integration and Support 01:03:36 Exploring Innovative Technologies in Revenue Cycle 01:10:29 Conclusion and Contact Information

Mastering Medical Billing: Overcoming Claim Denials and Utilizing Key Resources In this comprehensive episode, we dive deep into various medical billing challenges and solutions. Key discussions include handling billing issues with UnitedHealthcare, specifically around lab claims and CLIA validation, and addressing billing problems with Medicare Advantage and other insurers like Cigna and Blue Cross. We offer practical advice on resubmissions, correct coding, and documentation to avoid denials. The importance of leveraging resources such as the AAPC website, MACs for webinars, and networking for educational support is emphasized. The episode features expert insights, such as those from healthcare attorney on combating downcoding and dealing with insurance companies.  New and experienced billers alike can benefit from tips on maintaining contact lists, timely filings, and utilizing payer portals effectively. 00:00 Introduction and Initial Query 00:18 Clarifying the Issue with Modifier 90 01:00 Understanding CLIA Requirements 05:25 Dealing with UnitedHealthcare Denials 07:12 Exploring Other Potential Issues 09:33 Addressing Sentara Insurance Glitch 12:00 Blue Cross Medical Advantage Claim Issues 18:06 Cigna Appeal Process Challenges 22:01 Medicare Advantage Plan Denials 26:44 Medicare Billing Challenges 27:17 Humorous Anecdotes and Introductions 28:02 Addressing New Biller Concerns 30:06 Sharing Tips and Resources 31:33 Useful Websites and Tools 34:08 Insurance Company Contacts 35:02 AAPC Website Resources 36:32 Medicare Denial Codes and Policies 37:43 Importance of Bookmarking Resources 39:20 Access to Payer Portals 40:47 Training and Networking 42:00 Medicare Billing Programs 44:42 Final Thoughts and Suggestions

In this engaging podcast episode, participants dive deep into the complexities of denial management and revenue cycle strategies. Led by Vanessa Moldovan, a discussion unfolds around real-world challenges in handling denials and retractions within the healthcare finance sector. Key topics explored include the importance of working in denial management to gain comprehensive insights, effective strategies for managing Medicare and Medicare Advantage issues, and dealing with common denial reasons such as duplicate claims, out-of-network, and lack of authorization denials. The podcast also emphasizes the role of technology in streamlining these processes, highlighting how automation and AI can ease the burden of manual claims review. Participants are encouraged to utilize contracts proactively to fight against unjust denials, and valuable resources, like subject matter experts and tech solutions, are shared to empower professionals in the industry. For further guidance, listeners are invited to reach out to Vanessa at [email protected]. 00:00 Introduction and Newcomers 00:18 Challenges with Denials 01:12 Colonoscopy Coding Issues 01:54 Connecting with Experts 03:55 Educational Resources and Support 07:07 Podcast Discussion 08:27 Using Contracts to Fight Denials 10:54 Preparing for Payer Meetings 20:26 Duplicate Claims and Denials 24:05 Understanding Adjudication and Denials 25:33 Credentialing Denials: Challenges and Solutions 28:18 Common Issues with Authorizations and Network Status 30:47 Fighting Back Against Incorrect Denials 37:06 Technology and Tools for Managing Denials 42:08 Addressing Underpayments and Downcoding 50:06 Final Thoughts and Best Practices

Maximizing Provider Revenue with Payer Contract Insight In this episode of 'For the Love of Revenue Cycle,' host Vanessa Moldovan shares essential insights on how to maximize provider revenue by understanding and leveraging the nuances of payer contracts. Topics covered include addressing prior authorization denials, navigating payer reimbursement policies, ensuring clean claim submissions, and utilizing fee schedules and carve outs. Additionally, Vanessa offers strategies for managing payer plan limitations, timely filing guidelines, and escalation procedures for unresolved reimbursement issues. Listeners are encouraged to harness technology and AI-driven solutions to streamline these processes for enhanced revenue cycle performance.  00:00 Introduction to the Podcast and Host 01:23 Episode Overview: Maximizing Provider Revenue 02:01 Understanding Payer Contracts 03:04 Prior Authorization Guidelines 05:28 Payer Reimbursement Policies 08:08 Clean Claim Requirements 11:34 Carve Outs in Payer Contracts  14:03 Payer Plan Limitations 16:24 Fee Schedules and Contracted Rates 21:29 Requests and Recoupments of Overpayments 23:34 Denials Without Proper Justification 25:10 Timely Filing Guidelines 27:17 Escalating Reimbursement Issues 29:11 Conclusion and Next Steps

