In an era when up to one in five claims gets denied, AdventHealth isn't just fighting back with its denials management strategy. The Florida-based health system is fighting forward, so to speak, using technology to identify potential denials before they even happen.
"We’ve taken a proactive approach by using AI-driven tools that help our teams surface potential documentation gaps before a claim is submitted," explains Christopher Riccard, MD, vice president of hospital medicine and clinical documentation integrity.
"Our tech-enabled process helps analyze medical records after discharge and flag areas that might need clarification or additional details," Riccard continued. "That allows our clinical documentation teams to step in early and ensure everything is captured clearly and consistently. It helps us work more efficiently and keep the process moving for our patients."
Claim denials, after all, are not just a hospital's revenue cycle problem, even though statistics show that denials jam up $262 billion in provider revenue.
"Claim denials don’t just affect hospitals -- they affect patients," Riccard emphasized. "When a claim is denied, it can delay the billing process and create confusion or frustration for people trying to navigate the process."
To overcome both revenue and patient billing challenges when it comes to claim denials, AdventHealth has invested in the latest technology to "catch documentation issues early so our patients get accurate and timely information."
"Reducing denials helps us create a smoother, less stressful experience for our patients," Riccard said.
Going from reactive to proactive denials management
Denials management is traditionally a reactive process in which providers receive a denial from a payer and they rework the claim or appeal the decision in order to get reimbursed. Providers have tapped into predictive analytics to identify trends in claim denials and rejections to jigger their strategy, but even this innovation has left money on the table.
No technology is a crystal ball, but with the help of AI, providers like AdventHealth can spot potential claim problems before payers and fix issues that could lead to claim denials.
"AI allows us to move from a reactive to a proactive model by allowing us to review medical records after discharge but before a claim is submitted," explained Riccard. "For example, AI can help flag anything that may need clarification, such as unsupported diagnoses or missing documentation. This gives our teams a chance to act proactively, so claims move forward without unnecessary delays."
The AI tool, which AdventHealth beta-tested with Iodine Software, also helps the revenue cycle team prioritize cases to yield maximum revenue owed to the health system. The tool pinpoints patient records with the most significant financial impact.
Our broader goal is to build a sustainable, intelligent revenue cycle that supports both the consumer's experience and clinical excellence.
Christopher Riccard, MD, VP of hospital medicine and CDI, AdventHealth
As a result, Riccard reported an increase in "high-impact queries" that boost both revenue and quality outcomes. He said the AI tool has helped the health system to prioritize the "right cases" rather than trying to pursue as many denials as possible to recoup reimbursement.
Preventing potential claim denials has smoothed AdventHealth's revenue cycle, getting accurate medical bills to patients sooner.
"Since putting our pre-bill review enhancements in place, with support from Iodine’s AwarePreBill, we’ve seen real improvements that benefit both our teams and our patients," Riccard said. "Providers are responding to documentation questions faster -- more than 90% are answered within one calendar day -- which helps us keep the process moving without unnecessary delays. That means patients get clearer, more timely information about their care and coverage. The end result is a better experience for patients when it comes to how their care is documented and processed."
Building an intelligent revenue cycle
The application of AI-driven technology to claims and denials management is just one step in AdventHealth's journey to a more intelligent revenue cycle, according to Riccard.
"Our broader goal is to build a sustainable, intelligent revenue cycle that supports both the consumer’s experience and clinical excellence," he stated.
Becoming more proactive within revenue cycle management is key to achieving the health system's goals. Riccard intends to " shift toward upstream intervention -- identifying risks earlier, engaging providers in real time and embedding documentation support into their workflow."
AdventHealth is also exploring how ambient and generative AI can integrate into revenue cycle workflows to reduce clinical documentation burden and improve accuracy.
Ambient AI, or ambient intelligence, integrates AI into daily operations so humans can interact with it in a more natural, seamless way. These solutions aim to deliver insights in real time and at scale without explicit human interaction.
Healthcare is tapping into ambient AI through remote patient monitoring and smart hospital rooms, to name a few examples, as well as for capturing clinician-patient conversations for the health record.
Meanwhile, generative AI is making a splash in the revenue cycle management space as more providers and vendors scale this capability.
More practical applications for generative AI are emerging, including generating appeals for denials and managing prior authorization. But health IT leaders are finding that the AI capability can significantly prevent avoidable errors by analyzing documentation to pinpoint missing information, for example. Generative AI can also improve communications within the revenue cycle and between patients and the organization.
But it isn't a complete technology takeover, Riccard stated.
"A key lesson for us has been that tech alone isn’t the answer -- success depends on thoughtful implementation, strong change management and aligning the tools to actual workflow needs," he explained. "We chose to explore AI-based tools like Iodine’s because we wanted to scale our impact. We saw a clear opportunity to support our clinical documentation integrity and physician teams more efficiently and accelerate query response times, especially post-discharge. But it only worked because we partnered closely with our end users of the tools throughout the rollout."
Jacqueline LaPointe is a graduate of Brandeis University and King's College London. She has been writing about healthcare finance and revenue cycle management since 2016.
