Author: Kelly Wisness

In this episode, Sam Yeruva, Founder and CEO of Pycube, Inc., discuses the hidden cost of hospital inefficiency.

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Highlights of this episode include:

• What operational intelligence is
• How it changes the way hospitals function day-to-day
• How AI can be applied in hospitals
• Examples where operational improvements directly impacted patient care

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Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Sam Yeruva. Sam is the founder and CEO of Pycube, Inc., a company transforming the way hospitals operate behind the scenes. With a background in electrical and computer engineering and training from Harvard Business School, his decade working inside hospitals revealed a systemic problem. While clinical care is world-class, operations are often unpredictable. Motivated by a personal experience where critical biopsy samples were lost for 10 days, Sam launched Pycube to bring true operational intelligence to healthcare. Today, Pycube helps hospitals track assets and supplies in real time, saving caregivers hours and unlocking millions in recovered efficiency. In this episode, we’re discussing the hidden cost of hospital inefficiency. Welcome, and thank you for joining us, Sam.

Sam Yeruva: Well, thank you, Kelly. Thanks for having me.

Kelly: All right. Well, let’s go ahead and jump in. So, what is operational intelligence, and how does it change the way hospitals function day-to-day?

Sam: Well, operational efficiency is a day-to-day operations that hospitals have. They’re like a well-oiled machine that actually runs millions of people who come in and get into the hospital. I call hospitals as nothing but– some people call them mechanic shops, which they actually– if you look at a repair shop where you take your cars, they actually make them better and send them back. The same way we all get sick and we go there and get taken care of, and then they fix us and they send us back into the productivity mode. I was talking to some doctors and they call it expensive hotel rooms. They’re providing a specific service. It’s just they’re full all the time, but they’re very complicated, run by very smart people, and they save our lives. So, it’s a well-oiled machine. It has a lot of components to it. There are very complicated things that they do to save our things.

While doing that, they have to work with different disciplines to make sure that a particular patient is taken care of. While doing that, they have a lot of inefficiencies that pop up. It’s a process thing, right? People with good intentions come together who are well-trained in certain things. They do the job as well as they can. But you and I both know that recently the new technologies have come in. Now we are actually writing– when you go in patient registration, you have an iPad where you’re actually putting the information in. But when you go inside the hospital, there are a lot of places where there are still manual processes, they’re writing it on paper. There are good people, good nurses, and good people working in the health systems. They are doing the best they can to make sure they cater the patients. But what happens is things get lost. Things don’t appear. [laughter] It’s chaos inside that machine, and that is what we’re trying to fix to make sure it’s clean, it’s neat, the process flows are known so that the patient is taken care of properly in that area. So that affects us, you, me, and everyone who’s going into hospitals, and that’s what we are trying to fix.

Kelly: That’s a great goal. I most definitely agree with all that. So how can AI be applied in hospitals in a way that is practical, safe, and measurable, not just hype?

Sam: Well, [laughter] yeah, I’m very bullish about AI, and that’s a very good question that you asked. How do we do that? That’s a quick question. I was talking to one of the CFOs of a big health system and he would call me, and said, “Sam, is it true that I will have to change all my processes to make sure AI works in my environment?” I’m like, “No, no, no. AI should be used as a layer on top of what we’re doing. It should help us do things better. It should not change the way we are doing things drastically, but they should definitely help us do things better.” So, it’s a challenge to actually put AI in everywhere because it’s a common folklore right now that people think that, “Hey, this is not working. Maybe I’ll throw AI at it. Let’s see if it works.” No, it doesn’t work that way. I always go with a statement saying, “AI without PI is not going to work out.” Artificial intelligence is not working out– it will not work out without your practical intelligence. If you can’t fix it, if you don’t know how to fix it, then you can’t tell artificial intelligence to fix it for you, because it might give you something that you don’t like.

So, there are definitely different ways. So, I think, first, there are different ways of implementing AI. The first, you have to understand, what is happening in the environment? What is going to happen in a particular workflow? A patient who’s giving you the sample, the sample is taken to the lab, which might be in that hospital or the hospital next door, or a couple of miles away. It’s been diagnosed, and then the report is given back to the provider, or in this case, the doctor. The doctor reviews it and gives you right diagnosis. In this entire process, there are many parameters that can go wrong, and you could be misdiagnosed or mistreated. So how do you ensure these things? If this is tightly coupled and if it’s tightly maintained, the data, if you’re collecting it, then you’re able to apply AI to make it better. But if anything in this entire thing is not properly working, then applying AI might give you wrong information. Garbage in, garbage out. So, it’s very important for you to have a digitized workflow which is properly maintained so that you can apply AI in a proper way and you can have a measurable outcome significantly improving the entire workflow efficiency and helping patients and helping providers to take care of their patients.

Kelly: No, I love that. And I actually took down– when you said PI, the practical intelligence, I really loved when you said that. So, Sam, can you share a real example where operational improvements directly impacted patient care or reduced burnout?

Sam: Oh, yes. So, I’ll give you an example in one of the hospitals, that healthcare we were actually working on. So, I’ll give you anecdotal– I shouldn’t say anecdotal, but without naming names here. One of the health systems where we are working, we showed them our tools where– it’s a big health system. It’s a big hospital that we’re working at. About a 700-bed hospital when they’re coming in. What happens is they collected the sample from one of the patients in the OR room, operating room, when they collected some samples. Millions of samples, thousands of samples that are collected every day, and one of the hospitals was actually doing the same thing. So, whenever you collect a urine sample or a blood sample, they’re supposed to go– based on their diagnosis or what they’re supposed to do, they’re supposed to go to A-lab, any lab, cyto lab, or a molecular lab, etc. It’s a clinical sample. And whenever you have a cancerous or a tumorous sample that they actually have a procedure on you, by giving you anesthesia or collecting them, they actually have to go to certain labs.

We were just standing there and the nurse comes in– not a nurse, but a person who actually picks it up. He put them in the wrong spot. He picked up a sample which was supposed to go to A-lab, he put it in a B-lab, and the B-lab, he put it in A-lab and wrote it down and signed off and left. We were just watching there [inaudible] and I could figure that out. I’m like, “Oh, God, this might be in the wrong space.” It happened. And next day when we went back, and I was curious, and I asked the nurse, “Did you notice that?” And she was like, “Wow, would that happen? I didn’t know that.” She went back and started looking at it, and she caught it. And she tells me that these kind of things do happen. It goes to the wrong place. They don’t know where it is. Well-intentioned, but they’re all stressed out. They’re in a hurry. They write it down in the wrong space. That was one of the things that intrigued me because the intention of the person was not to go wrong, but when they’re writing it down, putting in the wrong bin, it just got routed to a different place.

I’ll give you an example. We were standing in an ER room as well, and there was a patient coming in, and the nurse was actually looking for the tools. There are different kinds of tools that are required to take care of a patient. They couldn’t find it. They were running around. They were actually calling people to see– “Go find me some tools. I don’t have it.” They’re called PAMs. They’re different kinds of tools that they use for this ER. They were not able to find it. So, we showed them how to actually go and look for using the right tools with our technology, and they found it in five minutes. And they were very thankful to us because normally it takes– in a chaotic environment, imagine it takes about three months. Imagine you’re losing keys in your house, if it’s a big house or in your office, and you’re not able to find it. That’s the kind of chaos they have.

So, we provide some technologies around it, which immediately they can go back and look for them. Having these tools, having this right technology to improve the workflow in the hands of the clinicians definitely saves the day and improves efficiency. It reduces the stress that the people have while they’re already in a stressful scenario. It actually de-stresses people a little bit, gives them back time, gives them time to think, gives them time to eat. You’ll be surprised, these clinicians and people, they don’t have their lunch sometimes. And when we were actually showing these technologies and solutions to make their life easier, yeah, the first thing they said is, “Wow, thank God. I had, at least, 15 minutes to have a lunch break here.” So that was very satisfying to me so that we could actually have some effect on the patient care in the U.S.

Kelly: Well, those are some great examples. Thank you for sharing those with us. You often say hospitals are clinically world-class, but operationally held together with duct tape. I love that. What inspired this insight? And how real is this problem? [laughter]

Sam: I’m an engineer by trade, Kelly. So, my life has always been complicated technology, right? My background was a data center architect. My job was to move things from New York to LA within milliseconds, and how do you design them and stuff? So, I come from that environment where nothing can go wrong. So, I go to a hospital and one of the niche players in New York– I was amazed to see this. I’m like, “Wow, this is like a 7-star hotel.” You go in, you have these LCD displays. You go to the cafeteria, and they have these AI machines that actually see what kind of change they are collecting, and is there any fraud? And they have so much technology in the patient room as well. But I go back to the administrative side of that hospital, and, wow, everything is hanky-panky. So, [laughter] I should put it that way. Because the main thing is they take care of the patients. They have these processes. They are figuring out how to do the best care that they can.

Ultimately, it’s a business, right? It’s a business in a good intent environment. It’s a nonprofit business environment that they’re trying to take care of their patients as best as they can. And what happens is they are not able– because it’s a nonprofit, a bulky environment, it’s a very huge ship that it has its red tape and it has regulations, they’re able to bring in technology on the consumer side or the patient side very fast, but adoption of technology in the administrative side is quite lagging. That was surprising to me because a person who goes into a 7-star hotel kind of a scenario, you would expect everything to be together. But when you go to the other side, it’s a different world altogether. And they do apply technology, but they are behind the curve on adopting new technologies compared to any other vertical in the market. So that made me think. It’s like, wow, this looks like everything is good, but imagine a latest and greatest LCD display, but on the backside, when you look at it, you have all these duct tapes put together. And that’s how they are making it run, and that made me feel like, “No, we have to actually fix these things from the backside as well.” And I do my part of it. Obviously, I can’t fix the entire part of it, but it’s a very complicated environment. But everyone has to do– who or can should solve these problems so that we have better running healthcare in our country?

Kelly: Wow. Well, thank you for sharing that with us. And thank you so much for sharing your insights with us on the hidden costs of hospital inefficiency. And, Sam, if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Sam: We have a lot of information on our website, https://www.pycube.com/. You can go there. We keep hosting, putting more information and latest information that we are gathering from our customers. You can also connect with me on LinkedIn. I’m more than happy to chat with anyone you have. If you are curious about, how are we doing this? Any curiosity about what we’re doing and what kind of technology we are using, and if it’s going to help you for any professionals, more than happy to connect with you and chat with you.

Kelly: Sounds great. Thanks for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

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.

In this episode, Konstantin Gorelik, HFMA Certified Healthcare Analytics and Operations Consultant, discusses how healthcare finance and revenue cycle leaders can use data stewardship and external benchmarking to proactively reduce compliance, reimbursement, and regulatory risk.

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Highlights of this episode include:

• What data stewardship means in the context of revenue cycle and compliance risk.
• How organizations think about the strategic value of internal and external data.
• What proactive monitoring looks like in practice.
• How strong data practices make a difference in a high-risk situation.
• How finance teams can use data to objectively evaluate issues.
• Practical steps toward building a more proactive, data-driven risk monitoring approach.

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Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Konstantin Gorelik. Konstantin is an HFMA certified healthcare analytics and operations consultant with over 10 years of experience advising hospitals and provider organizations on reimbursement strategy, compliance risk, and revenue cycle performance. He previously served as a managing consultant at BRG, where he led complex claims analysis, payor provider dispute engagements, regulatory assessments, and multi-hospital monitoring initiatives. Konstantin focuses on data stewardship as a strategic tool, helping healthcare leaders translate internal and public data into structured, proactive risk monitoring frameworks that protect revenue in an increasingly transparent and regulated healthcare market.

In this episode, we discuss how healthcare finance and revenue cycle leaders can use data stewardship and external benchmarking to proactively reduce compliance, reimbursement, and regulatory risk.

Welcome, and thank you for joining us, Konstantin.

Konstantin Gorelik: Thanks so much, Kelly. It’s great to be here.

Kelly: It’s great to have you. Well, let’s go ahead and jump in. So, when healthcare finance leaders hear data stewardship, it can sound abstract. So, what does it actually mean in the context of revenue cycle and compliance risk?

Konstantin: That’s an excellent question, and it’s not the first time or the last time that I get that when I start pitching on what exactly the importance of all of this is. Data stewardship is synonymous in my mind and hopefully in the industry as well with intentional management of how data is collected, validated, stored, and used across the organization. So, to that light, it would allow you to connect your finance, compliance, your operations team, and even your clinical documentation team. It’s not just your IT and their analytics team anymore. In our day and age where everything is becoming more interconnected and interoperable and able to be assessed by not only yourselves internally, if you’re a hospital organization, but externally by any type of group that’s taking a look at you, it’s important to have strong stewardship. It ensures that your reports are defensible and not just informative because honestly, many times you’re going to want to get to the beef of why things are happening at an organization. Numbers work, but numbers also need to tell a good story. And poor stewardship office services during audits, litigation, investigations, which you touched upon when you introduced me, and that’s when it’s the most expensive to fix. A lot of organizations will balk at the fact that they might want to invest a little bit more than they probably should upfront. But then once one of those investigations does come down the line, it’s better that they have done this proactively.

Kelly: Interesting. I really like what you said about intentional management of that. That was something I took down because it just kind of stuck with me. You talk about internal and external data. How should organizations think about the strategic value of each when it comes to mitigating financial and regulatory risk?

Konstantin: So when you hear internal and external data, regardless of what type of organizational vertical you’re in within the healthcare space, so if you’re an RCM, if you are a hospital, if you’re a provider, if you’re a biller or a payer, internal data typically will mean what you have in-house and what you have at your fingertips. So that comes in to you and your organization based on your standard course of business. So hospitals have a little bit of a different flow than maybe a payer would, but the bread and butter of this for hospital finance leaders would be like your revenue cycle data, your claims analytics, all of your metrics that have to do with your dollars and your cents and your bed counts and all the utilization that you have there. It allows you, when you’re internally investigating, to contrast your claims and billing data with past trends and essentially live in a closed container. External data is everything that’s out there in today’s world that wasn’t something that was mainstream maybe 10, 15 years ago, but is now. That includes implementing CMS’s public data sets, which include cost report data. We now have transparency in coverage, which is the payer side of price transparency, which this administration has really flaunted as a way to get transparency for patients. You have hospital transparency data, which is the other side of that type of data, which is the hospitals posting their charges and how much things cost.

And so you have these two juxtapositions of internal and external data, and risk emerges in the gap between your internal performance, which is that closed container of how am I doing this month? How am I doing this year? How many claims did I see this year versus last year? That internal performance, in comparison to external benchmarks is, like I just said, where the risk emerges because you might have a very good view of your own world and your own realm, but if you’re not conscious of everything around you and how you sit relative to peers in the market, you’ll end up in that risky pool, as I like to call it. And external data is particularly powerful for benchmarking, like I mentioned. So, figuring out where you sit as an organization, whether you’re a hospital, a provider, a smaller entity, a health center, whatever it is, versus peers in the market, whether that’s in your area or abroad, also helps you identify outliers. So, if you guys have some sort of– there’s so many outliers that I could probably name off. But for example, you’re identifying conditions that have higher complications than maybe others do in the market for the same one. Like your knee replacements for some reason are 10 times more likely to be complicated.

Those are types of things that maybe internally you, as your organization, can contextualize and understand, but when an auditor or the government is looking at that, they’re going to have questions and those are going to come down the line for you. And when they start asking questions, you got to know how to defend yourself there. And the last piece that external data is very powerful for is, like I said, so it supports or defends your reimbursement position. So context is everything in today’s world, and data is amazing, and there’s so much of it, and it’s beautiful to be able to access all of it, but contextualizing it and marrying it up so that there’s a story to tell will be incredibly beneficial in the years to come as other organizations, namely the government, become more tech-savvy and more proactive with their monitoring and strategy into finding fraud, waste, and abuse.

Kelly: That makes a lot of sense. Thank you for that explanation. Many organizations are still reactive, responding when an audit lawsuit or denial trend appears. What does proactive monitoring look like in practice?

Konstantin: That’s a good question. So, to understand proactive monitoring, you have to also understand reactive monitoring, and reactive in the context of these investigations and things that I’ve been a part of are responding after your denials, for example. So, you have a way that you’ve been billing as an organization for five years, the policies change, you don’t change anything, and then all of your money is hung up in a denial pool. And then now you have to figure out, well, what’s going on here? That’s one way where the reaction comes in. You also have a whistleblower claim that could come in. So that’s your qui tams, for anyone listening who’s in the compliance side of hospital finance, as well as payer disputes that come in. So those are ones that we’ve seen publicly. I live in Massachusetts. We had a public article posted about a dispute between Blue Cross Blue Shield and UMass Memorial Hospital. And those disputes are something that could have been solved privately out of the view of the public if proactive monitoring took place, which sets me up nicely to tell you what proactive monitoring really is.

So that involves routine monitoring of patterns that regulators and payers already analyze. So, I want to let that sink in for anyone listening here. Examples of that would be length-of-stay outliers, unusually high units or charges for certain services, services that frequently trigger outlier payments for anyone in the revenue cycle space. A lot of your contracts will be paid– or, sorry, excuse me, not a lot of your contracts, but generally, there are going to be contingencies in there where, if you have an outlier case, you get paid a certain different rate. We’re seeing in the market and over the past few years, at least in my work with other clients as well, that that triggering of an outlier payment is subject to review and analysis now by payers. So, you might be having your revenue held up because they’re doing that type of investigation these days.

And to get ahead of this type of work, so what does proactive monitoring really look like? There are various aspects that you can take on this. And frankly, I don’t think there’s enough time, even in a podcast, to cover everything that you could do to be proactive, because I believe in the essence of proactivity here. But you can use tools like the PEPPER, which is a report that’s submitted by– or released by CMS and something that hospitals comply with. They flag you for your outlier rating on certain metrics. It’s important to be aware of that type of monitoring. You have cost report trending. So those are publicly available reports that any hospital can download, and you can segment that market so that it fits you as an organization. So, if you are an RCM, a hospital, or a payer, you can take your clients, or yourself, if you’re a hospital, and you can figure out who has a similar bed count, a Medicare percentage, rates of certain type of codes and procedures. There’s all of this data that’s available, and not just the cost support data, but you also have these Medicare fee-for-service data files that are out there and are used extensively by all kinds of litigation firms and investigation firms as well.

So that’s one aspect of it. There are also these very cool new data sets being released that I’m a very big fan of and love playing with. Those are your transparency and coverage files and the hospital price transparency files. So those have ticked in and now are getting more standardized by the government. But now, for the patient side of things, you now have the opportunity to see all of the rates for all of the services that are agreed upon between a payer and a hospital. And so, understanding how you’re pricing and charging for things in disputes with payers and disputes with the government is going to be key because you have to start valuing your services and juxtaposing your value proposition with whether or not the quality is there or whether or not the outcomes are there for what you’re doing. And underneath all of this, so to reiterate, reactive, like I said earlier, is an expensive, expensive process to go in when something hits the fan, and you have to go back for it. It’s a much more expensive process to go in and try to plug all the holes in it when the ship is already sinking, versus going in proactively, which is usually cheaper and less disruptive than those post-event reviews.

Kelly: Wow, so there’s a lot to proactive monitoring, and it looks like it’s pretty important, though. Can you share an example of how strong data practices made a difference in a high-risk situation?

Konstantin: Sure. So, I mean, like I mentioned, there’s many examples of this that we could pull upon from work and maybe even in public news sources. But one that comes to mind is an investigation where I worked. It was a False Claims Act investigation that was triggered by the government. And this was important because it actually came based on the documentation requirements for a hospice. And this case study was important because of the billing and medical record validation that needed to happen. You end up having the government come in for a False Claim Act, essentially saying that you fraudulently have billed Medicare. And so, when that happens, they have their own formula. They have their own extrapolations. They take a small sample. Maybe they found a few things in there. You never know. I’ll never be able to know for certain how they get to it because I’m not ever a part of their investigations at the beginning.

But you end up having an extrapolation, they come to you with a damages model, and then that’s when kind of all the bees in the hive activate, and you have to start reactively looking at this. And so, when you have an allegation of overbilling for an organization like a hospice, for example, they’re not a data-driven entity outright. In today’s world, more organizations are becoming data-driven entities. But here, because it’s something that came to them out of the blue, they were not ready for this. And it required a claim-level validation of all of the visits that they had had with patients over numerous years that the government was looking for audit trails on. And you end up in this situation where this one organization just simply doesn’t have the infrastructure to support this type of investigation because they never thought that this could happen to them. Most people don’t think that something like that could happen to them until the government comes knocking.

And to look and actually look through everything that the government was seeking, we had to combine the billing and the claims data with scanned medical records that were hundreds and hundreds of pages long, admin reports that were generated during the standard course of business. You have to combine that with CMS hospice rate data to figure out about the rates and what they’re charging versus others. And you end up with this project that starts ballooning in effort, scope, and price, frankly, trying to centralize and validate legacy data that are critical because, for the False Claims Act, the only way you can defend against that type of situation as an entity is to actually prove that every single claim is not, in fact, a false claim. So, you have to evaluate each alleged false claim to come back at the government and kind of whittle down that number for them when you’re strategically trying to position yourself. And so, the key lesson that you have there for how strong data practice could have made a difference is that the integrity and the strength of the integrity in your data would determine the legal and financial exposure that you have down the line. So, for a smaller price, by centralizing everything, having everything ready to be analyzed, this wouldn’t have taken hours and hours of consultants, lawyers, deposition hours. All of that adds up a lot for an organization that’s pretty much being reimbursed on a day-to-day basis, right? So that’s just one example.

Kelly: That was a great example. Thanks for sharing it with us. Payer-provider disputes are becoming more common. How can finance teams use data to objectively evaluate issues like charge master increases or reimbursement disagreements?

Konstantin: Yeah, that’s another great angle. So just like I mentioned at the top, with my own home state dispute that was going on between the insurer and the hospital, essentially, the claims data will need to be reviewed internally and externally, and policies will need to be reviewed historically, and contracts will need to be reviewed outright. So those three aspects of it are time-intensive, but proactively doing that will help identify and avoid situations where you end up in a dispute because of contract terms, policies, or actual claim behavior, changes, and anomalies. So, to do that, it’s important for you as an organization to proactively identify your outlier services that are driving disproportionate financial impact, perhaps. You’ll also want to start benchmarking against similar hospitals using cost reports and claims data. So those are publicly available external data sets that you can set to realize and see how things are going. And so, for example, I can touch upon another example. So not exactly what happened in Massachusetts, but in another state that I saw a client and a provider. I was put right in the middle of them trying to figure out what would be an objectively good reimbursement rate. And the finance teams were not quite ready to evaluate the data. So, while the claims data that’s internal to that hospital and that payer were not utilized due to the presence of payer data, it was still used to validate.

So, in these cases, as an organization, like a healthcare organization, like a hospital, that data that you have internally is the gold standard of what you should be relying on. If your data is not as good as what the payer is using, you end up putting yourself at a disadvantage when those things come knocking. You also have the opportunity to investigate the claims data from the payer. So anytime that a claim is adjudicated, the payer will send back those files and those data sets that tell you about what was paid, what was adjusted, and it’s important to have the infrastructure internally to track that type of information, because you have to know why your dollars and why your cents are what they are versus your chargemaster. And the cost report data and the fee-for-service data that I was referencing and alluding to, as well as the transparency data that I talked about, are also key aspects nowadays because the data will bring objectivity where narratives often conflict. So, you’ll have a payer saying one thing, you as a hospital organization will say another, or vice versa, depending on who you are in this disagreement. And so, like I mentioned, again, the context and the quality of your data is going to be incredibly important.

Kelly: Sure, of course. That makes a ton of sense. You know Konstantin, if a CFO or a revenue cycle leader wants to get started, what are some first practical steps toward building a more proactive, data-driven risk monitoring approach?

Konstantin: So typically, when you’re trying to set up a more proactive way to manage all of your risk at an organization, there’s three main pillars that I like to focus on. So, the first is to define your goals. So, is it for compliance purposes? Are you trying to protect your reimbursements, or are you trying to make sure that your bottom line is above a certain level or threshold? Is it an operational insight that you’re trying to glean from this information in terms of blind spots? Once you define your goals, the next set of those pillars I’m going to go into is to set your scope. So, whether or not there are certain service lines that need to be evaluated, if facilities in particular need to be monitored or set up. So, hospitals and health systems are becoming incredibly complex, and they are acquiring and merging and becoming larger and larger entities. And that, by proxy, puts a lot more risk and onus on the organizations that are taking charge of some of these facilities. So being more strategic with which ones you’re monitoring is also incredibly effective because you don’t just want to throw a net over everything when really it could just be a few problem children, we’ll call them for this set. Or outside of facilities if there are risk areas.

So if you have a lot of surgeries or if you as a finance leader are reading the news in healthcare and you see that there are certain investigations that the government are targeting, it’s a good idea to go back and read that and then come back to your data team or your analytics team and be like, “Can I run some of this stuff? Can I figure out how many patients are suffering from major complications in my surgeries that the government considers to be routine.” That type of information. And then once you have your goal and scope, the stakeholders are also the next key piece because those are going to be your legs that make the machine kind of roll. While we are becoming more technologically advanced, I still like the Flintstones analogy where you have a group of people inside of a kind of a wagon and it matters what feet are in there pushing because that’s going to be the quality of your ride, right? So, whether finance, compliance, your RCM leaders internally, externally need to be involved, if the clinical team needs to be involved to help contextualize some of those abnormalities, right? If you have codes that are far and above and you’re in the top percentile in your state for a certain line of [Latin?] procedures or business, you’re going to want your clinical team to come in there and be like, well, this is why X, Y, and Z versus reacting to that later.

And once you have those kind of three pieces, so you have your goals defined, your scope set, and your stakeholders who are going to be helping you, you’ll want to start moving into centralizing and validating the core data sources that you’ll be relying on. So, as I mentioned at the top, you have your internal data sets, right? So that’s what you as your organization steward, manage, and have at your whim, essentially, since it’s your data, versus that external data that you might be purchasing. So, if that’s a CMS data set, something from a commercial vendor, right, like your Komodo Health, your Definitive Healthcares out there, your Kytheras, those types of– IQVIA is a good example of one too. Merging all of that in and combining it into one spot is incredibly important as you start your data-driven risk monitoring.

And the last few things that I want to say on this are pretty straightforward and hopefully no-brainers for a lot of folks who are dealing with this on a day-to-day basis, but it’s important to align your monitoring with CMS and regulatory focus areas. So, if CMS is releasing their information on what they found, what they’ve targeted in years past, that should be on your radar as a finance leader too. It’s not just on your compliance team to be ahead of the curve on all of this, because finance, data, compliance, all of that is emerging in today’s world, and they’re going to be even more intertwined as the years go on. And finally, building processes that are repeatable and refreshed regularly. So not one-off analyses that are siphoned off in Excel workbooks or in someone else’s local drive, but something that is refreshed regularly and repeatable, because you want to be able to have insight and stories to tell as often as you really need it, especially when the judge comes knocking.

Kelly: Most definitely. Well, thanks for providing those practical steps for us. And thank you, Konstantin, for sharing your insights with us on data stewardship as a risk strategy, protecting revenue in a transparent healthcare market. And if a listener wants to learn more, contact you to discuss this topic further, how best can they do that?

Konstantin: So, if anyone wants to reach out and talk about more of what we covered here today, you can reach me via email. So, it’s gorelikadvisory@gmail.com or via LinkedIn. I’m always ready for conversations and love to talk about this information. I think this is such an interesting age that we’re entering in and would be happy to connect with colleagues or anyone else.

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

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

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.

In this episode, Tom Furr, CEO and Founder of PatientPay, discusses how the Shift in ACA enrollment is driving more high deductible health plans.

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Highlights of this episode include:

• How the reduction in ACA enrollment numbers are affecting out-of-pocket payments
• How should providers prepare for this change in coverage
• Long-term projections

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Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Tom Furr. Tom is the CEO and founder of PatientPay, the leading patient payments partner for acute, ambulatory, and specialty care organizations. Prior to founding Patient Pay, Tom was the CSO and COO and board member at MobileSmith Health. He was also a co-founder and president of Kinetics Inc., an early online commerce provider for small businesses with partners such as Wells Fargo, First Union, and Netscape. In this episode, we’re discussing the shift in ACA enrollment and how it’s driving more high-deductible health plans. Welcome, and thank you for joining us, Tom.

Tom Furr: Hey, thanks for having me, Kelly.

Kelly: All right, well, let’s go ahead and jump in today. So how is the reduction in ACA enrollment numbers affecting out-of-pocket payments for providers?

Tom: Yeah, obviously, the Affordable Care Act was in the media a lot back in December. And so, it kind of got me thinking of, well, if these people leave the ACA, does that mean they’ll be uninsured, or do they move back to the employer insurance? And so, I started looking at the data out there and it’s quite interesting. It’s obviously, as of, I think, a week or so ago– and these are all numbers from Google Gemini. So, if they’ve changed, blame it on Google. But there was about 1.4 million people that had– or 1.2, 1.4 million that had left the ACA. And the ACA has kind of grouped within the private insurance market. And so, the private insurance market had been growing from ‘24 to ‘25. It was up about 1.4 million folks that were subscribing to insurance and are paying for insurance. And so, the question is, if they’re uninsured, there’s a different way to approach it if you’re a hospital or you’re an ambulatory group or what have you. If it’s insurance, what is that insurance going to look like? And so, what the numbers, the stats are looking at right now is, at least according to Google Gemini, so don’t blame me, the folks that are dropping off of the affordable moving over back to business insurance. Now, not all of them, obviously, but a vast majority of them. So, then the question is, okay, if all of these people are moving over to back to their employer-sponsored insurance plans, and are they all jumping into a fully high-end insurance plan? Is it a high-deductible plan? And because dealing with that versus uninsured, now you got to deal with claims and adjudication, and then you can only start billing at that point, or trying to do estimations on the front end of any services that are rendered.

And it was the numbers…I found them very interesting, at least on the high-deductible plans that are out there. And in 2024, there was give or take 27 to 29% of covered lives were using a high-deductible plan. That number grew to 33% in 2025. So, it was up, call it, 4 or 5%. And the estimation is now with more people moving over to their employer-sponsored insurance, that the companies now are having to find a way to help control costs in healthcare. And right now, it’s estimated it’s going to grow at least 20% in 2026. So, you could have upwards of 40% of people in employer-sponsored health plans now using high-deductible plans. And the other interesting stat was that 59% of employers out there are trying to find ways to control costs, unfortunately. And this is one of the ways to do it. So, it has been kind of an eye-opening experience because PatientPay obviously helps medical groups, hospitals, other folks in healthcare collect more dollars. And if you’re doing it on an uninsured patient, you want to catch them before they come in, you want to offer discounts, you want to incent them to do it. But if they’re moving to high-deductible plans, there’s a different strategy more on the back end, some on the front end with estimation. So, we’ve been digging into the numbers, and it’s been, to be honest, really quite eye-opening compared to the narrative that was kind of given back in December of last year on the potential that could happen with the shift in the Affordable Care Act. A lot of numbers, so I’m sorry to bore you with all the stats and everything.

Kelly: No, no, I mean, those are great numbers. I mean, it is very eye-opening. I have a high-deductible plan, so I can totally understand what you’re saying. But how should providers prepare for this change in coverage?

Tom: Well, that’s the next thing is, as we know, deductibles are becoming more and more a larger part of the dollars that are paid to providers out there. And the individuals now as a standalone, the largest payer into the system of healthcare, assuming you look at individual versus UnitedHealthcare versus Blue Cross and so forth and so on. So, there are lots of areas that need to be addressed in healthcare that, to be honest with you, haven’t been because they didn’t need to, but it’s continuing to become a material part of healthcare. And there’s a couple things that are necessary when it comes to the patient. And one, front and center is clinical care, and to have the best clinical care is priority number one. But priority number two is having a good experience with this portion of it. And for younger folks out there, you see that they are very interested in being able to pay things easily, understand bills, all the different components of what they live in outside of healthcare, right? They are able to go to Shopify to buy stuff. They’re able to do Instagram and buy stuff. I mean, it’s just a part of their day in life that allows them to, if they want to buy something, they can buy it. They can buy it easily. They don’t have to get checks out or get paper statements in the mail. And so, it’s important that medical groups and hospitals allow for patients, one, to understand going in with their eyes wide open on sort of what’s going to be expected of them. It’s kind of like when you take your car in to get fixed. You don’t know exactly what it’s going to be, but at least you have an idea of what it’s going to look like.

And then have an easy way for patients to pay these bills that can be through payment plans, electronically, all the different areas that help them to handle, quite frankly, some big bills. And it’s not that people don’t want to pay, not everyone, of course, but most people want to pay their healthcare bills. There are challenges when it comes to understanding those bills. There are challenges when it comes to paying those bills. There are all kinds of challenges. So, to make it as frictionless as possible for them to understand the bill and to make it as frictionless as possible for them to pay the bill in whatever manner they have. And as you know, Kelly, if you have a high-deductible plan, you most likely have an HSA account with it, hopefully, because it’s tax-free. And you also know that you have limited dollars that are put onto that by hopefully you and your company. So even though they want to pay $1,000 bill, they might only have $200 a month on that card that they can pay towards that. So, they might need a six-month payment plan to accommodate that. And so, to be able to help the patient, one, understand the bill. And one of the things that one of our groups uses, they allow us to integrate the EOB into the patient bill. So now you’re looking at your insurance EOB, you’re looking at your bill, you go, “Okay, these match up, check.” I understand I owe it. Number two, I have an HSA card. Do I even know how much is on this HSA card? So, to give them the ability to understand the total dollars on that card is important. And then three, to give them the ability to pay it based on the limited dollars that are put onto that card each month.

All of these things sound simple, but in healthcare today, it’s pretty challenging. And to be honest with you, I have the HSA card. I have a high-deductible plan. And inevitably, my wife will call me and say, “Can I use this card? Because I don’t want it to, quote-unquote, ‘bounce’?” It’s just you don’t have enough money on it. Right. So I have to log in, look it up. Then I call her back and I say, “Yeah, it’s only a $500 bill. We have it in there.” But if it’s a much larger bill than that, we might not. So, it’s a complex world out there in healthcare and to try and make it as easy to understand and easy to pay is kind of, we feel, mission critical.

Kelly: Completely agree. And I love what you said about making it as frictionless as possible. I can totally support that. So, what are the long-term projections for patients signing up for these high-deductible health plans?

Tom: Yeah, the assumption is that they could be at 50% of the total market within the next three years or so, at least from what I’m seeing. And the expectation is it’ll continue to grow from there. So, it’s a material part of the medical group’s dollars that they collect. And as you know, if you’re a primary care group, you’re now having to collect these dollars because the patient potentially hasn’t hit their deductible yet earlier in the year. And later in the year, you don’t have as much challenging in some instances. But it’s definitely an area that is growing and will continue to be challenging based on the complexities of healthcare. But there are ways to simplify it.

Kelly: Great. Well, having it simplified is always a good thing. Well, thank you, Tom, for sharing your insights with us on the shift in ACA enrollment and how it’s driving more high-deductible health plans. You know, if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Tom: Yeah, so our website is https://www.patientpay.com/, P-A-T-I-E-N-T, P-A-Y dot com. My email is tf@patientpay.com. And then our telephone numbers on our website if you’d like to call, but I’d be happy to talk more and learn more about this from others out there.

Kelly: Awesome. Well, thank you so much for joining us, and thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

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 update@besler.com.