Author: Kelly Wisness

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Revenue Recovery That Pays for Itself–Fixing Hidden Leaks

In this episode, Beverly Neal-Clinton, Marine & Co-Founder of Serve Heal Recover, discusses revenue recovery that pays for itself by fixing hidden leaks.

Highlights of this episode include:

• How remote care and RPM models create a new revenue stream without adding more burden to the physician or staff
• What specifically changes in the day-to-day workflow when Medicare Part B RPM and remote care programs are implemented
• Health and wellness, coaching, remote patient monitoring, and Brain Health Plus
• How 100% staff-free or low staff models actually work in a private practice environment
• How clinical gains translate into sustained Medicare Part B revenue and practice stability
• How to structure the financial side to start RPM and remote care under Medicare Part B without capital investment or overwhelming complexity

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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 Beverly Neal-Clinton. Beverly is a Marine and the co-founder of servehealrecover.com with her partner, Tim Meuret, an Air Force veteran. Together, they have created a healthcare revenue recovery firm that helps medical practices fix systemic billing issues, recover loss income, and protect compliance so they can focus on patient care instead of paperwork. She specializes in turning chronic revenue leaks, especially in rural and under-resourced communities, into sustainable cash flow and growth. Through her work with physicians, clinics, and pharmacies, Beverly is known for translating complex Medicare, Medicaid, and commercial payer rules into practical step-by-step strategies that front desk teams, billers, and clinicians can actually implement.

In this episode, we’re discussing revenue recovery that pays for itself: fixing hidden leaks. Welcome. And thank you for joining us, Beverly.

Beverly Neal-Clinton: Oh, Kelly, it’s a pleasure to be here. You’re a great interviewer because we’ve had tons of little conversations off the record. So, I’m excited to be here. Thank you for having me.

Kelly: Well, thanks for joining us. And let’s go ahead and jump in. So many independent primary care physicians feel squeezed by Medicare Part B reimbursement cuts. How does your remote care and RPM model create a new revenue stream without adding more burden to the physician or staff?

Beverly: We’re all doing more with less right now. And I always preface that, but then I come back to say, we are not shortchanging on content. I don’t ever want us to think we’re losing anything there. So right now, a lot of independent primary care docs are getting paid less to do more. They don’t have the bandwidth for one more thing that loads up their staff. And so, what we’ve done at Serve – Heal – Recovery is build a second revenue engine under Medicare Part B that rides along with their office visits. We bring remote care layer in by staff monitoring, engagement, documentation, and the physician actually gets to keep the billing and clinical control. So just think of a two doc clinic in a small town, which is, again, my scenario where I lived. They were terrified of any new programs because their desk was already drowning. And when we turned on the remote care for just 60 of their highest risk Medicare patients, the only real change for that practice was a short consent script in the visit and a few crisp alerts in the inbox. And then six months later, they had a new steady stream of Medicare revenue coming in every month. And the office manager actually said to me, “It feels like we’ve added a whole service line without adding a single employee.” And that’s the experience that we’re shooting for. We want people to know that we do all of the grunt work, all of the heavy lifting, because I’ve been in offices where literally the office manager was now answering the phones, and they’d come in on the weekend because their records person quit. So, this is a scenario we’re familiar with.

Kelly: No, and what a great compliment to receive. You and your staff. It’s very telling about your service and what you actually can provide for these clinics. So, your process is described as, quote, “turnkey and minimal workflow interruption.” For a small private practice, what specifically changes in the day-to-day workflow when they implement your Medicare Part B RPM and remote care programs?

Beverly: Great question. So, for a small practice, turnkey is either real or it’s a dirty word. So, I like to be very concrete when I say that. So, day to day, the changes are small and intentional. During visits, the doctor has a brief baked in conversation with eligible Medicare patients about what RPM is and the ongoing support. After the visit, the staff sees the structured notes and clean alerts from our team instead of just raw data, extra phone calls. And billing is actually supported with documentation that fits right into an existing process.

Here’s another example. So, we worked with a solo PCP whose Medicare Advantage was already doing the check-ins, the roomings, the refills, prior authorizations. When we started, she was worried that this would be a one more job, and then three weeks in, she realized the only new step was a checkbox in the visit template and occasionally attaching our remote care note to the encounter. The rest of her day looked the same, but the difference is that the physician started seeing Medicare payments tied to the services that were happening between visits.

So that’s another point that I’d like to bring up with people. When we’re looking at– when we’re having conversations, I tell people, you’re already doing the work, whether you listen to our advice or not, you’re still doing the work. We’re just aligning it now so that you actually get paid.

Kelly: Right. And that’s an important piece of that, right?

Beverly: That’s a big, important piece of it. Yes, ma’am.

Kelly: Yes, it is. So, you highlight core programs like health and wellness, coaching, remote patient monitoring, and Brain Health Plus. How do these fit into a primary care practice’s existing chronic care management under Medicare Part B?

Beverly: Aha, I love you. Okay, so most primary care practices already live in the chronic care land. They’re shepherding diabetics, CHF, COPD, and older adults with memory concerns. The challenge is always aligning the real-world work with how Medicare actually pays for it. So, our health and wellness coaching, the RPM, and our signature product, BrainHealth+, those are programs that sit right on top of what they’re already doing. That ties into what I said before. You’re already doing the work. Now we’re just compensating for it. So, the coaching turns the physician’s plan into an ongoing actionable support. RPM turns the readings into a real process. In other words, triage, interventions, and physician-level decisions.

Now, BrainHealth+ gives them a structured way to track and support cognitive risks in their senior population. So, take a practice that had lots of hypertensive and diabetic patients who kept yo-yoing, going back and forth. The PCP was giving great advice in the room, but nothing happened between the visits. So, we layered in the coaching plus the RPM. And now the patients started getting nudges without– well, they got nudges about meds, about their diet, and about their activities. And then the PCP began to receive structured summaries instead of surprises six months later.

And the doctor even said, “It feels like my chronic care finally matches what Medicare thinks I’m actually doing.” The codes didn’t change. The infrastructure did. So again, that alignment of getting paid for the work that you’re already doing.

Kelly: Yeah. I mean, those nudges sound really important. I know my own dad would benefit a lot from that. Yeah. So, Beverly, independent PCPs often don’t have extra staff for outreach or data monitoring. How does your 100% staff-free or low staff model actually work in a private practice environment?

Beverly: So, when independents hear remote monitoring, they usually picture someone on their team glued to a dashboard all day. But that’s a non-starting. It would be for me too because I’m like, I thought you said I was going to be doing less and now you got me doing more. So, our model is built so that the practice doesn’t have to add that job. We handle the outreach. We handle the enrollments. We handle the monitoring and the coaching as well as the documentation. The practice sees the important signals and the revenue, not the noise. So, a good story here is let’s say there’s a three-exam room clinic that was flat out told, they flat out said to us, we will not hire another body for this. And if we have to hire an FTE, we’re out. They were very honest, straight up, just the way I like them. So, we’ve launched with 40 high-risk patients. We did all the outbound calls, the tech support, and the daily data review happened on our side. The doctor’s staff only saw a weekly summary and an occasional urgent alert. After the first quarter, the office manager actually said, “I kept waiting for the moment where we’d have to add a person and it never came.” So, when I say to people, “This is how we work,” I want people to understand, it’s not like we’re going to come in and you’re going to hear [inaudible], and the angels are singing, there is some work for the doctor to do as well. But what we’ve done is we’ve minimized that and he will review the records at the end of the week. It’ll take him, I don’t know, 15 to 30 seconds per patient, which is, what a cakewalk.

Kelly: Yeah. That time savings is, that’s money in their pockets too, right? So that’s–

Beverly: About 884 hours. That’s what we found when we did our surveys…we found the average was about 884 hours.

Kelly: Wow, that’s impressive. So, you mentioned significant improvements in adherence and reductions in hospital use. From a practice owner’s perspective, how do these clinical gains translate into sustained Medicare Part B revenue and practice stability?

Beverly: Okay, so we talk a lot about better adherence and fewer hospitalizations, but practice owners need to know that land is in their– well, practice owners need to know how that actually lands in their bank account. So, when patients are monitored and coached consistently, we found that crises dropped and predictable touch points go up. So instead of seeing patients only when they crash in the ER, the practice sees them through the scheduled visit, plus ongoing remote activities. We do the reviews, we do the coachings, we do the adjustments, and those are all tied to reimbursable work. So over time, that creates a steadier, more diversified Medicare revenue stream. Here’s another real-world example. We worked with a practice that had a small group of– we call them frequent flyers when they always go to the emergency room because sometimes that’s how they engage. They don’t have any other family members. And that’s a true statement. So, they were going in and out of the hospital. Once we wrapped them in the remote care monitoring with the coaching, their blood pressures came down, their meds were more consistent, and their hospital trips slowed dramatically. And so, the physician told us seeing them in the office when he was seeing them in the office when he planned to, not when the hospital sends him a note. So financially, the practice went from unpredictable, low margin chaos around those patients to a rhythm of billable remote care, plus planned follow-up. So the clinic wins, the revenue stabilizes, and that’s all what showed up together.

Kelly: Wow. No, that’s impressive. And I mean, it sounds like a win-win for everybody there. And for a primary care practice that is nervous about risk and upfront costs, how do you structure the financial side so they can start RPM and remote care under Medicare Part B without capital investment or overwhelming complexity?

Beverly: Oh, that, especially for small rural clinics, every penny counts. And one of the things I tell people, I say, “When you’re in a small community, there are four pillars. There’s the church for the soul, there’s the pharmacist for the body, there’s the bank for your money, and then there’s a beautician or a barber shop for how you look.” [laughter] Those four things, those matter. So, for many primary care physicians, the scariest part, it isn’t the clinical idea. It’s the financial risk. They’ve seen tech projects eat their cash and then disappear. So, we’ve structured things so that they don’t have to make a big bet.

No major upfront capital for platforms or devices. No requirements to hire a new team and hope the numbers pencil out. Our economics align with actual remote care activity, and everything runs through the familiar Medicare Part B pathways with the documentation to back it up. So, we knew of a practice owner who told us, “We loved the concept, but we literally cannot afford to be wrong.” And that’s why we say to people, “Well, listen, set up a limited launch.” I tell people, “Give us your hardest patients. So set up a limited launch where their only commitment was letting us work with that segment of their Medicare panel and sharing the data we needed.”

Now, device and staffing risks started with us. So, three months later, after seeing claims paid and patients stabilized, he saw the proof. And so, what he said was, “We got proof before we ever had to take a big leap.” And that’s our design. We let them tiptoe in, see the real outcomes and real revenues, and then decide how far they want to lean in. Because I’m going to tell you something, there’s nothing worse than throwing good money after bad, nothing.

Kelly: Yeah. No, and that’s a beautiful thing that you’re letting them kind of tiptoe into that and just kind of take a kind of little glimpse inside before they fully commit.

Beverly: Yes. Try it before you buy it. And even when I say buy it, there’s nothing to buy because there is no upfront cost. Like I said, we do everything. Now, the one thing that I will say that– and if I have time to plug this really quickly, BrainHealth+ is an amazing tool. The data has shown that patients who engage with this particular technology, it slows down the– if they have Alzheimer’s, or if they have dementia, or if they have balance problems, what we found is that using this app, it retards and slows down the rate of Alzheimer’s or dementia.

And we found that the relationships that people tend to develop with the therapist, they will tell the therapist things they may not tell the doctor. So that way, the doctor’s always informed because they’re letting them know in their notes, “Hey, here’s something that you may want to know about.” So, when the patient comes in, it’s like everybody’s on the same page. And the BrainHealth+, because it’s an app, we have something called Selfie to Healthy. It takes a picture of your face, reading the subcutaneous layers, and with 95% accuracy, it’ll give you your CO2, your blood pressure rate, and your heart rate. And so,S for seniors who are anxious, that’s a great tool for them because it just helps them alleviate that angst that they may have.

Kelly: Oh, definitely. Well, thank you so much, Beverly, for sharing your insights with us on revenue recovery that pays for itself, fixing hidden leaks. If a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Beverly: Oh, please, go to servehealrecover.com, or you can find us on LinkedIn. If you’d like to give us a call, we can be reached at 505-369-9613, or my personal number; it is 505-412-0995.

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.

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Locking Down Corporate AI Usage Webinar

In this episode, Jason Nadal, Besler Holdings’ and Sypher Security’s Information Security Officer, will provide us with a glimpse into the next Hospital Finance Academy Webinar, “Locking Down Corporate AI Usage,” live on Wednesday, October 7th, at 1 PM ET.

Highlights of this episode include:

• How companies deal with artificial intelligence and how they should make the decision to embrace this technology
• What the benefits and detriments of AI usage are
• What tools out there to help protect your company and your data
• What other challenges you have in keeping aware of AI usage
• How you manage third parties not directly under your control
• The key takeaways

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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 back Jason Nadal, Besler Holdings’ and Sypher Security’s Information Security Officer. In this episode, Jason will provide us with a glimpse into our next Hospital Finance Academy Webinar, “Locking Down Corporate AI Usage,” live on Wednesday, October 7th, at 1 PM Eastern Time.

Welcome back, and thank you for joining us, Jason.

Jason Nadal: Hi. Thanks for having me.

Kelly: All right. Well, let’s go ahead and jump in. So, we know artificial intelligence is everywhere now. How should companies deal with this and make the decision to embrace this technology?

Jason: Well, if you run a company right now, somebody on your team is likely already using AI. So ideally, that would be via an approved path that you have already set up, but maybe it’s just a browser tab they opened up at lunch, putting something in Google and getting AI results. Either way, the question is not, “Should we use AI?” It’s already embedded in a lot of the approved corporate tools that are already out there. So, the question is, “Do we know what we allow, what we forbid, and how do we keep that promise when the tools keep changing under our feet?” So those are the kinds of conversations that security and IT folks have when leadership asks for a practical plan around AI. So, over the next 10 minutes or so, I’ll walk through some of the benefits and risks. We’ll get into that a bit deeper during the webinar that’s upcoming, but this will give you a methodology of control you can actually run, some of the categories of tooling that support it, and the challenge of feature creep in tools that you’ve already approved. And we’re also going to look at how a vendor and open-source software assessment has to catch up.

Kelly: Yeah. I mean, it is really everywhere. It’s embedded in everything now, it seems like. [laughter] Yeah. It’s a lot to keep up with. So, what are the benefits and detriments of AI usage?

Jason: Sure. There’s a lot of benefits, and there’s definitely a lot of detriments as well. So, AI earns its value when it shortens the work that you’re already doing, especially that work that used to waste a lot of your time through just tedium, repeated tasks, and things like that. So, I find it really shines at drafting, summarizing, searching or researching, coding assists, and also triaging helpdesk tickets. So those are real-time gains when the data and the use case match the risk. So, in healthcare and adjacent work, that might be a little less clear. So, a nurse or revenue cycle analyst can summarize a long chart note, draft a patient letter, or speed up some prior auth paperwork. A cost report or appeals team can find patterns faster. So done carefully, ideally with this human oversight as to what’s produced, that is time returned to care and to accurate billing. But the downside is just as concrete. So, paste the wrong note into a public chatbot, and you may have moved protected health information, PHI, or something else confidential or sensitive, outside your control. So, a helpful summarizer can invent a fact, called hallucinations, that then gets treated like clinical or financial truth. There’s really a huge downside to that if it’s not checked over by humans with clinical experience. An automation that writes into scheduling, ticketing, or an EHR-adjacent system can turn a bad model answer into a real patient or operations problem. Outside of healthcare, the pattern is much the same. So, marketing could paste customer lists into a public model. Finance could paste financial forecasts. Engineering could paste source code or API keys, maybe in a hurry or just this one time, and leak information that you don’t really intend to leak. Legal can paste contract language. You get the benefit of speed, but the detriment of leaking your data, over trusting the AI, and a trail that, once it’s out there, you can’t really tidy it up after the fact. So, a key point to establishing governance is having frank discussions of what data is acceptable to this risk if it were to leak. I really can’t say that one enough.

Kelly: Yeah, I mean, I know that in marketing we use it quite a bit, but I mean, you all help us really understand what we’re really in for there. So, I know there’s a lot to keep in mind. So how do you lock this down without pretending people will stop being curious?

Jason: So yeah, you do need this methodology. The first thing I’d say, write an AI usage statement. This is your company’s position on how AI is used. Let it have plain language that’s easily readable. And this company position will include what interactions are allowed and what are not. Who’s able to use what classes of AI? What data classes may never leave the building? It may not just be PHI or employee data. It could be financials, as we said before, or just confidential mergers and acquisition information. So, what AI interactions require a human in the loop? What happens when someone isn’t sure? They should always be trained to ask before they just paste data in somewhere. Publish this conspicuously, train on it, and make sure that people know what’s appropriate to do with their AI. Refresh it when the landscape moves. So, if you don’t have a written position, every employee is going to have their own assumptions on what is good or bad. That’s not really empowerment. That’s just risk that’s out there unmanaged. I’d also recommend don’t write this usage statement from scratch. See what others in the industry, especially your industry, are doing, and tailor what’s out there to yourself. Secondly, you should assess the AI that is in question, the AI that you want to use in any given situation. When a third party uses AI in a product that you buy, treat that as part of vendor due diligence. Ask the vendor, “Where are these models running?” Ask whether the prompts or the outputs of those prompts are retained with them or are they used for training. Ask about sub-processors. Maybe that vendor is using somebody else to do their AI work. Ask also whether AI features can write back into your system. Don’t just accept a blanket, “We’re AI-powered,” as a checkbox. You need enough clarity to decide, yes, this is an acceptable risk. No, this isn’t going to work for us. Or yes, but we need these conditions in place to feel good about the risk of using this tool. And keep logs. Review those regularly. What is not AI today might become AI tomorrow. I’m sure all of us have seen an application that we’ve used online that just, after approved, suddenly has new AI functionality. So, train your users to notice new AI functionality added to the products that they already use. Third, you want to control access to your systems. And there are different types of access that you need to be aware of all three of these and looking into where AI touches all of these. First off, private access. This is ideal if you’re using sensitive data. Your employees would then be using AI that is hosted locally within company boundaries. Private model and private instance, your network. You can still govern who can use it, what data they may feed it, and how you log that use. Just because it’s private doesn’t mean it’s unsupervised, but at least you can keep the inner boundaries of where that data can go. Next up would be public access, people reaching third-party AI sites out in the open internet. So, you decide who can get there under what policy and how that policy stays current when new sites appear every week.

So, blocking everything forever, that’s rarely an answer. But blind open access is worse. Pick that controlled path and make sure you maintain who has proper access to it. And internal access is different from private. So, this is AI that’s baked into platforms you’ve already approved. Productivity suites, especially CRMs, ticketing, EHR add-ons, collaboration tools, all of these are things that we’ve seen ripe targets to add AI functionality to. Again, the purpose is to make them easier to use, but you need to make sure you maintain the risk of that if it wasn’t there when you initially assessed that vendor. So, it could be somebody just flipped a feature flag or a vendor released a sidebar assistant. It’s not really a new public chatbot to evaluate from scratch, but there could be changes to what models are being used and the risks associated with that. So, you should treat it as a change to an approved system. You should have that same change management, the same risk review that you do for a new vendor, the same data classification questions. So, if you’re only policing public websites, you’re going to miss that AI that arrived inside your door because you’ve already let it in.

Fourth, control AI access to your data. The data classification is very important. Label what your data type is. Is this file public? Is this one confidential? Is this one regulated because it’s PHI? Ask the impact question out loud. If this data type was released, what would be the impact to our company and to its reputation? So that framing is a lot clearer to executives than just jargon. It puts them in a place where they’re actively thinking about, “Our internal secrets, if they got out to the public, how would this affect our reputation? How would this affect us financially?” If the impact is high, that data probably doesn’t belong in a public prompt, and it may not belong in a loosely governed private one either. And fifth, the last one, input sanitization. Now, this is an interesting topic out there because of how bad actors can try and subvert the normal use case. So, at a high level, this means that people and attackers are going to try to override instructions. They’re going to try and steer AI agents off policy or try to trick them into doing things that the designer never intended. So you don’t need to exploit the recipes yourself to take this seriously, but you need defenses that assume prompts and retrieved content can be hostile.

Agents should have the least privilege, and that high-impact actions or actions to highly risky data always need human confirmation. So, think about that misuse at scale. So compromised agents or automations can be turned into attack infrastructure: scraping your data; it’s spam. They could create helpers for stuffing passwords in to try and guess. Any of the sort of modern botnet abuse that you see out there with malware can also be used with AI. So, if an AI agent can browse, if it can send email, or if it can call APIs with broad credentials, we’ll treat that like any other privileged information. You want to limit the scope of what it can touch. You want to monitor what it can do, and you want to make sure you have the ability to revoke those permissions really fast when something looks wrong. Because AI attacks work a lot faster than standard kind of malware attacks where you have a bad actor that’s on the phone trying to do impersonation of people, for example.

Kelly: That’s all great advice, Jason. So, with all that being said, what tools are out there to help protect your company and your data?

Jason: Sure. Well, what’s good is that there’s a lot of options out there. I want to emphasize that those tools don’t replace your methodology. They help support it. So, you got to stick to what fits your stack of infrastructure without turning this into just a shopping list. But here’s some examples. So, AI filters and firewalls are great because they can inspect your prompts, looking for kind of manipulated input. They can look for policy violations, sensitive patterns, and unsafe instruction attempts before the data leaves. DLP, or data loss protection, for prompts and uploads. That is aimed more at people, what paste, and what files they attach to AI tools.

You can look at secure gateway controls for some of the public sites. That’s how you allow or block access to third-party destinations, like a whitelist. And you can keep that list maintained. You want to log and monitor your AI use to know who used what, when, and with what data sensitivity signals, and whether that matched policy. And you can also look at identity and single sign-on gating for the private models. So even though it’s private AI, you’re still going to need to have authentication, authorization, and preferably single sign-on. So, access follows that same identity and policies that you have for that as your other internal tools. Now, again, none of these replace judgment. But they make the policy enforceable, and especially they make the exceptions more visible by bringing them to your attention.

Kelly: No, thank you for sharing those tools with us. Those are great. So, what other challenges do you have in keeping aware of AI usage?

