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Hi, everyone. This is Lucas Voss with the

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Becker's Healthcare podcast series. Thanks so much for

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tuning in today. Very excited to have you.

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And I am excited and thrilled to be

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joined by Mark Johnson, senior vice president at

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Saris, who will talk to us about payment

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integrity. Very important topic. Mark, thanks so much

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for being here today. Thanks for having me,

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Lucas. Appreciate it. Mark, we'll start off with

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introductions here. If you just wanna give us

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a quick introduction to yourself and just your

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your background in health care and your career

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so far.

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Absolutely. I've been with,

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Cirrus now for a little over five years,

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but my background, you know, is around thirty

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years experience in the health care space. I've

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been in patient care at the bedside,

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into medical billing, payment integrity, insurance.

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Really, I've I've led significant product improvements in

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that thirty years at Cirrus. We're part of

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the CorVel Corporation.

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I've been at Blue Cross Blue Shield in

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Minnesota.

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I had a stint at UnitedHealth Group as

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well. My background includes patient care,

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payment integrity,

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vendor management,

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regulatory

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compliance.

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I've done some international

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operations startups as well.

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Educationally, I've got a bachelor's degree in physiology

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from the University of Minnesota

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and an MBA from Regis University.

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Go Gophers

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in in that case. Go Gophers. Go big

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10. Yeah. Ex exactly. We'll we'll go with

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that.

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Well, again, Mark, it's it's great to have

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you, and this is an important topic today.

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I was doing research for this podcast, and

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and this stat just really stood out to

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me. There's an estimation that up to eighty

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percent yes. You heard that right. Eighty percent

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of medical bills

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contain

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errors, which is staggering.

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As leaders in the payer space increasingly

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look to really optimize

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processes, we know that's happening, especially around billing

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and payments.

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What's the role of payment integrity

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from your perspective, and why is it so

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important?

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Yeah. Payment integrity

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in the payer space is incredibly important. It

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just ensures that claims are accurately

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processed

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and more importantly, accurately reimbursed

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to the providers.

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It helps prevent errors, fraud, waste, and abuse.

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Really, this is crucial

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because it helps maintain financial stability, not only

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for the payer, but for the providers being

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impacted.

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It also enhances the trust between the payers

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and the providers.

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And, you know, lastly, it ensures that the

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health care dollars are being used appropriately.

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That's why payment integrity is so important.

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Yeah. It's sort of a I view it

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sort of as a as a foundational

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piece. It's really the foundation that a lot

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of things stand on. And if that foundation

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isn't there,

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then there are going to be problems as

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you've outlined.

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And

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the process is is really key to this

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to this area,

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the process around,

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around everything that you've touched on.

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How can changing the process

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around payments

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reduce some of these numbers of errors, right,

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80?

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And what strategies have you found beneficial?

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Do you have any examples that that stood

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out to you and some of the results

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that that you see that that make a

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difference?

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Sure, Lucas. I'm I'm trying to think over

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thirty years, payment integrity really didn't exist thirty

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years ago. Right? And it's going through a

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lot

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of transition right now, a lot of growth.

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I can think of maybe four or five

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key strategies that payers might wanna contemplate.

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The first would be

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to centralize their payment integrity strategy.

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Take a centralized approach that integrates your prepay

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editing reviews,

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your post pay auditing capabilities,

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and as well as your innovation teams, your

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r and d teams in order to streamline

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processes

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and try to reduce those errors,

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especially prepayment.

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Secondly, I would say

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when you're thinking about artificial intelligence

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and machine learning, those are big buzzwords

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lately,

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really think about it as a complement to

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the clinical teams that you have deployed in

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your payment integrity space as well as your

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certified coders.

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Utilizing AI,

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machine learning for real time analysis of claims,

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proactively

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identifying high risk claims,

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and really helping your clinicians and your coders

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identify,

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those claims quickly can significantly

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enhance your accuracy and as well as throughput

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for the teams working those claims.

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Third strategy,

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contemplate a second pass claims editing process.

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A second pass vendor, second pass process, or

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even a final filter on claims

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can really help catch errors that are missed

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in primary editing phases.

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Just, again, reducing inappropriate payments from going out

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the door.

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Fourth, and this is a big one,

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coordination of benefits.

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Mhmm. We really need a strong coordination of

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benefits program. You may want to consider adopting

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a pause and pay approach

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with advanced analytics again, right, to ensure you're

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correct payment responsibility,

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eligibility validation before the claims are even paid.

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Just reduce that overpayment from going out the

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door

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and all of the overhead associated with the

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pay and chase model.

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Lastly,

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quality assurance programs.

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Establishing a robust

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QA program

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to conduct pre billing audits can really catch

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errors early and then just improve overall billing

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accuracy.

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I guess with these strategies,

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you know, health care payers

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can really enhance their payment integrity program and

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reduce those errors, really ultimately

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improving overall financial performance.

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Yeah. Absolutely. And just as a as a

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quick follow-up to that, should this be a

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a holistic approach as in we're focusing on

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all of these strategies, we're incorporating them all,

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or is there one focus area from the

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things that you just mentioned that that, organizations

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should look at?

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I all. I would I would be looking

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at all of these right now. If you

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had to prioritize,

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something, I would I would try to centralize

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your payment integrity strategy.

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You may have payers may have post pay

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services, prepay services,

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clinical utilization

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management services, all under different

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leaderships

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Mhmm. Or strategies.

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And some of those strategies may be at

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odds with each other. Make sure you're all

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aligned

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first.

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And then you then you can really start

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digging into

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solutions,

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vendor partners,

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like Cirrus

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or any other,

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technology play.

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Yeah. Absolutely.

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Which leads me to my next point, and

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this was one of your your strategies or

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one of the pieces of that you've mentioned

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that are really important right now. The modernization

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efforts

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efforts that are happening in the payer space.

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They are all over. You've mentioned the buzzwords.

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Right? AI. It's it's all over the place.

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Again, touch on how you see technology

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evolving and really making an impact on reducing

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errors and enhancing

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payment integrity.

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What are you looking forward to right beyond

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those buzzwords, and how should organizations prepare?

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Wow. That's it's such a big area. The

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technologies are just evolving

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so rapidly.

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I would say that if if you have

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an AI strategy,

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excellent. If you don't, get one quickly.

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Innovations such as artificial intelligence,

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digital payment systems,

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finance solutions, just embedded finance solutions are really

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transforming health care payments. Mhmm. Providers

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themselves

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are starting to look at these these technologies

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as well to help them with their revenue

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cycle.

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So while this these technologies

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I mean, all of this tech play

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can really help automate billing processes and reduce

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manual errors and just improve that rev cycle

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for both payers and and providers.

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It's still going to be important to have

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that

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human

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touch, that clinical

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overview, that coder overview.

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You don't want to get caught

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automating your your edits, automating your your solutions.

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Technology can help,

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but you shouldn't put all of your eggs

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in just in that baskets.

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You know, adopting advanced payment technologies,

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making sure that that cash is flowing

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smoothly and accurately between the payer and the

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provider. And I think that's that's really where

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you're gonna wanna be focused.

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Yeah. Absolutely.

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Well, Mark, thank you so much for sharing

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all of your insights here. Again, thirty years

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of experience. We really appreciate you taking the

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time today. Thanks for being here.

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I appreciate it, Lucas. Thank you for the

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time. I I really do.

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Yeah. Absolutely. Thanks for sharing everything. And I'd

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also like to thank Suresh as well for

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sponsoring this episode. And you can tune in

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to more podcast from Becker's Healthcare by visiting

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our podcast page at beckershospitalreview.com.