In this episode of the bimonthly Denials Q&A, host Vanessa discusses her extensive experience and expertise in handling denials, focusing on changes and challenges in the field. She emphasizes the importance of understanding contracts, payer guidelines, and exploring new technologies to improve denial management. Vanessa shared insights on leveraging contract information and innovative technology to fight back against complex denial processes. Key topics include the use of CARCs, dealing with Medicare Advantage plans, navigating E&M downcoding, and strategies for obtaining necessary documents from payers. Listeners are encouraged to stay proactive, utilize technology, and network within the healthcare billing community to address evolving denial issues effectively. Email Chester Montefering at Recon.health at [email protected] for more information on utilizing contract automation.   00:00 Welcome to the Bimonthly Denials Q&A 00:26 Introduction to Denials and Career Background 01:27 Starting a Company and Industry Engagement 03:19 Denial Codes and Industry Changes 04:37 Complexity in Reversing Denials 06:35 Importance of Contracts in Denial Management 08:50 Accessing and Understanding Contracts 12:01 Technology Solutions for Denial Management 15:06 Open Q&A Session 23:12 Networking and Sharing Experiences 52:18 Final Thoughts and Next Steps

Navigating Insurance AR: Tackling Claims with No Response In this episode, Vanessa Moldovan, CEO and host of 'For The Love of Revenue Cycle,' delves into the intricacies of Insurance Accounts Receivable (AR), focusing on claims with no response. Vanessa explains the significance of managing AR to maintain financial health and provides practical strategies for identifying, resolving, and preventing claims with no responses. Key takeaways include the importance of tracking all claims, the role of technology, and assigning the right tasks to team members. Vanessa also emphasizes the need for preventive measures and invites listeners to ongoing discussions and networking opportunities. 00:00 Introduction and Welcome 01:06 Episode Overview: Insurance AR and Claims with No Response 02:00 Understanding Insurance Accounts Receivable (AR) 03:57 Managing AR: Best Practices and Key Performance Indicators 07:07 Focusing on Claims with No Response 16:13 Steps to Resolve Claims with No Response 22:22 Preventive Measures for Claims with No Response 26:05 Conclusion and Upcoming Episodes

In this episode, Vanessa Moldovan, CEO and Founder of 'For the Love of Revenue Cycle,' leads a live Q&A session on handling denials in medical billing. Participants from different sectors of the healthcare revenue cycle, including medical billing for home visits, nursing homes, and surgery centers, discuss challenges they face with denial codes, modifiers, and reimbursement issues. Key topics include understanding the new FY 2024 hospice final rule, addressing denials related to modifier codes, and strategies for handling electronic remittance advice (ERA) take-backs. Suggestions for actionable steps and resources, such as consulting specific websites and joining relevant forums, are also shared.  00:00 Introduction and Purpose of the Q&A Session 00:49 Challenges in Revenue Cycle and Denials 02:07 Participant Introductions and Their Goals 03:11 Open Forum for Questions and Discussions 04:14 Lauren's Denial Issue with Chronic Care Management 09:26 Exploring Possible Solutions and Resources 21:08 Roseanne's Issue with Take Backs on ERAs 28:22 Provider Targeting by Payers 28:38 Options for Receiving Take Backs 29:03 Challenges with Electronic ERAs 29:44 Appeal Deadlines and Paper Forms 30:11 Denials Due to Grouper Edits 30:53 Hospital Denials and Resources 33:13 Questions on Prolonged Services Billing 37:08 Issues with Nursing Home Billing 45:29 Seeking Expert Advice and Final Thoughts

Show notes for today's live denials Q&A session: The differences in denials and appeals processes between in-network and out-of-network providers Strategies for appealing out-of-network denials, including involving patients and leveraging laws like the Arisa law Trends in payer requests for documentation and potential reasons behind sudden increases in these requests Frustrations with payers' downcoding practices and lack of transparency in reimbursement The shift in the medical field from a profession to a business, and the need for better revenue cycle education for providers

Tech-Enabled RCM: Tips and Solutions with Mike Marshall + Vanessa   In this episode, Vanessa welcomes Mike Marshall to discuss the intricacies of revenue cycle management (RCM) and the challenges faced by healthcare organizations. Mike is currently the Managing Director of the North American division of e5 Workflow, with a rich background in healthcare focusing on turnaround projects for operation, finance, and revenue cycle management.   They explore the root causes of common RCM issues, the hesitations around adopting new technology, and emphasize the necessity of becoming tech-enabled to survive in the current market. The conversation delves into innovative solutions, actionable data, optimizing human resources, and technological advancements like AI and automation. They also provide guidance on selecting vendors and the importance of staying informed about industry innovations through networking, conferences, and professional advice.   00:00 Welcome and Introduction 00:31 Introducing Mike Marshall 01:03 Industry Challenges in Revenue Cycle Management 02:09 Hesitancy in Adopting Technology 03:48 The Pain of Outdated Systems 07:35 Fear of Change in Revenue Cycle 11:32 Importance of Training and Support 16:47 Encouragement to Explore New Solutions 21:19 Leveraging Technology for Efficiency 33:15 Medicare Challenges and Strategic Technology Integration 33:52 Middle Management and Delegation with Technology 35:08 Industry Changes and Knowledge Gaps 36:04 Leveraging Technology for Delegation and Efficiency 36:53 Outsourcing and Onshoring in Revenue Cycle Management 39:34 Navigating Vendor Selection and Industry Resources 45:16 Maximizing Conference and Vendor Interactions 53:40 Evaluating Automation and AI Claims 57:55 Strategic Technology Integration and Conclusion

In this episode, Vanessa Moldovan hosts a Q&A session focused on the challenging issues of denials in revenue cycle management. Vanessa, along with the attendees, discusses the complexities around denial prevention, resolution, and best practices. The session covers specific payer issues, including downcoding by Anthem and Humana, as well as rampant documentation requests from UnitedHealthcare. The discussion also provides strategies for handling denials, escalating issues to provider representatives, utilizing contracts, and ensuring accurate coding practices. Expert insights are shared on balancing the administrative burden, proactively managing claims, and leveraging technology to streamline processes. The conversation aims to empower healthcare providers and billers to tackle denials effectively while advocating for systemic changes in payer operations. 00:00 Introduction and Welcome 03:27 Purpose of the Q&A Session 04:28 Host's Background and Experience 05:25 Community and Participation 07:00 First Question: Handling Downcoding 1 1:44 Discussion on Denial Trends and Strategies 23:02 Challenges with Payers and Denials  31:41 Industry Trends and Payer Practices 35:26 Frustrations with Office Testing and Pre-Authorization 37:22 Tactics for Fighting Unjustified Denials 38:27 Challenges Faced by Small Practices 40:21 Importance of Documentation and Predetermination 42:16 Role of Professional Organizations and Social Media 49:12 Differences in Denials: In-Network vs. Out-of-Network 54:53 Leveraging Contracts and Provider Networks 58:46 Final Thoughts and Recommendations

n episode 31 of 'For the Love of Revenue Cycle,' the host discusses patient accounts receivable (AR) in a clinic setting, emphasizing the importance of professional billing over facility billing. Key topics include naming conventions in billing systems, the role and definition of a guarantor, and the nuances between insurance processing and payment. The episode delves into best practices for managing patient AR, handling self-pay arrangements, and understanding patient financial responsibility, especially under high deductible health plans. The host also explores the impact of technological innovations on both pre-service and post-service collections, strategies for reducing collection costs, and compliance with federal and state regulations. Finally, the session provides practical recommendations for managing self-pay balances and patient shares, offering financial assistance, and ensuring consistency in collections policies. 00:00 Welcome and Introduction 01:27 Understanding Patient Accounts Receivable (AR) 01:54 Naming Conventions and Guarantor Responsibilities 05:40 Insurance Processing and Patient Responsibility 19:26 Collecting Patient Payments 22:58 Technological Innovations in Revenue Cycle 25:34 Best Practices for Self-Pay Balances 27:00 Handling Balances After Insurance 28:03 Developing Effective Collection Policies 34:45 Conclusion and Final Thoughts

Get ready for Season 3 of For the Love of Revenue Cycle, premiering tomorrow with Episode 30! I'm back with a deep dive into denials and accounts receivable in the revenue cycle. Listen in, as I unpack the complexities of denials and their impact on healthcare organizations. I'll share insights from recent industry events and personal experiences, highlighting key strategies for prevention and resolution. Also, stay tuned to the end for a big announcement about For the Love of Revenue Cycle.

In this episode, we dive into effective strategies for preventing and resolving denials in healthcare billing. Our speakers cover essential tips like checking the place of service, sharing experiences, and networking with other professionals. We explore various types of rejections in healthcare claims, emphasizing the need to understand their origins and track them meticulously. Discover valuable insights on managing appeals and reconsiderations, staying organized, using timely filing tools, and navigating complex appeal letters. Plus, learn about the importance of resources for identifying plan types and tackling excessive medical documentation delays. Join us for this comprehensive discussion on mastering healthcare billing challenges.

During today's live Q&A we had some great discussion about important denials that you and your organization are probably experiencing.  We had some great interaction with 28 attendees.  Check out the conversation!