Jason: [laughter] Well, here’s the challenge that keeps security teams awake, existing approved tooling. So, we said that before with the vendors. And we’ll get into that more with the webinar as well. But it’s a real risk when you have something already approved and they just added AI, either publicly or even silently. Last year’s CRM didn’t have a generative AI sidebar. And this year’s update does. EHR add-on ships smart summarize. A collaboration suite turns on meeting transcription and AI notes by default. So, these are all common situations we’ve seen. Feature creep means that your old approval letter is incomplete. So, you have to build a habit of, whenever an approved vendor ships AI, reopen that assessment. Don’t wait for an incident to discover the new button. And train your people to look out for things that appear.

Kelly: Yeah, it sounds like training your people is probably the most important thing there to look for those things. So, you mentioned third parties. So how do you manage third parties not directly under your control?

Jason: That is also a very tough one. So, the key couple of ones that come to mind would be with product engineering and with procurement. So here you have, on one side with product engineering, you have code tools. A lot of times, open-source packages are included there. And procurement, again, here’s the vendors that have AI functionality kind of baked in and not at the forefront, where they’re just adding it in later. So for managing the third-party risk, look at every SaaS contract and every integration to determine whether AI is somewhere in that path, where that data is going, and who the sub-processors are. Look into what happens if the vendor’s model provider changes terms overnight. Put some AI questions into your vendor questionnaires and your security review checklists, and actually make decisions based off of those.

On the other side of things, when you’re looking at managing your embedded open-source software libraries, a lot of modern products pull in the AI-related dependencies that you might not know just from the package that you’re pulling in. So, some model SDKs, vector libraries, agent frameworks, those dependencies inherit the supply chain risk like any other library, plus some new ones. You could have unexpected outbound calls, default logging or licenses that don’t match your appetite for risk. You want to have inventory on those. You want to dig deeper and have some tooling that looks into those dependencies and also analyze risk of those. Pin versions so that you know that the version that your libraries are using is the one that doesn’t introduce more than you had already identified. Look out for vulnerability advisories. Don’t let an AI SDK become that side door into production data.

Kelly: Yeah, I mean, it sounds like managing the third parties is a whole job all in itself. So, Jason, what are the key takeaways here?

Jason: Well, I’ve got several here. If you remember nothing else from the discussion, these would be the ones to look at first, right? You want to write that AI usage statement. What’s allowed? What’s forbidden? Make sure you ask first. You want to assess AI wherever it shows up: new vendors, old vendors, look for new feature flags. You want to separate your public, private, and internal access and govern those. Change management. You want to classify your data with an impact question. What’s the reputation and company harm if these data types were leaked? You want to sanitize your inputs and constrain any agents. You want to assume bad actors will get access to it and don’t give free rein. Make sure that scope is limited for attacks. Use tooling categories to help enforce and observe. There are your filters, DLP, logging, identity, gateway controls, all the extra tooling. You want to revisit approved tools when AI appears. Again, that’s with vendors or with software libraries, so look at that for that feature creep in your vendor tools. And you want to extend your vendor and open-source review to AI dependencies. Third-party vendors and libraries would both count there. So, AI is going to keep showing up in places you already trust. This lockdown isn’t about scaring people off the tools, but it’s about knowing the rules and enforcing them where you can. And stay curious enough to notice when the product on your feet grew some extra tentacles overnight. So that’s the biggest takeaway you should go back to your leadership with. Have these conversations about what you have, how you’re using it, and manage those risks for AI. It’s critical before an incident happens. And you want to work with your security team on their security incident playbook to make sure you have reactions to some of these bad actor situations or rogue agent situations.

Kelly: That’s all great advice. Thanks for sharing those key takeaways with us. And thank you so much for joining us, Jason, for giving us this glimpse into the Hospital Finance Academy’s free Webinar, Locking Down Corporate AI Usage. Join us live on Wednesday, October 7th, at 1 PM Eastern Time. And as a bonus, you can also earn CPE. Thanks again, Jason.

Jason: Thank you.

Kelly: 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.

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Healthcare Has a Revenue Problem, But It’s Really a Decision Problem

In this episode, Angelica Landers, Healthcare Executive & Growth Strategist, discusses how healthcare has a revenue problem, but it’s really a decision problem.

Highlights of this episode include:

• Before a hospital or healthcare organization launches a new service line, what financial questions should leadership answer first
• How to determine whether the service is actually worth offering
• Will the service actually make money?
• How to determine whether your payer mix can support a service line or business model before you invest significant capital into it
• How healthcare organizations can build stronger relationships with their payers to improve reimbursement and resolve issues
• What a true service line profitability analysis looks like
• What the financial and operational questions you want answered before you ever get to the purchase price
• When a healthcare organization is trying to grow, how do to decide whether to build internally, acquire another organization, or partner with someone else

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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 Angelica Landers. Angie is a healthcare executive and growth strategist with more than 18 years of experience working at the intersection of healthcare operations, sales, M&A, revenue cycle, technology, and startup growth. Her experience spans provider organizations, MSOs, DSOs, digital health, telehealth, healthcare technology, and high-growth startups. She has directed 58 concurrent M&A integrations, managed revenue cycle operations generating up to $45 million in monthly collections, sold more than $500 million in managed services agreements, and built scalable operating models for healthcare organizations navigating growth and transformation.

Angie brings a unique perspective that connects the financial decision to the operational reality behind it. Her work includes acquisition strategy and integration, revenue cycle transformation, payer and reimbursement strategy, healthcare commercialization, P&L and financial analysis, operational scalability, strategic partnerships, and startup growth. Through Alleviate Strategy & Solutions, Angie advises healthcare executives, investors, founders, and growth-stage organizations on the systems behind performance, helping them make better decisions about growth, acquisitions, technology, operations, and revenue.

In this episode, we’re discussing: Healthcare has a revenue problem, but it’s really a decision problem. Welcome, and thank you for joining us, Angie.

Angelica Landers: Thank you for having me, Kelly. I’m so excited to be here today.

Kelly: Yeah, we’re excited to have you. Well, let’s go ahead and jump in. So, healthcare finance isn’t just about collecting the money. It’s about making better decisions before the service ever happens. Before a hospital or healthcare organization launches a new service line, what financial questions should leadership answer first, and how do you determine whether the service is actually worth offering?

Angelica: When everyone first proposes this question, everyone automatically assumes demand or growth equals revenue. And when everyone assumes this, before everyone can get their answers out, the CFO walks in and asks the most difficult question, but I would say the most correct question. Will this service actually make money, given our payer mix, our cost structure, and our referral patterns? Or, in just the shorthand question, is this a profitable demand? Will we make money, or our ROI off of implementing this new service? So, a service line can have strong community need, excellent clinical outcomes. Your neighbor practices might be doing this, and you might have heard of their uplift in revenue. You might have heard of their growing patient population. But are those transferable to your practice is the question. Before launching any new service, leadership must determine whether the opportunity creates that sustainable economic value within their practice. So, the goal is not simply to generate revenue. The goal is to generate revenue that exceeds the cost of care. By the time a claim reaches your billing department, leadership has to make these decisions beforehand that determine whether that claim is profitable or payable. So many healthcare organizations, to start with demand is great, but we should also look at margin.

Kelly: Right. No, I mean, I love what you said. I wrote it down. Will the service actually make money? It’s a great question.

Angelica: Yeah.

Kelly: So how do you determine whether your payer mix can support a service line or business model before you invest significant capital into it?

Angelica: Yeah, so I would start with the obvious question, is there really a revenue opportunity? There’s a series of analyses and just questions that leadership should go through, grouped together with their committee, their investors, and really go through each variable of economic value. So, starting with, obviously, what service to offer? Everyone is being innovative in the healthcare industry. Within tech, the startup rise of telehealth, value-based care, I mean, all of this brings different payment models, different strategies, different positions you can bring to your practice. But the key question here is, does this service create strategic and financial value, again, to your unique situation? Not every clinical service creates that economic value.

Some services just generate direct profit. They create downstream referrals, straighten payer relationships, even support other strategic growths. So, looking at just the variable of, ‘How much does this service make by revenue position?’ isn’t the entire story. Leadership should evaluate community need, of course, competitors’ offerings, strategic alignment. But a service with moderate demand and strong reimbursement may outperform a high-demand service with weak reimbursement. I would say look at both the economical value and also the community need and demand that comes with it.

Kelly: That makes a lot of sense. And I think the bottom line that I kept– and the word I kept hearing over and over again was value. So that’s definitely key. So beyond negotiating the contract, how can healthcare organizations build stronger relationships with their payers to improve reimbursement and resolve issues?

Angelica: So, payer collaboration does not end after a payer contract is executed. It’s just the beginning. Your payer contract director should not be the only one talking to your payers. This is a collaboration between RCM, your payer contracting department, and really with a dotted line to finance through RCM. Within each contract, you are assigned a provider relations advocate, which is the bridge between your practice and the insurance company. Many organizations only contact payers when there’s claims denying or, obviously, when contract negotiations are up for renewal. But high-performing organizations treat payers as strategic partners.

You can contact your provider relations advocate when there’s prior authorization problems, when there’s an increase to your denial trends, when you’re having coverage or network access issues. But they can also help you leverage strategies that you’ve never heard of, like good-faith appeals, payout negotiations. They can also help you while you’re transitioning through billing companies, or also help you with provider education when you’re dealing with referrals and orders coming from or referring providers. When problems occur, there’s always a relationship in place. And that’s why it’s smarter to do this early on in the contracting phase. The best reimbursement strategy is often operational excellence, not aggressive contract negotiation.

Kelly: Yeah, and I mean, those relationships are key there. It makes a lot of sense. So, healthcare leaders often know their revenue. But do they really know what it costs to deliver that revenue? What does a true service line profitability analysis look like?

Angelica: So, this is referred to as a cost analysis. The main question we ask when performing this analysis is, how much does each service actually cost to deliver? Only after understanding this margin should expansion decisions be made within leadership. One of the most dangerous questions in healthcare is: what’s our revenue, or where is it coming from, or what is that profit margin? Without asking what is our cost per unit of care, we’re not really understanding that profit margin just yet. Many organizations obviously know their charges, their collections, their net revenue, but they’re not doing the deeper analysis of cost. So, cost per patient, cost per visit, cost per procedure. A true service level profitability analysis includes revenue, direct cost, indirect cost, and even deeper dives into those fees of those indirect costs that ultimately get calculated into the cost of care. Cost analysis also includes what volume is required to break even. So how many patients, study visits, or procedures are required before we start losing money? Also, we would like to include in that analysis what is required to generate that profit margin. So, it’s not so much if we schedule it, but do we have the staff, the tools to render that service? And all of that is included in that indirect cost that we perform during that cost analysis.

Kelly: Yeah, that sounds like a pretty important process. I know that the profit margin is really important. So, Angie, when you’re evaluating a healthcare acquisition, what are the financial and operational questions you want answered before you ever get to the purchase price?

Angelica: Oh, Lord, this is probably one of my favorite topics: merger and acquisition. So, a common mistake, organizations buy revenue. So usually during the due diligence process, normally we take out, obviously, the Aged Trial Balance report or your AR report, and everyone starts looking at those numbers. What does the revenue look like? But I would argue it’s not just about the revenue; it’s also about the capabilities. So, when you’re thinking about buying or even partnering for an added revenue growth to your practice, or obviously service lining, revenue can appear different after acquisitions. So again, after mergers, relationships, staff can leave, referral patterns can shift, key physicians can retire. There’s so many variables that we take into consideration during that due diligence period. The real value of an acquisition pretty much lies in its capabilities, people, market, position, and operational strengths. So, during that sale, you must ask yourself, why are they selling? Understand the motive behind the sale. Help determine whether buying them in the future or buying them in their current state is optimal. We should also ask ourselves, how dependent are their key physicians and key stakeholders to this acquisition?

Again, if all services are being rendered by one physician or two, how strong is that operation’s post-integration if that physician decides to leave or has a different sentiment about the acquisition itself? So, we like to review people, culture, which is a big part of merger and acquisition. But then, obviously, we get into the financial part, which is the revenue. Financial questions we might ask is, obviously, the EBITDA qualities. So, is this repeatable, right, next year? Or was it an added revenue added specially for this year, right? A one-time gain, a temporary cost reduction, or just variables that are temporary. We want to get as close as to the repeatable EBITDA for year after year, which is one of the financial hurdles that that we watch for. Service line margins. So again, those cost analyses are so important here, determining the strength of the AR. So again, what are those challenges that they’re experiencing? Is the corrections to these denials an easy task? Are you fighting an uphill battle within regulation with these denials? Or is it simple corrections that could be made with just a human touch, right? Refiling of a claim. So, reviewing these in a much broader light, and I would say in a deeper, not just the balance sheet, right? Interview the people that are in charge of your daily cash flow to better understand how much of the receivable balance is actually collectible. And you would find that most of those conversations will be a lot more insightful than sitting in a room with the CFO that’s negotiating the deal.

Kelly: Yeah, it sounds like there’s a lot of really valid, important questions in there that you need to ask. And when a healthcare organization is trying to grow, how do you decide whether to build internally, acquire another organization, or partner with someone else?

Angelica: I would say it has a lot to do with the answers to the analysis that we talked about today. I think if you really determine that there is demand, that there is a lower cost to service than the reimbursement that you’re bringing in all of those variables in there, to me, make the decision of building, buying, or partnering such a louder than ever. Partnering, I think, would be best for a practice that is trying to test the waters. Some of the analyses are not definite and don’t bring you the best warm and fuzzy feelings about moving forward of investing the capital.

Partnering, I think now more than ever, the market is open to joint ventures to, again, jointly pursue deals that their vendor partners may have the capabilities that they’re lacking so that they can close the deal jointly as a joint venture. Again, I think the bottom line here, it’s determined on rather the capital is there, the investment is apparent after your cost analysis, your market analysis, and your geographical analysis. And then that will then better position you to rather invest the capital or maybe test the water with a vendor partner.

Kelly: Thank you, Angie, so much for sharing your insights with us on healthcare has a revenue problem, but it’s really a decision problem. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Angelica: Yes, you can email me at Angelica, A-N-G-E-L-I-C-A, at alleviate, A-L-L-E-V-I-A-T-E-S-A-S dot com.

Kelly: Awesome. 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.

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The Growing Denials Crisis and What Healthcare Leaders Can Do

In this episode, Noah Breslow, CEO of Revecore, discusses the growing denials crisis and what healthcare leaders can do.

Highlights of this episode include:

• Why denials are becoming such a significant challenge for health systems
• What the financial implications are on health systems
• Why so many organizations struggle to prevent denials before they happen
• What the biggest reasons denials continue to slip through the cracks
• How health systems can shift from reacting to denials to preventing them
• How AI and automation can help identify and address denial risks earlier
• What roles dedicated denial prevention processes play in improving outcomes
• What revenue cycle leaders should do now to strengthen their denial strategy

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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 Noah Breslow. As CEO of Revecore, Noah brings more than 20 years of executive leadership experience with a focus on driving growth, innovation, and transformation in complex, highly regulated industries. Most recently, Noah was a partner at Bain Capital Ventures, or BCV, where he led their portfolio support team, built out data-driven investment tooling, and helped incubate two startups at the forefront of applying AI in the insurance claims processing and wealth management industries. Prior to BCV, Noah served as chairman and CEO of OnDeck, a pioneering online small business lender where he built the business from its earliest stages, took it public, and ultimately facilitated its acquisition. Earlier in his career, Noah held leadership roles in product, engineering, and marketing.

He holds a Bachelor of Science in Computer Science and Engineering from MIT and an MBA from Harvard Business School.

In this episode, we’re discussing the growing denials crisis and what healthcare leaders can do. Welcome, and thank you for joining us, Noah.

Noah Breslow: Thanks so much, Kelly. It’s really great to be here.

Kelly: It’s great to have you. Well, let’s go ahead and jump in. So why are denials becoming such a significant challenge for health systems? And what are the financial implications on health systems?

Noah: Yeah, it’s a trend that’s obviously been there for a long time. But it’s getting worse and worse. So, denials have really moved from a back-office kind of nuisance to a real top-line, front and center margin issue. So, research from McKinsey shows that nearly 3% of net patient revenue is written off due to clinical denials alone. And then if you add in underpayments, the cost of appealing those denials, timely filing issues, you might get another percent or two as well, hitting hospitals. So, I think you have a big financial set of changes going on, and we can get more into that. And then you’ve also got the fact that payers have gotten a lot more sophisticated. So, they’re using AI to do AI-driven claims review, deny claims in a more automated way, in a more nuanced way, maybe than they did before. And we’re seeing just denial trends going up across the board.

Kelly: Yeah, I mean, I know denials are a huge issue with such significant financial implications. So, Noah, why do so many organizations struggle to prevent denials before they happen?

Noah: It’s got a variety of reasons here. I think organizations struggle to prevent denials, not because they don’t intend to stop denials. So, 47% of organizations cite improving clinical denials as a top priority, yet only around 36% have standardized processes to actually do it. So even though they want to make this an issue, actually implementing the process and the infrastructure to better manage denials is more of a challenge. The other thing about denials is you can obviously engage in that firefighting motion, right? You get a claim denied, you appeal the claim, you go back and forth to adjudicate that one claim. That’s a very different thing than fixing that root cause of the denial upstream. And I think most organizations are better positioned to do that firefighting on a claim-by-claim basis than really do that systemic analysis. “Why is this denial happening? What process do I have to fix on patient intake, or on clinical documentation, or on billing and coding to make sure that that denial doesn’t happen again in the future?” And that fragmentation is a huge challenge for hospitals.

Kelly: Yeah, it seems like doing that hard work is key there. So, what are the biggest reasons denials continue to slip through the cracks?

Noah: Yeah, I think it’s a multidisciplinary thing. So, you need kind of that combination of data intelligence, the reporting that says, “Hey, we’ve been submitting claims to this particular payer and these types used to get denied at this rate, but we’re seeing this uptrend in these particular types.” You have to connect that intelligence piece. What’s actually happening, and trend analysis, but then you need really human expertise to go, “Okay, why is this trend happening? What could I change upstream to maybe prevent this denial from happening in the future?” And that’s a very multidisciplinary thing. It could involve changing processes. It could involve retraining staff. It could involve system changes, collecting different pieces of information at different points in the process. So, I think it’s that multidisciplinary way to integrate the data on the back end and the intelligence gathering with the process engineering upfront to prevent those denials from happening in the future.

Kelly: Yeah, I love what you said there about the combination of data intelligence and human expertise. That totally makes sense to me. Probably to others as well. So, you know how can health systems shift from reacting to denials to preventing them?

Noah: Yeah. There’s a few different ways I think health systems can go from reactive mode to prevention mode. First is organizational. You have to set up processes and teams inside your revenue cycle organization that are dedicated, that make it someone’s full-time job to making those structural changes to prevent denials from happening in the future. So, organizations with those dedicated processes to prevent denials have a much higher appeal success rate than organizations who don’t have those dedicated teams. And then the other piece of it is around timing. If you imagine you go to the doctor’s office and they hit your knee with a hammer, and it takes you two months to kick, your reflexes are pretty slow, right? And so, two months later, that procedure happened a long time in the past. The patient has already gone home. The documentation may be locked down. And so working on your feedback loop, that rapid cycle from the moment that denied claim comes in to the trend analysis to going upstream and working to make those changes, it’s a governance question as much as it is a technology question, and denial trends should be front and center in revenue cycle leadership meetings, not something you check in on once a quarter.

Kelly: Completely agree. And I love what you said about the reaction mode to prevention mode. That makes a lot of sense in this specific example. So, AI is all the hype. How can AI and automation help identify and address denial risks earlier?

Noah: Yeah. So, AI is a tool that payers frankly have a head start on over providers. I think they’ve been implementing AI at scale now for a few years. Providers are starting to catch up, but it’s a little bit of an arms race, and providers really need to deploy AI, I think, to be the best position to handle increasing types of denials in the coming years. So, AI’s real value is pattern recognition at scale, right? Finding those connections across payers, service lines, procedure types that are driving recurring denials faster than someone could just reviewing claims one by one on their own. And so getting that AI deployed to find those patterns is critical. And the other piece, it is a moving target. So, the claims that are denied this year may not be the ones that are denied next year. There are always new types of denials coming in, and some of them can be addressed very basically, right? They could be administrative denials. They could be missing documentation. Those are more sort of straightforward process issues, but there are a lot more subtle ones in terms of the way procedures are coded and billed, the way procedures are bundled together. And that’s where, again, having that human expertise to complement the AI is so important.

Kelly: Completely agree. And I mean, it does really seem like providers really need to get on the AI trainer in a major way. So, what role do dedicated denial prevention processes play in improving outcomes?

Noah: It’s massive. They have that dedicated team focused on improving outcomes We see it all the time in our client base at Revecore. Some of our customers, maybe the smaller health systems that don’t have those dedicated teams focused on denials, they’re, again, more in that reactive mode, but our larger customers often do have specialized denial teams or executives focused on those. And we’ve seen some of our more sophisticated clients not only have dedicated teams, but have dedicated analytics. So, they’ll know to the analyst level on their team what their overturn rates are by procedure type, by payer, and then they start to actually optimize. So folks on the team who are better at getting certain types of denials overturned will focus there. And then other areas might be gaps that need to be addressed by training or hiring new skill sets. So dedicated team, specific measurement of payer-specific trends, procedure-specific trends, and training and upskilling are all a big part of this.

Kelly: I love what you said about the dedicated team. That really is key here. So, Noah, what should revenue cycle leaders do now to strengthen their denial strategy?

Noah: I think the first step is– forgive the phrase. The first step is admitting you have a problem. And you have to get honest about that infrastructure gap. 64% of organizations lack the infrastructure to prevent denials. You can’t do any of this without these processes, dedicated teams, workflow systems, tracking mechanisms. And so, you have to sort of assess what you really have to fight denials and then start to up-level it if you don’t have all of those pieces in place. I think the next thing is really making denial a frontline activity in your revenue cycle team. So, segmenting by payer, by service line, by root cause, making it a recurring executive topic. One healthcare revenue cycle leader I know has daily stand-ups with their team where they read out on the latest trends of denial. So, it’s not a weekly meeting, it’s not a monthly or quarterly meeting. It’s literally every day they’re talking about this. And then I think really looking at that delay between hitting your knee with the hammer and then having a kick, right? So when you see a new trend, measuring your time as an organization from detecting that trend to making that upstream fix, I think if you can do that and work on shrinking that time down, getting really agile and fast with your processes and with your changes, that is the ultimate weapon because denials are always going to be a moving target. It always impairs economic interest to deny some fraction of claims. And so, you have to be moving to where that puck is going every year, every month, every quarter.

