In healthcare revenue cycle management (RCM), technology—especially automation and artificial intelligence (AI)—is celebrated for its ability to streamline processes, reduce errors, and enhance efficiency. While these tools are transformative, they are not a complete solution. A blend of technology and human expertise is essential to maximize reimbursements and operational success. Here’s why.
The Limits of Technology
The 80% Automation Ceiling
Automation and AI excel at handling repetitive, rules-based tasks, such as claim scrubbing, insurance verification, and payment posting. However, these systems often plateau at automating approximately 80% of the process. The remaining 20% involves nuances, exceptions, and edge cases that require human intervention.
For example, in the physician billing arena, 25% of all claims get initially denied. CMS reporting an industry high denial rate of 33% for UnitedHealthcare, but many other large payers such as Aetna, Cigna and Anthem in the 20-30% range.
Many of these, such as those for unclear documentation, payer-specific quirks, or complex coding issues often fall outside the capabilities of automation. These require a nuanced understanding of healthcare regulations, payer policies, and clinical documentation—skills that technology cannot replicate.
In addition, payer denial reasons constantly evolve, which challenges AI systems that depend on claims history to develop their algorithms and use them to prevent or quickly solve denials. Instead, to be effective, AI technology will need to understand and predict how insurance companies are likely to change in the future, which is much harder to do.
The Human Touch in High-Stakes Scenarios
While bots and AI can provide insights and handle bulk tasks, they lack the critical thinking, empathy, and creativity needed in patient billing disputes, appeals, and high-value claims. These situations demand trained professionals who can navigate complex conversations and advocate effectively for reimbursements.
Michael N. Brown, CEO of Fellow Health Partners, explains, “Technology can handle the predictable, but the unpredictable requires skilled professionals who understand the intricacies of payer behavior and medical billing.”
The Power of Human Capital
Experience and Expertise Matter
Physicians, administrators, and billing specialists bring a wealth of knowledge that technology cannot replace. Their training allows them to spot patterns, anticipate challenges, and resolve issues that would stymie even the most advanced AI.
For example, seasoned professionals often recognize emerging payer trends or subtle coding issues long before they become widespread problems. This proactive problem-solving keeps the revenue cycle running smoothly.
Continuous Improvement and Adaptation
The healthcare landscape evolves rapidly, with frequent regulatory changes, payer rule updates, and shifting patient expectations. Humans are uniquely equipped to adapt and refine processes to meet these challenges. While technology can support, it requires human guidance to evolve in tandem with the industry.
The Hybrid Model: Technology + Human Expertise
The future of RCM lies in combining technology with human ingenuity.
Technology Enhances Efficiency
Automation and AI reduce the manual burden, allowing staff to focus on high-value tasks. For instance, bots can flag claims needing human review, prioritize tasks based on urgency, and analyze data trends for better decision-making.
Humans Drive Strategic Outcomes
Experienced professionals leverage the insights provided by technology to drive strategic improvements, optimize payer negotiations, and ensure compliance. They provide the critical oversight needed to prevent errors and seize opportunities that machines might overlook.
A Partnership for Success
As Michael N. Brown, CEO of Fellow Health Partners, aptly puts it:
“Technology is a tool, not a replacement. It amplifies what skilled professionals can do, but at this time it cannot replicate the depth of human judgment, creativity, and adaptability needed to navigate the complexities of healthcare.”
The true potential of RCM is unlocked when organizations embrace a collaborative approach, investing in both cutting-edge tools and the people who wield them. By balancing automation’s efficiency with human expertise, healthcare providers can achieve greater accuracy, higher reimbursements, and a more resilient revenue cycle.
Conclusion
While automation and AI have transformed RCM, they are not the ultimate solution. The most successful healthcare organizations recognize the power of a hybrid model that integrates technology with the expertise of skilled professionals. In the complex world of healthcare reimbursements, this synergy ensures that no opportunity—or dollar—is left on the table.
