The Money is in the Note, Not the Claim [PODCAST]

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The Money is in the Note, Not the Claim

In this episode, VerifyMedCodes Co-Founders Nathan Turock and Angelo Selitto, discuss why the money is in the clinical note, not the claim.

Highlights of this episode include:

• What it means when they say “the money is in the note, not the claim”
• What problem VerifyMedCodes solves
• How the deterministic approach is different
• “You can’t defend a code you can’t reproduce.”
• How to catch issues before the claim goes out, missing modifiers, unsupported codes, and linkage problems
• How hospital finance leaders should be thinking about readiness
• How to process a clinical note without patient data ever leaving the building

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Nathan Turock and Angelo Selitto. Nathan is CEO and co-founder of VerifyMedCodes. He leads strategy, partnerships, and go-to market, focused on helping hospitals and RCM teams turn clinical documentation into defensible, denial-resistant revenue. He founded Verify Med Codes to close the gap between what clinicians document and what actually gets paid. We have Angelo, who’s co-founder and chief architect of VerifyMedCodes. He’s a healthcare integration architect with 13-plus years’ experience across Epic, FHIR, HL7, Identity, and Clinical AI. And he’s delivered production CDS hooks and FHIR for value – based care and led ambient AI documentation rollouts across 33, 000 providers. He designed the VerifyMedCodes deterministic PHI-safe coding engine.

In this episode, we’re discussing the money is in the note, not the claim. Welcome, and thank you both for joining us, Nathan and Angelo.

Nathan Turock: Thank you for having us.

Angelo Selitto: Thank you for having us. Thank you for the intro, and wonderful to be here.

Kelly: All right. Well, let’s go ahead and jump in. So, VerifyMedCodes started as a coding engine. What problem did you set out to solve, and why do you say the money is in the note, not the claim? And Nathan, I’m going to toss this one over to you.

Nathan: Okay, that’s great. The money is in the note. The way it all works, if we’re going to make it easier for the audience, the progress note that the doctor writes is actually what gets paid by the insurance companies. The way it’s set up in the United States healthcare system is the doctor writes the note, then it goes to a coding or billing agency, and they have to put in all the codes that have been created since the ’50s and ’60s by the insurance industry to make sure it’s accurate so they get paid. The problem with that is the insurance companies have made it so convoluted and so difficult to find all the proper codes.

And I won’t get too into the weeds, but you have your ICD-10 codes, your EM codes, your RAF scores, your HCCs, etc. And it gets very difficult for the physician, hospital, provider to get paid what they’re owed. We created this to make it transparent. So, it goes right from the doctor’s note, we code that the English language, then we code it into the medical nomenclature of actually the entire globe, and then we code it into the coding system that has been created by the insurance companies in the United States to maybe not pay exactly what they should. So, we’re going for clear transparency because I believe that the healthcare provider should get paid what they’re worth, and they shouldn’t be convoluted or changed up by the insurance company just because they want to put all this coding into play.

Kelly: Right. No, I love that y’all made that transparent. I know there’s a lot of complexities in the coding world. So, a lot of AI coding tools make compliance teams nervous because they can hallucinate a code. How is a deterministic approach different, and why does same note in, same codes out matter for revenue integrity? And Angelo, I’m going to toss this one to you.

Angelo: No, it’s a great question. And a probabilistic AI coder can read the same note twice and give you two different code sets. And for revenue integrity, that’s the whole problem. You can’t defend a claim you can’t reproduce. So, our deterministic core is same note in, same codes out every time. And that’s the type of defensibility that we want to offer, right? Is that we have the history, we have the evidence-based, we are giving you the information because of what the note stated. It’s not a hallucination. It’s there in the documents. So, we’re really just carrying it forward, and you’re going to reproduce the same information because the same defensibility and the same information always surfaces. So, it’s just the AI can do its suggestions. It could offer and flag, basically recover anything that was missed and offer options. But in the end, the AI doesn’t have the final say. And I think that’s the difference between fast and defensible.

Kelly: Yeah. No, I love what you said about, “You can’t defend a code you can’t reproduce.” I actually wrote that down because I really thought that that was very interesting that you said that. I love that. So, Nathan, where are hospitals leaving the most defensible money on the table today? Is it risk adjustment capture, denials, or is it somewhere else?

Nathan: It’s in all those, to be perfectly honest with you. The denials is your holy grail, capturing the right amount of money for the service that you provided. The reason being is the insurance companies like to deny a lot. I know everybody out there in podcast land has never heard of an insurance company denying anything.

Kelly: Right.

Nathan: Exactly. So, with that being said, I’m going to sort of piggyback off of what Angelo said and to make this very digestible. Angelo loves when I say it’s an incredibly complex tool that we’ve created, but it’s an A plus B equals C or A plus B plus C equals money. Coding system A is the progress note, which is written in the English language. B is the medical terminology that we’ve also coded into a large LLM. C is all the codes from the insurance companies that we utilize their language against them so they can’t deny. So, we have A plus B plus C equals the correct dollar amount. It’s deterministic. It’s accurate. It’s to the point. So, where they’re leaving money on the table is a couple of different sectors. The first one is first pass rate, which means that the note goes through cleanly and insurance says, “Yep, it’s good to go. We’re going to pay you for it.” The second one is– the big one is denials, which when an insurance company says, “Nope, you don’t have enough data on that. We are denying this for XYZ reason,” it costs money to reprocess that note again.

So, we decrease the first– or increase the first pass rate so it’s a better coding system that goes through insurance and they pay. We decrease the denials because we’re using their language, their wording, and their codings directly against them, directly correlated to the progress note. And there’s also a whole lot of other scores like RAF scores, which is risk adjustment factor, and HCC scores that get very, very complicated, that would drive most coding people nuts and gets lost a lot in the shuffle. With the technology that we have now and with how we coded this, it can’t miss. It’s A plus B plus C, LLM. It’s like a giant calculator. I know, Angelo, it’s a lot more complicated than that. But basically, it’s a giant calculator that makes sure the provider, the healthcare provider, the doctor, the hospital, what have you, gets paid what they’re owed by the insurance company. First pass rate is up, productivity for getting the claim through is increased, and denials go down. Simply put, it’s a giant calculator to make sure the doctors get paid what they’re owed.

Kelly: Yeah, no. I love that A plus B plus C equals the money that you’re owed. So that’s awesome that you guys came up with that. So, Angelo, you catch issues before the claim goes out, missing modifiers, unsupported codes, linkage problems. What does that look like on a real claim?

Angelo: That’s pretty much the bread and butter, right? We catch the missing modifiers, the unsupported codes, linkage problems before the claim goes out, just like you said. And it really looks like a straightforward office visit, 34-year-old, appendicitis. The engine builds the full claim, the diagnosis, six procedures, the levels, the EM. It then scrubs before submission and catches two things the payer would have bounced, one procedure, maybe a lab, an 82565 that needed a modifier 59. And without it, the payer bundles it, and you don’t get paid for it. The EM might have needed modifier 25 to sit alongside the procedure without the denial. There’s denial risk scores at 10 %. Both items flagged with the payer denial reasoning spells it out. And we basically are doing that double-check work. We’re doing that assessment before it goes out. And we also do it before an RCM tech might even see it. So the real capture is that we’re able to surface these as options as well. So, in the deterministic engine that we have, it’s not saying this is the end-all be-all. It’s a really nice system that allows you to see all of the options and see what is missing and what could have been created to build and bundle the exact claim that you guys were looking for or want to execute.

Kelly: Wow, I mean, that sounds pretty impressive there. With CMS interoperability and prior authorization requirements landing in 2027, how should hospital finance leaders be thinking about readiness? And Nathan, I’m going to let you take this one.

Nathan: Okay, pretty much this is the transparency, and CMS is your Medicare, Medicaid. And that goes out to all the insurance companies throughout the United States. So, they want to make sure that this is extremely transparent. It’s fire-based exchange. The clean data is moving between the payers and the providers. So, there is an awful lot of data, and we’re not going to go read all the CMS data points that they’re making up. With that being said, all the hospitals and all the providers and everyone else have to have cleaner capture across the board in 2027. So, the crunch time Angelo specializes in and the team specializes in is that we can help integrate all this into whatever system that they’re running now, either with Epic or any other EHR system that is on the market right now. Simply put, it’s got to be more transparent, easier to decipher, and cleaner data that flows through all this, or CMS isn’t going to pay you, which is going to be a bigger headache.

Kelly: Yeah, I mean, I know transparency is key here, especially. So, PHI safety is a real concern with AI. How do you process a clinical note without patient data ever leaving the building? Angelo, can you help us with this one?

Angelo: Yes, I sure can. So, the concern is real. Most AI coding tools ship the raw note to the cloud, and we don’t, or maybe it’s not to the cloud. It might be a homegrown LLM or AI that they built internal. The deterministic engine runs locally with full access to the note. So, before anything touches an outside model, we do a structural transformation. Every clinical concept is preserved, but the patient identifiers are replaced with typed placeholders. We also have a way of the– basically a backwards communication. So, if something, if they have a question about the local progress note, there could be a communication to say, “Is this a name, or is this–?” maybe it’s the name of a medication, which is another big issue that happens within PHI redaction is that it misses or it hides the name of a medication or anything, a building. And so, what leaves the building is the PHI-free representation, the medicine, not the patient. So, 99.5 % of the clinical content is preserved, and the identifiers don’t travel. That is probably the most impressive piece that we built because it uses a very interesting method to get that data and to transform it, and it’s fail-closed. So, if the gate is ever unsure whether something is safe, if it blocks it, uncertainty defaults to do not send. That’s to a 100 % onshore, and the AI helps us reason, but the medicine never sees who the patient is.

Kelly: Very interesting. I know PHI safety is a real concern across the board. Nathan, if a finance leader listening wants to start small, what is the first step?

Nathan: The first step is just to go on our website and check us out. So, it’s verifymedcodes.com. And the great thing that I designed the website is Angelo comes from the tech side. I’m still in healthcare, but I’m on more of the finance side. So, they can go onto our website and look at the slider scale that we have that can tell how much money that they’re losing on the first pass rate in productivity, in denials, and so on and so forth. They contact with us. We are actually doing right now a 100 notes for free. So, they can send us our 100 worst notes, and we can actually– Well, we’ll process it for them. It doesn’t cost them a dime. And we’ll show how our system is better, faster, more efficient, and will make them more money. So, as a finance person, and I designed this because that’s where I sit in the healthcare sector. I want to know why it’s going to make me more money, why it’s going to make my facility more productive, how much money am I leaving on the table, and how much I’m saving, but want a freebie of a 100 notes or so. So that’s what we offer. We offer the easiest process across the board. So once again, go to verifymedcodes.com, look at our finance calculator, contact us, send us the notes, and we will prove what will work.

Kelly: That sounds like a great offer. Well, thank you so much, Nathan and Angelo, for sharing your insights with us on the money is in the note, not the claim. And if a listener wants to learn more, contact you to discuss this topic further, how best can they do that?

Nathan: Well, they can contact me at nturock, that’s N as in Nathan, last name Turock, T as in Tom, U-R-O-C-K, at verifymedcodes.com. Or, once again, go to the website, verifymedcodes.com, and all our contact information is there. And, Angelo, you can tell them where your contact info is.

Angelo: Yes, thank you, Nathan. Contact info is same. It’s on the website as well. You could also contact me at Angelo, A-N-G-E-L-O, dot Selitto, S-E-L-I-T-T-O, at verifymedcodes.com.

Kelly: Awesome. Thank you both for writing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes our episode of The Hospital Finance Podcast. For show notes and additional resources, visit us online at besler.holdings. The Hospital Finance Podcast is a production of Besler Holdings; Built on partnership, Driven by success.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at contact@besler.holdings.

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