Kelly: Wow. Yeah. I mean, I love what you said about the daily meetings. That is certainly an impressive dedication to this issue. Well, thank you so much, Noah, for sharing your insights with us on the growing denials crisis and what healthcare leaders can do. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Noah: Yeah, no, thanks, Kelly. It’s been great to be here. And if folks want to learn more about what Revecore does to help health systems manage denials and get them overturned and get hospitals the revenue they deserve, they can visit us at our website, https://www.revecore.com, R-E-V-E-C-O-R-E, dot com. Or they can reach out to me directly. I’m just noah.breslow@revecore.com.

Kelly: Awesome. 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.

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Why Patient Access Is the Missing Link in the Revenue Cycle

In this episode, Jake McCarley, CEO & Co-Founder of Alluvium, discusses why patient access is the missing link in the revenue cycle.

Highlights of this episode include:

• Why leaders should see access as the first step in financial performance
• How front-end decisions around scheduling, provider availability and patient engagement do influence downstream revenue cycle outcomes
• What financial impacts health systems experience when patients face access barriers, missed appointments, or delays in getting care
• How improving front-end processes can help reduce denials, accelerate reimbursement, and create a more efficient revenue cycle
• What role AI and data play in helping health systems can better understand demand, optimize capacity, and improve patient access
• What steps healthcare leaders should take to better connect patient access, operational performance, and revenue cycle strategy

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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 Jake McCarley. Jake is the CEO and co-founder of Alluvium, the enterprise access and capacity performance platform, purpose-built for large health systems. With nearly a decade of experience working alongside some of the most complex health systems in the country, including HCA Healthcare, CommonSpirit Health, CHS, and Memorial Hermann. Jake has spent his career at the intersection of patient access, operational performance, and revenue cycle outcomes. Before founding Alluvium, formerly BlockIt, Jake identified a systemic gap: health systems were making billion-dollar capacity and access decisions with fragmented data, disconnected workflows, and reactive processes. His answer was to build a platform that gives health system leaders the ability to see where capacity and demand are misaligned, predict what’s coming, model scenarios collaboratively, and act with confidence.

Today, Jake is one of the most vocal advocates for using AI, not as a buzzword, but as a precision instrument, one that transforms raw access data into revenue cycle clarity, reduces over-reliance on expensive BI infrastructure, and helps health systems move from reactive scheduling to predictive access management.

In this episode, we’re discussing why patient access is the missing link in the revenue cycle. Welcome, and thank you for joining us, Jake.

Jake McCarley: Thanks for having me.

Kelly: Well, let’s go ahead and jump in. Patient access is often viewed as separate from revenue cycle. Why is that a mistake? And why should leaders see access as the first step in financial performance?

Jake: Yeah, we see this a lot where patient access is set off to the side or, at best, is kind of treated as a separate function to the overall revenue cycle of the hospital. And we would argue that that’s a mistake to look at it in that way because the patient access components of a health system are what ends up flowing into the revenue cycle process itself. If you look at revenue cycle, it’s kind of a captive thing. It’s what comes through. What are the patients that are showing up? Who are those people? What kinds of cases are those? Where are those cases? And so, a lot of the things that make up patient access end up becoming the material, if you will, that the revenue cycle teams are working on. And so a lot of times you’ll see revenue cycle folks who are optimizing and optimizing and trying to make that experience better within Rev Cycle, which are all really good things to do and thoughtful things to do, but they’re working with kind of a set group of things that they had no influence or impact on receiving. And so what we’ve done over time has helped organizations think about patient access not as a thing that we also do or a separate discipline, if you will, but something to think about alongside or within the same system as Rev Cycle so that the goals that you’re setting as an organization, whether that be a quality goal or a growth goal or [inaudible] goal or whatever the case may be, all of those actions actually sit up in the patient access space. So how do you shape user experiences that kind of create the kind of demand, the demand shaping that you’re looking to see as an organization, that you can then apply those really great disciplines from Rev Cycle on. And so, we really view them as part of the same interconnected system, versus viewing access as an entirely different function.

Kelly: Yeah, such an interesting perspective there. So how do front-end decisions around scheduling, provider availability and patient engagement influence downstream revenue cycle outcomes?

Jake: Yeah, it mainly relates to what is the makeup of the patients that we’re going to see directly comes from those front-end decisions. Some of it has to do with data and what you’re able to see. Some of it has to do with the user experience. Some of it has to do with accessibility. But scheduling as the front-end component of how a patient enters into that health system is extremely important to the revenue cycle equation. It’s most basic. It’s the efficiency of that, the data collection of that, the elements that are a part of that process that are going to contribute to a more effective revenue cycle process later on. A lot of times, work that revenue cycle teams are doing are going back and fixing things that were happening in the upfront patient access component. So that’s part of it. Provider availability and just the engagement of the patient in general is also super important. And so, providers, they’re very particular about their schedules. They’re very particular about the way their day goes. And we continue to think about these as interconnected systems. So, the way that that provider experiences their day is directly related to how their schedule is shaped, which is directly related to how the patient experiences their in-office visit. And so, all of these things are connected. And so, the tighter those things are and the more aligned they are, both in terms of the efficiency of that experience and the shape of that experience so that you’re getting the right patient to the right place at the right time is good for everyone. It’s good for the provider. It’s good for the staff. It’s good for the patient. And when you put that level of discipline into the front-end process that generally is called patient access, the downstream revenue cycle impact is high.

You get a higher follow-through rate, you get a higher return rate, you get a higher referral capture rate, you get lower leakage, you get higher provider satisfaction because the experience of their day is better because it’s been more thoughtful in terms of how those patients end up landing in the clinic. The data collection is better. So, to me, kind of back to the idea of it being one interconnected system, those front-end decisions have such an impact. If you step back and think about anyone with Rev Cycle experience, a lot of the things they’re fixing are because that wasn’t true in their environment and those front-end decisions were made independently of the collective goal of the health system, which is, how do we provide great patient care? And eventually collect the dollars necessary to continue that mission.

Kelly: Yeah, no, it makes a lot of sense, Jake. So, what financial impact do health systems experience when patients face access barriers, missed appointments, or delays in getting care?

Jake: Well, I mean, we’re still in a pretty big fee-for-service arena. People generally get paid for what they do. I would say even in the situations where you have a captive or you have an ACO oriented financial instrument, this still has an impact on the financial health of the organization in some way or another. If a patient– even if you’re collecting to manage their care, if that care is not done from a proactive standpoint or they’re not following up on the basic things that they need to do, it’s very easy for that to escalate into something that has a higher acuity, which has a higher cost. And so regardless of whether fee-for-service and you’re getting paid when they show up, or whether you’re managing their care, the financial impact’s pretty significant. The challenge in healthcare world is that these providers schedules, or if you’re in an acute setting, the beds or the ORs or whatever the care delivery mechanism is, they’re finite resources. So, if you don’t use them, you lose them. If a patient doesn’t show up or you have a really high cancellation rate in the clinic, those slots are gone. That’s capacity you could have used to see another patient or to move a patient up who was scheduled later. If you have an OR that sits empty on Saturday and Sunday because the logistics aren’t worked out on how the health system could make the case for opening those ORs on the weekends, then that’s lost capacity. It’s like a plane sitting on a tarmac with no passengers in it, waiting for Monday to come around, right? And so all of these things that are happening within the capacity of the health systems on both the acute and the ambulatory side have significant financial impact just because those resources expire, those slots, those beds, those ORs that you can’t reuse something that you missed. And so having a really tight system where that’s managed really well from a supply and demand standpoint has a pretty significant impact on the financial health of the system.

Kelly: Yeah, I mean, it does seem like the financial impact here is quite significant. So why do many organizations still overlook patient access as a revenue driver? And what prevents them from making it a strategic priority?

Jake: I think a big part of it, from what we’ve seen, is purely the visibility into how the system works. I mean, anyone who has worked within a health system, or I would say a delivery network, doesn’t have to be a health system. It’s true on the payer side as well. It’s really foggy. And maybe it’s the word to use. It’s foggy. You can’t really see what is happening on– what capacity do we have? How are the different patients coming in through what channels, and what’s happening within each of those channels? So, these supply and demand dynamics that have been solved in other industries for a very long time are really foggy in these environments. And I think when you have organizations or you have environments where these complexities create this fogginess, where leaders are just not able to see what is happening and how those systems connect and be able to predict from there like, “Okay, we can now see it.” If we made these changes, what would happen to our capacity if we hired these 10 people, or what would happen if we opened these ORs on the weekend? If they’re not able to see it and then predict it and use some of the modern tech to be able to make those decisions, then you don’t know what you don’t know. You feel it doesn’t work and it doesn’t feel right and you know something could be better, but you’re not quite able to connect those dots because you can’t see the system. And that’s what we find in a lot of organizations is patient access has kind of sat in its own department for a very long time, and rev cycles set in its department. And there just hasn’t been enough visibility to say, “Oh, if I optimize this within the access strategy, that’s going to have these impacts on the rev cycle strategy.” And these are actually the same goal. So how do we actually align incentives and create a unified operating system where we can see those things?

And so, visibility, I think, is probably the primary reason why these things have continued to exist in isolation. Once people can actually see how they’re connected, it’s impossible to go back because you understand how these steps end up downstream effective on care or outcome or financial metrics or whatever. So, we see visibility as really the primary. It’s too foggy for them to see it. And so there hasn’t been a strong driver to drive that alignment historically.

Kelly: No, I mean, it makes sense. I mean, they’re still way too siloed. I totally get where you’re coming from there. How can improving front-end processes help reduce denials, accelerate reimbursement, and create a more efficient revenue cycle?

Jake: Yeah, this is back to the idea of simplifying those processes and aligning those experiences with the goals of the revenue cycle process itself. And every health system, every delivery environment is set up a little different in terms of kind of what they’re going after. And if your front-end process isn’t set up to deliver what that back-end process on the rev cycle side needs for it to be efficient, then that’s going to trigger a lot of work that someone has to go and fix later on. And what we see a lot of times is now you’re seeing AI being used, the agent process to go and resolve that, which is great. It’s efficient because you’re not having a human do it. What we would challenge is, let’s fix that so it’s not a problem at all, right? I’m glad that we’re using AI agents to automate that work. But what if we didn’t have to do that work in the first place? So, I think having the right leaders around the table who are unified on their goal– and incentive alignment is a huge thing within leadership teams, where often we’ll find within these two groups, and even within the groups, that the incentives are not actually aligned in such a way that everyone’s working together. So you have a fogginess against you, you have an incentive misalignment against you. And so then people just become frustrated and can’t quite name that frustration. I’ve experienced that in my own work. And so that’s generally what we’re encouraging when looking at that from an efficiency standpoint, is let’s try to solve things where we don’t have to do them rather than repeating the same workflows in a more efficient manner that shouldn’t have been there to begin with.

Kelly: Right. Yeah. Seems like improving those front-end processes are key. So, what role can AI and data play in helping health systems better understand demand, optimize capacity, and improve patient access?

Jake: Yeah, this is a crazy thing. So, AI is only as useful as the environment it’s sitting on top of. And what we find over and over again is people that are experimenting with AI and pulling data out of context and putting it into ChatGPT or whatever, a large language model and getting a data point or an outcome. And that’s good exploration, but AI has to be thought of in a more holistic sense. And the usefulness of AI is only as useful as the comprehensiveness of what it’s sitting on top of. And so being able to take the data environment within an organization and to apply healthcare domain expertise within that data environment to shape that in such a way and to align the AI through the lens of healthcare expertise to deliver insights and bottlenecks and things like that are really key to setting up an operating system that leaders can actually benefit from. The data is there. The challenge is not, is there enough data to do it? Getting at the data historically has been very hard. A lot of that’s been solved. It’s more how do you construct the right data and how do you construct the right shape of AI? AI is a very big word, a very general word…

Kelly: It is.

Jake: …but often, yeah, the most impactful AI use cases are different combinations of models and different ways that deliver a specific outcome. And so that’s what we’ve been working with groups on and have found it to be pretty successful, is you have to be able to see the environment; you need to be able to predict and to model what’s going to happen. And that’s kind of been the challenge with existing business intelligence, is business intelligence is really great at telling you what happened. It’ll give you a metric or a static or the number of appointments or the number of beds that were filled, right. It gives you a historical view. And what leaders end up being challenged by is like, “Great, I’ve got this historical view.” They then have to take their goals, which are kind of in their head or on a PowerPoint slide and these ideas that they have, and those things have to converge. So, I have to take what I think is happening with what I want to happen, and then I have to find a way for those two things to play those things out. So, I have this idea, I want to do this, I want to do that. How do I figure out what’s going to happen? Or how do I know what’s going to happen? That’s what happened historically, but what’s going to happen in two months? Am I going to have enough capacity in two months to be able to hit my goals? When is it going to break? So, all of these forward-looking things are at the end of the day, what leaders want. It’s what I want as CEO of a company. I need to understand what’s going to happen. I need to understand what I could do today that’s going to affect that. I want my leaders to be aligned on what those actions are. I want to be able to track the outcome of the actions that we’re taking, and I want that system to learn and be a constant learning loop so that we’re continually moving towards the goals that we set as an organization, which is to help health systems get what they should be out of their delivery network. And so that’s all to say like optimizing capacity, improving access demand. These are all really– the shape of those problems are all really the same.

And what we’ve found is being able to craft that into an operating model where leaders can see, they can predict, they can derive insights and action those things. If you have insights without action, then that’s just slightly more useful than not having insights, right? You have to actually do something with that, right? And so, how can these models help us action that? And yes, use AI agents when it’s possible to do that, but how could we make it easier for the staff when necessary to have to take a human-oriented action? How can we make that process easier? So, AI plays a big role. It just has to be very thoughtful. It has to be through the lens of healthcare domain expertise for it to be able to work because you’re dealing with a people dynamic that generalized AI can’t really overcome in and of itself.

Kelly: No, I love what you said there. It has to be insights with action, so that’s the key piece I pulled out there. So, what steps should healthcare leaders take to better connect patient access, operational performance, and revenue cycle strategy?

Jake: Yeah, the first step is getting the right leaders around the table. This is usually not in an annual retreat or not a once-a-year thing, but when we think about the entire patient experience, who are the key leaders that represent that value chain and getting them around the table and doing the hard work, this is what we find. We do a lot of people work before we ever apply technology. Understanding like, okay, these are the people. These are the steps. These are the things that need to come together. What are the incentives? How are people coming to the table and thinking about that? What does good look like to them? There’s a lot of people-oriented work of aligning that leadership team before you can start to think about what’s the model operating system that would make that better. So, I think the first step is what is that journey? Who are those leaders and aligning on the people part before you get into the tech side. Second is taking the environment and creating an operating model where you can actually see it. And if you can’t see the environment, it’s very difficult to make decisions. Right. You can guess, you can wait and see what happens, but you can’t really make data-informed decisions if you don’t have an operating system that gives you visibility into that. And so, that leadership team being able to connect the dots on here, here’s the model that would work. Here’s the data that supports that model to give you visibility into that. And then, from there, setting the goals that all of the leaders are aligned on and being able to use the advanced modeling to help derive actions that can be taken, to use those AI models for insights, and to have a regular cadence where that’s being reoriented and reorienting. What we find often is people don’t do the people leadership upfront, and then they don’t do the people oriented stuff after the fact. And just being a human, this happens to me personally in my work and my personal life, we have to constantly reorient, reorient. What are we doing? What is good? Where are we in that process?

And thinking of it in terms of, hey, we’re going to get together once a quarter or once a month is really not the same thing as reorienting. And so, these models have to not only give visibility, drive insights, help you action it, but they should be something that your leadership team can use asynchronously and together to be able to constantly reorient to why we’re here, where we’re at, what I need to do, what I need to sacrifice maybe for Kelly to be able to do her step, right? It’s that reorientation. So, it’s people, then tech, then people again, that then informs process and outcomes, I think.

Kelly: Yeah, no, that makes a ton of sense. Well, thank you so much, Jake, for sharing your insights with us on why patient access is the missing link in the revenue cycle. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Jake: Yeah, a couple of different ways. Our website is alluviumhealth.com. That’s an easy way. But honestly, if something struck a chord, you want to chat, love to do that. I’m very easy to get hold of. Email address, I’ll just give you my email address. My email address is jake@alluviumhealth.com and would love to chat and hear the challenges that you’re facing on some of these operational decisions and share anything that we’ve learned that would be helpful to what you’re doing in your environment.

Kelly: Awesome. 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.

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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

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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 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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Impact of ‘Failure to Progress’ in Value-Based Care on Healthcare System and Patients

In this episode, Theresa Hush, CEO at Roji Health Intelligence, discusses the impact of value-based care’s failure to progress in achieving the economic sustainability of the healthcare system and if or what can change the course.

Highlights of this episode include:

• Obstacles to reaching success in value-based care
• How healthcare providers are reacting to the affordability issue and the benefit plans/coverages
• Consolidation of health systems factors
• How business’ ability to afford coverage will affect consumers and health systems
• The expanding value-based care contracting efforts
• How will AI improve or hinder patient access to services
• Are we seeing a move of consumers away from health systems except for major illnesses
• How to accomplish a big change
• CMS payment models’ impact

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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 back Theresa Hush. Theresa, who prefers to be called Terry, is a healthcare strategist and change expert with extensive experience across the healthcare spectrum. A dynamic speaker and thought leader, she focuses on value-based healthcare, the latest healthcare trends, consumerism, and transformation, including AI. Terry’s diverse experience spans executive roles in the public, nonprofit, and private sectors with expertise on both payer and provider sides. With a background in healthcare policy and regulation, she often jokes that she has held every seat in the healthcare ecosystem except in the pharmaceutical industry. Her career highlights include transforming Blue Cross Blue Shield of Illinois, reforming the Illinois Medicaid program to improve access and funding, and leading strategic and contracting initiatives for a large clinically integrated hospital system. As a co-founder and CEO of Roji Health Intelligence, established in 2002, Terry has been instrumental in helping providers prepare for value-based healthcare through innovative technology and consulting services. In this episode, we will explore the impact of value-based care’s failure to progress in achieving the economic sustainability of the healthcare system and if or what can change the course. Welcome, and thank you for joining us again, Terry.

Theresa Hush: Thank you so much, Kelly. It’s great to be back.

Kelly: Yes, great to have you back. Well, let’s go ahead and jump in. So, are we on a tipping point to success or a downward slide in value-based care? With the increasing investment of health systems in data and technology, is there a good chance that we can pull out of the stall, and what are the obstacles to reaching success?

Terry: Well, I tell you the chances are looking better right now than they were at the beginning of the year. There’s been a lot of activity in CMS with new payment models coming down the pike and really cementing a strong value-based care direction. They may well force providers into mandatory models, and that may break the stall. But providers are really worried about the sustainability of their systems right now, especially after the cuts. And the forces that facilitated that kind of stalling of value-based care are still there. The financial sustainability is one of those, but providers’ whole systems are still geared towards fee-for-service. And what we’re seeing come down the pike right now are episodic and total cost of care per capita cost of care payments. And that’s a very different structure and requires a different kind of background to be able to do that and accept risk at the same time. So yeah, I think it’s a toss-up right now. There’s a good chance that providers still think that someone’s going to come to their senses about this strategy in CMS. But there are some emerging leaders who are taking the ball and running with it right now. So I’m a little bit more hopeful than I was in, let’s say, January, February.

Kelly: Well, that’s really good. And I know CMS is always keeping us on our toes. Yeah. So how will the cuts in government Medicaid eligibility and funding expand through Medicare and state programs to address perceived unaffordability or competition of resources for healthcare in the federal budget? And how is business reacting to the affordability issue and its benefit plans and coverages?

Terry: All these things happened as planned by the administration. And I think a lot of healthcare providers and business did not really believe that they would, especially some of the subsidies for the ACA coverages. And they are definitely worsening the sustainability issue in pockets. We’re seeing that in hospital finances right now, we’re seeing it in the consolidations that are occurring because the providers believe that there’s safety in size, I think, still. That’s still a very strong motivation backing the consolidation. Business definitely pulled back on coverages. We saw at least a 20% to 30% drop in coverage through their insurance mechanisms. But also, business is taking a very interesting focus right now– and they’re doing new things to prevent chronic disease and changing lifestyles. And we see business, for example, adopting health coaching as a technique for its employees to be healthier and avoid issues with finances down the pike.

Kelly: Yeah, no, that 20-30% drop, that’s pretty substantial. Yeah. So, with consolidation of health systems continuing to be a factor in higher costs, are economies and efficiencies ever likely to occur? What prevents that from happening? And is healthcare now too big to be nimble and responsive to change?

Terry: That may very well be true, but I think the real underlying problem is not just the newfound size, but more important is the perception of economies of scale when they really don’t dig down into the dirt of how they really want to provide care as providers. They’re erecting this large system on top of a traditional mechanism for delivering care through doctors, not through care teams, not as ACOs– I mean, although ACOs are there and they’re having an impact, by and large, the old model is still alive. And what we see is that large systems who are still offering care in the traditional way are now setting up immediate care centers so that they can head off the complaints of patients who can never see their doctors now or who have to go through call centers to find them. And patients don’t like that system. They don’t like the immediate care system and they don’t like the system of not being able to find their doctors or see their doctors when they’re in trouble. And on top of that, we have the issue of shortages coming up in the system. So, I’m not really sure that we will see an end to this cycle very soon. It may be a combination of being extremely big and also having not enough providers that make it very difficult for traditional healthcare to overcome this.

Kelly: Yeah, I mean, we certainly have some significant challenges right now, that’s for sure. Employers have been exploring new options for mainstream health coverage, like offering technology-enabled metabolic disease platforms, provider-specific arrangements and wellness coaching. I think you mentioned that earlier. How will business’ ability to afford coverage affect consumers and health systems?

Terry: Well, I think these new apps are a very interesting happening right now. And I think they will have an impact. But they are still largely focused on that group of people who are literate in healthcare or health, that they are more educated, they have the money to purchase devices, and so on. But we see that this whole problem of access and cost right now is starting to activate consumers. And that will be an interesting new development. We’re seeing it in the political rhetoric on the democratic side. And the other thing that’s happening, side by side, is the impact of AI. So as AI starts to have an impact on people’s jobs, people are starting to actually question out loud in the market right now, should we be looking at other mechanisms than business to provide coverage to people? And that’s a new question that business hasn’t really grappled with, and neither has the current administration. How do we afford this system, and how do we make it possible to withstand the pressure of both AI and these new cost cuts?

Kelly: Yeah, no, I mean, I love what you said about the apps and what is their impact going to be? There are some challenges there for sure. So, payers continue to expand their value-based care contracting efforts. How will that affect providers and patients?

Terry: Well, risk is going to expand without question. The new coverages that we’re seeing through TEAM and ASM and CJR-X, which are all payment models that CMS has either announced or implemented at this point are all either episodic models addressed at patient episodes of care, either surgical episodes or various conditions like back pain and heart failure. And then we have the ACOs under LEAD, the new type of ACO, which will be on a capitated basis. That will really change the dynamic of those remaining providers who are not in that camp, who aren’t ready for risk, and who are not having to participate in these models. But because the specialty models are so big and so self-encompassing, right now, we’re looking at a situation in which joint replacements, lower extremity joint replacements, will be at 100% or virtually at 100% risk within a couple of years. That’s huge. And that will have an impact on hospitals because they’re the ones bearing the risks under these payment models. It will have an impact on access, and it will have an impact on patient ability or willingness to get joint replacements. It will drive innovation in some of these apps and some technologies and also some efforts to make people fitter, to go a different path, go the health path as opposed to go the intervention path.

Kelly: Wow, those are some big numbers there. So, isn’t this model just the health system monetizing its own patients? I mean, convince us that this is not a compliance and trust problem waiting to happen.

Terry: Well, they buy these products anyway, and they buy them based on your physician’s recommendations. So, it’s not like you’re getting them to buy something they wouldn’t buy. There are lots of laws relating to what a healthcare system can and can’t sell. There’s the anti-kickback laws that relate to what we call DME products. These are products that would be prescribed. So hypothetically, let’s say you needed a wheelchair. Your insurance company normally would cover those types of products. And there’s laws relating to that. And healthcare companies sell those products today. They just are very controlled in the mannerism they sold. There’s a lot of regulations around it. Obviously, there’s what we call the physician self-referral law. It’s mostly a law that is self-governed. And there is an ethical obligation to do what’s right for your patient. You shouldn’t be recommending them something that you wouldn’t be doing it anyway. But as I said, if these patients are going to be buying these products anyway, you giving them the opportunity to buy this actually is helping them. You’re helping them choose the correct product because many times, they go to these stores and they don’t buy the correct product. Here they have now the ability to actually take a product that’s recommended, and you, as a physician, get to actually see the purchases they’ve made. So it really adds to your whole care and your health plan as to the physician for the very first time ever knowing actually, did you or didn’t you actually go forward and execute on the recommendations they made?

Kelly: Yeah, no, I agree. Risk will definitely continue to expand here. Will the growing reach of AI and healthcare enhance or inhibit healthcare from reaching an equilibrium on cost escalation? And will it improve or hinder patient access to services?

Terry: I think the big impact of AI as we go through 2026 and 2027 is the effect on job loss. And what happens to people who have lost their jobs having coverages? So that will be– but at the same time, we’re also seeing new AI apps develop, functional medicine, different testing, independent labs, gene testing, “Get your diet from your gene testing.” A lot of new things that are really appealing to consumers who don’t have any other mechanism to be able to find answers to what they can do for their healthcare. So, I think AI will have an effect, but it’s not clear right now whether that will– what that will do to spur providers, if anything, to offer different kinds of opportunities to change the system in value-based care.

Kelly: Yeah, there’s a lot definitely happening there. And I agree with the job loss. That’s definitely an issue there. Terry, consumers’ trust in the healthcare system is at an all-time low. Some are now purchasing technology and investing in genetic and functional medicine testing. Consumer-directed wellness are companies focused on maintaining health. And you kind of talked about this already. Are these fringe efforts, or are we seeing a move of consumers away from health systems except for major illnesses?

Terry: I think that is a significant risk. People who are healthy and who are literate, as I mentioned, are really focused on how they can keep that way and keep away from the doctors. Nobody wants to spend three hours in an immediate care center because they’ve got a respiratory infection. So, I think that people are really focused much more than they have been in the past on proper nutrition. Health coaching is making this surge of popularity across the health system now. Businesses, insurance companies, healthcare providers, ACOs are all hiring health coaches, not just to help people who are really sick, but to help people who want to avoid going to the doctor at all. So, very, very interesting development right now from the consumer side. And I think this is gathering steam. Unfortunately, there’s also a lot of influencers out there suggesting who knows what supplements and techniques that are not really evidence-based. But alongside that, we have keen interest in lab testing and a lot of these things that have real data that consumers really want and need.

Kelly: Yeah, I mean, I can speak from experience. A lot of my girlfriends and I… we talk a lot about this and different supplements, and especially as we go through menopause, what we can do. So, it is interesting that consumers are really driving this conversation.

Terry: Well, and you’re raising a particular interest about women that I think is important because women, for a long time, have felt like their providers don’t listen to them. And especially going into hormonal fluctuations and not feeling good, they don’t want to go to their providers. They might want to go and get hormone replacement, but that’s really all they’re looking for from those providers. They are gravitating to other venues to find out how other women deal with it and how are they going to deal with it in the future.

Kelly: Exactly. Yes. Definitely. So how can healthcare providers and institutions take leadership over value-based care with efforts to create alignments with consumers and business, focus on improvement of access and affordability, and create tailored care models for patients? And what would they need to be and do to accomplish a big change?

Terry: Yeah, I think that’s an excellent question. What would they need to be and do? Providers have had a long history of creating systems without any patient involvement and are not vetted by patients. And so, patients are pretty– they’re pretty mad. It’s more than a level of mistrust. It’s a real feeling that they are not being cared for adequately because they’re not being listened to. And so, I think this whole call center thing– and granted, I live in an urban center. And so, the world I’m involved in doesn’t involve calling your doctor’s office. It involves calling a call center. In this world, concierge medicine is becoming a really big thing for people who can afford to do that because they want to be able to connect. The issue we have with providers and patients is that listening thing is the ability for patients to be met where they actually are and to actually motivate change. Aside from all the surveys which say, “No, I’m totally dissatisfied,” in which you never hear any change. They need to be driven by patients. They’re not driven by patients right now. They’re driven by providers. And providers have a legitimate need to be wanting to practice in a certain environment, have reasonable schedules and all of that. But there needs to be some huge effort aimed at patients to regain the trust of those patients and to fill the space that all these apps and influencers and groups are fulfilling. Sponsor them, for example. Sponsor them, be open to them, be open to health coaching. Don’t close the doors because it’s not a physician who’s providing it.

Kelly: Completely agree. I mean, I do think we need to get the patients more involved in those conversations and directions of where they’re going to be heading. So there seems to have been a real uptick in CMS payment models this past year that have affected providers, especially specialists. What impact do you think this is going to have on value-based care and the whole picture regarding providers taking action?

Terry: Well, I think in terms of the action that is necessitated by these payment models to live within a risk payment and to pay attention, there should be a message that’s being heard by the providers that they need to start getting in action on data, understanding surgical episodes, aligning with providers, working with their patients to understand what their needs are, connecting with primaries. But I haven’t seen that happen yet. I think we’re still in a deer in the headlights phase right here, because even with TEAM, which was the first mandatory payment model that came out and affected the five top types, categories of surgeries, even with TEAM, I thought that providers would say, “Wow, this is really an indicator of what’s coming in the future.” But instead, what cropped up, instead of looking at what was really driving costs of surgeries, which are complications, by the way. It’s about complications. And a lot of those complications can be avoided by better coordination of care and adoption of certain practices like ARIs, evidence-based guidelines and various surgeries, to minimize complications. But instead, we’re seeing providers go to benchmarks to see where they are and see whether they need to do anything. Am I high on the cost scale? Oh, I might need to do a few things. I’m low on the cost scale. Oh, I have room. I’m okay. So, we don’t need to do anything.

And a lot of them are taking a pass on risk this year, which I can understand. They want to practice with risk. But are they using that year for practice? I don’t see it. I see most of them sitting it out and thinking that they can avoid dealing with this, and maybe it’ll just go away. Now, when CJRX came out and it addressed all of the hospitals outside the TEAM hospitals, so now you’ve got a universe of hospitals that are under joint replacement episodic payments. There should be a correction there. Will it happen? Maybe not in 2026. Maybe in 2027. We’ll see. I’m not seeing a lot of activity at the level there should be, especially to focus on the right things. I’m looking at, “Oh, what we should do is cut SNF payments. That’s our big problem.” It’s always, “It’s the other person’s problem. It’s not our problem. It’s not what’s going on with us.” So there needs to be a mechanism. Most of them do not have the ability to look at episodes of care and evaluate what the cost drivers actually are. That’s an immediate need that anybody who’s going into TEAM this year or who’s in TEAM now needs to be looking at, is, “What is driving each of these costs? How do I get the clinical teams advanced in looking at this, engaged? And what can I do as a hospital to improve the risk inside the house, which is infection control and blood control and ERAS adoption?” So, there’s a lot to do, and we’ll see how many hospitals are really taking up the mantle. But I don’t think it’s the majority.

Kelly: I mean, definitely interesting times, and you bring up a lot of really good points. Terry, the lines between the provider-based healthcare system and technology-focused healthcare seems to be blurring. How do you think the introduction of all these apps, including AI bots, testing, and coaching– how are they going to affect the health system? And are we going to see consumers walk away from healthcare in favor of digital technology?

Terry: Well, I think the healthcare system runs the risk of being forever a sick care system. And the healthy people, if they have avenues to deal with their healthcare, they will stay out of it as long as they can. If they don’t have avenues, they’ll go into the healthcare system as a sick person and need to be dealt with. So that’s the risk…that I think healthcare is not grasping the opportunity right now to be able to really sponsor this kind of technology and go in full force, really look at how they can help consumers be literate, the group that’s just under those who are really health-literate and are at the gym and eating well and so on. There’s a group right under them who can be health-literate and who would like to be health-literate. But behind the paywalls of all the journals, they have limited access to be able to be health-literate. And that’s one of the first things that healthcare providers could help with.

After that, they can start really looking at the tools to help consumers get the information they need out of their lab tests, out of any kind of health coaching, work with independent groups who have risks to avoid the risks. Everybody’s working with the people who are diabetic right now and people who have advanced cardiology issues and also kidney disease. The whole metabolic syndrome is, of course, throwing everybody into a tailspin of how big and fast it’s growing. But who’s looking at the people with prediabetes right now and growing insulin resistance instead before those things go down the highway? When you’re prediabetic, you are on that highway, and it won’t be too long before it escalates. There needs to be a way of dealing with that, not just with drugs, but with lifestyle behaviors that is working from the healthcare system inside out, not just through apps, not just through other organizations, but through the traditional healthcare system if they want to have a system that is not just sick care in the future.

Kelly: Yeah, I completely agree. You’re right. We do have a sick care system right now, and a lot of these things may definitely keep it that way. Well, thank you, Terry, for sharing your insights with us on impact of failure to progress and value-based care on healthcare system and patients. If a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Terry: Well, the best way to contact me is through email, which is Hush, H-U-S-H, at, and it’s Roji, R-O-J-I, Health Intel, I-N-T-E-L, dot com.

Kelly: Awesome. 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.

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The Revenue Walking Out Your Door–Capturing Wellness Spend at the Point of Care

In this episode, Kevin Torf, Co-Founder & Managing Partner at T2 Group, discusses the revenue walking out your door, capturing wellness spend at the point of care.

Highlights of this episode include:

• What to say to leaders who have already optimized every revenue line they have.
• How large the market size is
• Wellness products
• Model for a system based on size
• Compliance
• Implementation and what it costs
• The opportunity is now in wellness

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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 Kevin Torf. Kevin is a seasoned information systems executive specializing in large-scale IT strategic plans, project design, procurement, and implementation. With a career spanning over 40 years, Kevin has successfully led complex IT infrastructure deployments worldwide, including some of the largest communication network systems. As co-founder and managing partner of T2 Group, Kevin introduced the company’s hybrid-agile methodology, guiding program, and project managers in planning and executing client projects. He also plays a pivotal role as a chief strategist and advisor for leading hospital systems in the US. Prior to co-founding T2, Kevin founded and sold several technology companies, including Intelliverse, Mobile Gaming Technologies, Inuntius, Tornado Development, and Torsys. He has also held senior roles as CEO, CTO, and CIO, and other board positions. In his book, Getting the Job Done, Kevin unveils his hybrid-agile approach, dissecting effective project management tips to ensure punctual, high-quality outcomes.

In this episode, we’re discussing the revenue walking out your door, capturing wellness spend at the point of care. Welcome, and thank you for joining us, Kevin.

Kevin Torf: Thanks for the opportunity. I’m looking forward to the discussion, and thanks again.

Kelly: Yeah, it’s great to have you. Well, let’s go ahead and jump in. So, a lot of finance leaders are going to say they have already optimized every revenue line they have. What would you say to them?

Kevin: Well, as you know, with healthcare systems today and the financial constraints they are under, I think everybody’s looking for an opportunity. I think the opportunity we’ve identified is in the purchasing of wellness products. Some healthcare systems do sell these products in their pharmacies, mainly in hospitals, and some clinics will promote one or two different products, but it’s not done at the scope and magnitude of what CVS, Walmart, Amazon do today. So, there’s a huge opportunity for healthcare systems to participate in that revenue.

Kelly: Yeah. No, it sounds like it. So, let’s talk about the market size. How large is this market? And why should any health system believe a meaningful share of it is theirs to capture rather than someone else?

Kevin: Well, people today are spending over $3 trillion a year on wellness products. And wellness products vary. Everything from wellness tech, that could be a Fitbit or even an Apple Watch that you wear on your wrist, to taking vitamins, from vitamin D, C, the different types of vitamins people take every day. And then there’s other categories that would include nutrition, sleep aids. So, the industry is relatively large, and each one of these market segments make up a good couple of hundred billion dollars, totaling over $3 trillion, as I said.

Kelly: Yeah, $3 trillion in wellness products. That is a big number. So, Kevin, walk us through what happens today after a patient visit. The care team makes a recommendation, and then what happens next?

Kevin: Well, I don’t know when you were last at your physician, but Kelly, if you recall, they might have done a blood test and told you that you need some vitamin C or maybe D based on your blood tests. Those aren’t covered by insurance, and they’re not part of the DME products that a doctor might prescribe to you. You are obligated to go to the store and buy those products yourself. And there’s no real telling whether you do or you don’t. So, when you’re at that physician visit, they might verbally tell you this. In many cases it will actually be in your visit summary where they would suggest go get a sleep aid, maybe some eye covers. Or maybe noise is interfering with your sleep, get some ear blockers. With that said, you are then, when you leave that physician practice, are either going to go to the store and do this yourself or go to even Amazon today or online. And half the time you do, half the time you don’t. And there’s no real full cycle in understanding, did you actually do what the physician suggested?

Kelly: Yeah, that’s very true. I know I purchase a lot of things myself on Amazon. So, when a vendor tells a CFO they can add revenue with essentially no cost to acquire it, most of them stop listening right there, but why shouldn’t they?

Kevin: Well, the opportunity is that the healthcare system, it’s their patient, it’s their customer. And they’re the ones that are making these recommendations, but aren’t participating in that revenue. So, the opportunity here is that these products can be fulfilled through many other organizations. The healthcare system isn’t obligated to carry this inventory and actually incur the costs to store it and manage it. They can take the order, have someone else distribute the product on their behalf, but they would participate in receiving the profits that come from that. So, there is no burden on the healthcare system. They don’t have to make any upfront investment. This is something that they’re doing already today in their visit summaries and basically can continue doing it this way, but participate in that opportunity to profit from this.

Kelly: Doesn’t seem like there’s a downside there. So, give us the model for a system based on their size. We have seen plenty of projections built on optimistic assumptions. What are yours and why should we trust the margin that you’re quoting?

Kevin: Well, there’s numbers out there and there’s no shortage of them. As I mentioned, it’s a trillion-dollar industry. So, CVS has financials, they disclose a lot of what they’re doing. There’s lots of healthcare companies that have done studies on wellness products. So, I think there’s a lot of evidence out there as to what the opportunity is. The model right now generally reflects that any of these types of products that are sold, a healthcare institution can generate approximately 26% margin. So, if a healthcare system, let’s take a very large one. I had a million clients. That’s unique clients, unique patients. And not every one of them is going to be using the patient portal. So hypothetically, let’s assume only half of their patients, or 500,000. And then, what is the potential spend today that a person does buying wellness products? It’s anywhere from $1,500 to $2,500 a year a person spends. When you do more analysis on that, you’ll find that the average conservative spend online is about $600. So, assuming you’ve got 500,000 potential patients that might purchase products, and each one of them are going to spend $601. Now, you’re not going to be able to successfully penetrate that market fully. So, if you took a 6% market share of that, which is very realistic for something of this magnitude, you will generate approximately $18 million in revenue, and you can profit at least just under $4 million from that.

Kelly: Wow, those are some big numbers there. So, isn’t this model just the health system monetizing its own patients? I mean, convince us that this is not a compliance and trust problem waiting to happen.

Kevin: Well, they buy these products anyway, and they buy them based on your physician’s recommendations. So, it’s not like you’re getting them to buy something they wouldn’t buy. There are lots of laws relating to what a healthcare system can and can’t sell. There’s the anti-kickback laws that relate to what we call DME products. These are products that would be prescribed. So hypothetically, let’s say you needed a wheelchair. Your insurance company normally would cover those types of products. And there’s laws relating to that. And healthcare companies sell those products today. They just are very controlled in the mannerism they sold. There’s a lot of regulations around it. Obviously, there’s what we call the physician self-referral law. It’s mostly a law that is self-governed. And there is an ethical obligation to do what’s right for your patient. You shouldn’t be recommending them something that you wouldn’t be doing it anyway. But as I said, if these patients are going to be buying these products anyway, you giving them the opportunity to buy this actually is helping them. You’re helping them choose the correct product because many times, they go to these stores and they don’t buy the correct product. Here they have now the ability to actually take a product that’s recommended, and you, as a physician, get to actually see the purchases they’ve made. So it really adds to your whole care and your health plan as to the physician for the very first time ever knowing actually, did you or didn’t you actually go forward and execute on the recommendations they made?

Kelly: No, I mean, that makes a lot of sense, Kevin. So many vendors say that implementation is easy. What does an organization actually have to build, staff, and pay for? And where are there costs involved that you aren’t mentioning?

Kevin: Today, as we said, the physicians are already building out those summaries of the visits. So that doesn’t change. We’re using artificial intelligence. We will extract that information off that visit summary, and we will then match that to products. This is done all in the cloud, so it’s no burden to the healthcare system. They don’t need any technology on site. They don’t need to invest any money in building that technology architecture. We will then provide those recommendations in the patient portal, where the patient can then procure those products. Now, that does require a little bit of integration. It’s minimal. The healthcare system has to allow us to come in and build this into the EHR platform. It’s pretty much EHR agnostic, so we can work with any of these platforms out there. And then once those products are purchased, third-party companies will do the fulfillment. If the healthcare system actually has a company that they work with through their GPO today, we can work with them as well. So, they can still keep their current supply chain and have those same vendors provide those services on their behalf, or we will recommend a vendor to them. But the healthcare system doesn’t have to go through any burden to do this. This is coming directly off that visit summary that the physician did anyway prior to this product being installed.

Kelly: Yeah, no, I love that there is no burden to them. I love that, and I’m sure that people listening love that too. And you talk about finally seeing what patients do at home. Is that a nice-to-have, or does that visibility show up somewhere a CFO cares about? Can you put that in dollars for us?

Kevin: Well, the dollars is going to be on the money they make with the indirect dollars is at the end of the day, your physician’s there to make sure you get better. Usually, these products that they recommend are because you need them, and you wouldn’t recommend them otherwise. So, they don’t really know whether you’ve actually made those purchases or not. And then they don’t usually solicit any feedback from you if any of those purchases actually helped you. So, by having this now all electronically digitized and having a history of those purchases, there’s so much more that we can do with data and deep diving into what you’ve purchased, when you purchased it, how has that affected your health. And the opportunities are endless as we take advantage of this data that for the very first time the healthcare practice will ever have.

Kelly: Yeah. No, I love it. It seems like there’d be a lot of data available to them now, and I love that. So why is this an opportunity to consider now and not in three years? What does a health system lose by waiting? And if there’s interest, what’s the first thing that someone should do?

Kevin: Well, like anything, there’s an opportunity here. And opportunity costs money if you don’t take advantage of it. So, there’s going to be nothing wrong with them implementing this later, but it’s not a big effort for them to implement now. They can do this in different stages. They can pilot this with a few specialties or a few clinical groups. It doesn’t take much effort in getting this up and running. It can all be done within a few months from the moment they decide they want to move forward and then learn as technology grows, as these AI models– as we know, everywhere we go these days, we’re hearing about AI playing more of a role in our life. These AI models need to be fine-tuned. They need to evolve over time. And as different products are recommended, these AI models learn from that. So, the sooner you get started, the better these models will learn about the needs of your patients. And you’ll be able to capitalize and take advantage of it.

Kelly: Yeah, no, I love that. Well, thank you, Kevin, for sharing your insights with us on the revenue walking out your door, capturing wellness spend at the point of care. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Kevin: Definitely come to our website. We are actually taking healthcare systems that want to participate in our early pilot programs. We’re looking for partners because as I mentioned, these algorithms and models need to learn over time. And we want health systems that are looking to be innovative, that are looking to really find new ways to help their patients. And we are going through a vetting process to select which healthcare systems we want to work with. And the goal is that this is at no cost to the healthcare system, and we will work together to validate and improve these models. And they can come to our website. It’s t2group.com, and they can go to the EasyCare, which is the name of the product. And there’s an application form they can fill out, and we can engage with them and see if this is a good fit for them.

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.