Corey started Covered Health to automate the most challenging element of appealing denied medical claims by streamlining the access to diverse databases and sources to pinpoint denial root causes. I decided to partner with Covered because we share the same vision: preventing patients from getting stuck with bills that should be covered by their insurance, and helping to empower revenue cycle management experts to resolve those denials with greater efficiency. We discussed Corey's motivations for starting Covered - his brother Russell's experience with unfair insurance denials during his struggle with Ulcerative Colitis.  Corey's family was hit with massive bills, and at a time when they wanted to focus on Russell's health, instead they were focused on denied claims. Covered intervenes to help providers overturn denials, and prevent bills from becoming patient responsibility.  Corey discussed his journey through the Special Forces, Parachute Health, and running sales for healthcare companies, eventually selling into insurance plans prior to starting Covered.  We discussed my career as well, and turning down Harvard undergraduate in pursuit of a life and career that aligned with my values of giving back and sharing what I've learned with others, which is why I started this podcast.  Corey and I met because he was looking for a podcast on denials and he found mine! We connected over a shared passion to create a denial resolution tool with the goal of harnessing the multitude of databases & sources of truth that a biller has to access in order to identify the root cause of a denial and create an appeal. We are not only reducing the clicks required to gather the information, but creating a smart tool that will guide RCM professionals through the decisions required to compile the body of the appeal, and eventually generate it for them. We addressed Covered's competitive differentiation within the denial management space, and the rapid advancement of AI and LLMs, which have given an advantage to new companies. We touched on the slow moving nature of incumbents, and why they often don't succeed in building product lines that are as innovative as their original core offering.  If Covered's mission to fight back against incorrect denials resonates with you, we want to connect! Especially (but not exclusively) if you are an independent specialty provider group, an RCM company fighting denials, an, or a regional/community hospital/health system. If you are struggling to address denials as a result of staffing shortages/payer policies/behavior, or you are just passionate about denials, please reach out!  Today, Covered acts as a software enabled services company, utilizing technology to overturn denials (they've returned tens of thousands of dollars to physicians). In addition to helping Covered build out their product, I am helping Covered to actually fight denials as an extension of customer RCM teams. If you're struggling with denials, we can immediately step in and help you, and help identify trends and root causes. In special cases, we also provide consulting services.  One of the advantages of fighting denials on behalf of our customers is that we enter their world, and get to see their problems firsthand. That, in turn, allows us to tweak our product for each customer based on their specific pain points.  You can learn more about Covered on their website, and you can find Corey on Linkedin.  As you discover more about Corey and his mission with Covered, I encourage you to check out his podcast Healthcare Reimagined (Apple or Spotify). _____

Dive into the world of healthcare industry in our special episode of PM Symposium where we uncover the many facets of the revenue cycle. Hosted along with Jennifer McNamara, we discuss the impact of practice managers, the importance of understanding the revenue cycle, and how to combat revenue leakage. We explore some of the major challenges including staffing shortages, the lack of standardization and the crucial role of both management and line workers. Tune in to gain invaluable insights, understand the power of community teamwork and informed decision-making. See you at the practice management symposium on February 16th!

Hello friends and welcome to episode 28 of For the Love of Revenue Cycle.  Thank you so much for tuning in today!  A big welcome back to my loyal listeners and a special shout out if today is your first episode.  This season is part of the going back to the basics from season 2. I know that it has been about 5 months since Episode 27 was posted.  As you may recall, me and my production team were experience technical difficulties.  But here we are back again!  In this final episode of Season 2,  I'm going to share with you my experience with using reporting and analytics in revenue cycle management.  This will include discussing why I believe analytics is so vital, what my favorite reports are and how I use them to run a clean revenue cycle.

Hello Friends!  Welcome to the kickoff of season 3!  I am overwhelmed to still be running this podcast after 2 years. Thank you as always for your support.  In this episode, I share what the topic of season 3 will be and share a big announcement.  Speaking of the big announcement, here is the link that I reference. https://fortheloveofrevenuecycle.aweb.page/p/7d25c7b7-9c16-490c-95cd-7bd2052fd396    

Hello Rev Cycle Lovers!  This episode is a recording of our live Q&A session today.  It is raw and unedited, but that does not diminish the great conversation.  We discussed some challenges with the end of PHE, operational challeges that cause denials and also different options for assigning individuals within the revenue cycle.  We also spent some time talking about the current state of affairs in our industry related to payer guidelines and staffing shortages.  I hope that you enjoy this conversation.

In today's episode, we go back to the "Language of Revenue Cycle" to discuss the differences between the concepts of prior auth, referrals, precertification and predeterminations.