AI vs. AI: The Next Generation of Revenue Cycle Management — A Conversation with ModMed's Rob Ware

On this episode of the MGMA Insights Podcast, host and senior editor Daniel Williams has a conversation with Rob Ware, senior vice president and general manager of revenue cycle management at ModMed, about how artificial intelligence is reshaping medical billing and financial operations. Ware explains why revenue cycle management has reached an inflection point, how organizations can respond as payers adopt increasingly sophisticated technology, and what practice leaders should examine before adding another solution to their technology stack.

Episode takeaways

• Revenue cycle management is moving beyond rules and individual expertise. Billing has traditionally depended on experienced professionals navigating an enormous and constantly changing mix of payers, plans, codes and requirements. Machine learning and AI can evaluate more of those variables at once, giving organizations an opportunity to make revenue cycle performance more consistent and scalable.
• Smaller amounts of revenue can no longer be dismissed. Rising operating costs, stagnant reimbursement and expanding administrative requirements have narrowed practice margins. Under those conditions, improving net collection rate by even one or two percentage points can have a meaningful financial impact.
• Practices increasingly need to “fight AI with AI.” Payers are using automation and AI to apply edits, conduct initial claim reviews and accelerate denial decisions. Practices need tools capable of identifying changing denial patterns quickly, rather than relying exclusively on monthly or quarterly reports that describe problems after they have already affected cash flow.
• Technology purchases should begin with a specific source of pain. Before selecting a solution, leaders should determine whether their primary leakage comes from charge capture, prior authorization, coding, denials, appeals or another part of the workflow. A clearly defined problem makes it possible to choose the appropriate technology and establish a meaningful measure of success.
• Integration matters as much as individual functionality. Stand-alone applications may solve isolated tasks, but using numerous point solutions can produce expensive and unreliable data transfers. Ware advises practices to prioritize technology that integrates closely with the EHR, practice management platform and other core systems of record.
• Prediction is most valuable when it leads to prevention. Flagging a claim immediately before submission may be too late if the missing information must come from the patient or physician. More advanced revenue cycle tools can bring guidance forward in the workflow, allowing staff to obtain required information while the patient is still present or while the clinician is completing documentation.
• Technology may reshape staffing and outsourcing decisions. Persistent hiring challenges are encouraging more organizations to consider strategic RCM partnerships. Better dashboards, real-time tracking and operational visibility can help leaders retain oversight even when work is handled outside the practice. AI-enabled guidance may also help less-experienced employees become productive more quickly, although knowledgeable revenue cycle professionals remain essential.
• Net collection rate remains a critical measure of financial health. By comparing the amount collected with the amount contractually available to collect, net collection rate provides a broad view of revenue cycle performance. Because it is a lagging indicator, however, practices should monitor it alongside earlier operational measures that can expose emerging authorization, denial and workflow problems.

Resources

• ModMed Revenue Cycle Management
• Connect with Rob on LinkedIn
• MGMA Insights Podcast Network
• Beyond the hype: Practical AI applications that improve access, capacity, and revenue (MGMA article)
• How AI and Human Talent Can Work Together to Transform Medical Practices (MGMA podcast)

Email us at dwilliams@mgma.com if you would like to appear on an episode. If you have a question about your practice that you would like us to answer, send an email to advisor@mgma.com. Don't forget to subscribe to our network wherever you get your podcasts!

This episode is sponsored by ModMed.
Every denied claim costs time and money to rework — for care you’ve already delivered. While payers sharpen their own AI tools, ModMed RCM Services pairs seasoned billing specialists with AI designed to help flag claims at risk before they go out the door, so your team can fix issues upfront instead of appealing after the fact. Learn more here.