Revenue Cycle Insider

AI is here to stay, and organizations will embrace the technology or risk being left behind.

Across healthcare, organizations use data analytics in a variety of ways, but not always to the level of detail possible, said Debra Rossi, CPC, CPMA, in her HEALTHCON 2026 presentation with Pam D’Apuzzo, CPC, CPMA, ACS EM, ACS MS, “Data-Driven Revenue Optimization: Leveraging Analytics for Financial Improvement in Healthcare RCM.”

“We don’t only look at data analytics for compliance reasons — we also look to see if there’s a revenue opportunity, which is something we often find. So, there’s a return on investment to actually doing a lot of this,” Rossi said. Keep reading for some tips to burnish your organization’s revenue cycle management (RCM).

Establish a Revenue Optimization Committee

While RCM is affected by everyone in a practice, people with leadership roles can steer the team toward higher or more consistent revenue and reimbursement. Forming a committee comprised of leadership in compliance, revenue cycle, and clinical roles can give your practice a comprehensive, thoughtful team for optimizing revenue. This committee can focus on operational oversight, including determining analytics for monitoring, reviewing results and validation methods, determining areas of risk versus opportunity, and planning for communication or change and implementation of corrective actions, Rossi said.

With so many changes coming in the way healthcare is administered, coded, billed, audited, and, thus, reimbursed, practices need to be able to adapt with agility, both in terms of mindset and workflow. Having such a committee can help an organization stay cohesive in its mission and goals, while still being flexible in the face of change. Rossi discussed artificial intelligence (AI) and how stakeholders across the healthcare industry — and some outside opportunists — are using it as a tool to make progress and chase money.

Be Wary of AI in Coding and Data Mining

Checking in on your compliance should be a priority, because AI is proving to be an important tool in analysis and audits — and not just internally. As the Centers for Medicare & Medicaid Services (CMS) makes more data publicly available, private parties like “data-mining relators” are investigating and reporting results, leading to qui tam actions under the False Claims Act (FCA) and chasing a percentage of the respective recovered funds. The U.S. Department of Justice (DOJ) has formalized its engagement with such actors and will be looking to triage and filter such reports as part of broader fraud enforcement trends, Rossi said.

More broadly, AI coding may be a target under the auspices of the FCA as well. “Recent FCA-focused commentary and settlements suggest the government is willing to trace billing patterns back to the coding logic, not just the human submitter. What’s the core message here? The safest framing is that AI can assist coding, but it cannot replace a compliance program, it can’t replace human validation or audit readiness,” Rossi said.

If you’re using AI alerts to look for patterns that could become problems, make sure you follow up on the results. “Regulatory commentary says identification can be triggered by information that should prompt a reasonable inquiry. That makes AI-generated alerts especially important because they may be treated as notice to the organization,” Rossi said.

Consider AI for Teaching

Whether you love or hate AI, it’s not going away, so it’s best to embrace it and figure out how it can work for you, Rossi said.

AI can be a great tool for evaluating denials. AI can “look” at denials and determine why the denial shouldn’t have happened, find the supporting information within both the documentation and the regulatory guidance, and then write the appeal. Your practice can get an advantage with these strategies, especially because early adoption of analytics can sharpen your competitive edge by positioning your organization at the forefront of innovation, she said.

AI can be used in daily operations to enhance clinical workflow (though with intensive provider oversight), optimize scheduling and resource management, limit billing and coding risk, and improve supply chain efficiency. Rossi also said that AI can be helpful in longer-term planning like budget estimation.

If you’re identifying patterns that suggest change is warranted, education can be a means of communicating those adjustments, but the way in which you approach it may matter. Rossi recommended that if your analytics produce a pattern, then you can reach out to your providers and let them know what you’re seeing, possibly in a one-on-one meeting or through information given for them to review on their own time. With many organizations encompassing dozens of providers, it may not be realistic to conduct an annual audit per provider, but using analytics that look for broader patterns can help mitigate the gap in data.

AI is a multifaceted tool that is being utilized across the healthcare industry, and making sure your organization has a cohesive and comprehensive strategy, covering analysis, compliance, education, and oversight, is key for continuing to optimize your RCM into the future.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC