Hi, everyone. This is Erica Spicer Mason with
Becker's Healthcare. Thank you so much for tuning
into the Becker's Healthcare podcast series.
So today, we're going to talk about how
AI and data driven insights are transforming reimbursement
strategy, pair contracting, and value based care readiness.
And joining me for this discussion are two
leaders from the Crane Ware Group. We have
with us Brian Werkinger,
senior vice president of revenue intelligence,
and Laurie Hanlon, vice president of reimbursement policy.
Brian and Laurie, welcome to the podcast. Thank
you so thank you both so much for
being here today.
Thank you for having us. Thank you.
Yeah. Thrilled to have you both. And before
we get into our conversation,
would you both like to say just a
little bit more about yourselves, your role, your
organization?
Brian, maybe you could get us started there.
Happy to, Erica. So Brian working here, senior
vice president of revenue intelligence at the Crane
Ware Group. Group. Me, myself, I've actually been
in the health care industry for for over
twenty years at this point,
coming with a a background
in heavily in the area of pricing and
payer analytics
in the healthcare industry, but that is not
all
what the Crane Ware Group does. That's just
me, myself.
And the Crane Ware Group as a whole
that we're here representing,
they they run the gamut of the revenue
cycle, what is historically known as the revenue
cycle within a health care organization.
Speaking of the provider side that is,
meaning we we get into making sure that
the bill is completely accurate from a coding
standpoint
via what we were founded on from a
CDM management standpoint about over twenty five years
ago,
to
making sure that we're modeling your payer information
appropriately into our platform in order to help
organizations
make decisions,
based on how they're being reimbursed,
doing medical necessity, charge capture. We also have
a whole other arm beside the the revenue
cycle side, which is the pharmacy, business of
pharmacy,
getting into helping organizations with the three forty
b side
and making sure they're tracking those appropriately
and optimizing
areas in the supply chain realm.
Wonderful. Brian, thanks so much. It's really helpful
to know a bit more about the Crane
Ware Group as well, some important work your
organization is doing.
Laurie, would you like to say a little
bit about yourself as well?
Sure. Thanks again for having us. My name
is Laurie Hanlon. I'm currently the vice president
of
reimbursement policy at the Craneware Group.
And as with Brian, I've been in the
industry now for quite some time, over twenty
years approaching well, actually, twenty five plus years
at this point.
And I've been in the space,
focused around reimbursement,
coding, billing, revenue cycle.
I've been in the academic world as an
adjunct
instructor,
for a a large university in Central Ohio.
But, you know, it's near and dear to
my heart as I continue
to go down this path of understanding how
hospitals,
providers are paid
and what can we do to support them.
Laurie, thank you so much for rounding us
out with the intros, and great to know
a bit more about your background and your
work in the academic space too.
And I know the the basis of our
conversation today, you know, we're we're talking a
lot about
payment processes
and and payer contracting,
reimbursement strategy.
And a lot of those areas, we're seeing
greater and greater use of technology
by health care organizations
to really better facilitate those processes and hopefully
see,
more robust reimbursements.
So my first question to you both is
how can AI and predictive modeling help providers
better understand the impact of current utilization patterns
within the context of those payer contract terms?
Yes. Yeah. So we're actually seeing AI and
predictive modeling becoming increasingly central
to how health systems evaluate their payer contracts,
especially
as utilization patterns shift in this post pandemic
world and care really continues to, migrate,
as we've seen it over the years, migrate
to the outpatient settings, and it's increasingly doing
so.
Traditionally, analyzing contract performance required that manual review
and retrospective
claims
reimbursement.
And that's changing. It's exciting, but it it
is changing. And today, organizations are starting to
use
artificial intelligence, as we all know, to interpret
the terms that are embedded in those payer
contracts.
So things like reimbursement logic,
carve outs, or even those tiered payment structures,
and and you pair that with real time
or recently utilization data.
This shows providers it allows providers to model
those what if scenarios.
For example,
what happens if orthopedic cases shift to ambulatory
settings? Or what if emergency department volumes spike
unexpectedly?
The models can forecast the financial implications
across multiple payers,
which obviously will give leaders
much more information and a clearer view of
where their exposure lies.
And importantly,
AI also supports being more, efficient with benchmarking.
It streamlines that process of comparing an organization's
performance to internal targets,
historical baseline,
or even if you went as far as
looking at external peer groups.
This is critical not just for identifying variances,
but also for guiding conversations around strategy,
air delivery optimization,
and
really looking at that contract refinement.
Another really important use as I think we're
all starting to hear more about is
detecting patterns.
So using AI to to do that pattern
detection.
And by analyzing
utilization alongside those contract terms, that we're talking
about, organizations can identify
underperforming
services
or utilization trends that aren't aligning with how
the contracts are structured.
And, really, this is especially relevant as more
payment models introduce complexity,
if you think of, like, those bundled payments
or tiered rates or even site neutral payments.
So as industry moves towards value based care,
which I know we're gonna get into,
as as we believe it's essential for providers
to build those internal capabilities around contract modelings.
And it's really not just for finance teams,
but for those clinical and operational leaders as
well.
And the goal is to shift from reactive
to proactive.
Using that data
to inform service,
line strategy,
maybe understanding risk better,
and preparing for those negotiations,
with much more informed position.
So ultimately, the health care system is heading
towards a more dynamic reimbursement structure.
Providers can combine
that AI driven contract intelligence
with real time utilization insight, and they're gonna
be better positioned to respond
to those market challenges and policy shifts before
they impact that bottom line.
Yeah. Laurie, thank you so much. Really interesting
to hear how technology is really driving this
proactive approach
to contracting,
negotiations,
reimbursement.
So really helpful overview. I I appreciate that
so much.
And you mentioned in your response,
well, you referenced complexity a few times. And
I know that we're seeing
payer and provider contracts becoming increasingly complex. So
can either you or Brian just elaborate a
bit more on how AI can help standardize
information to support better analysis of current payment
terms and also prepare for future contract structures?
Oh, absolutely.
Oh my gosh. And payer contracts today, I
think everybody could agree,
are anything
but uniform, anything but standardized.
As many out there know, even within the
same organization,
same provider,
terms and contract structures can
vary widely across their payers.
You have different methodologies,
different carve outs, different definitions of how you
find those carve outs,
and much more.
And that variability makes it so difficult for
providers to truly understand how they're gonna be
reimbursed and even harder
to compare performance
across payers or negotiate with confidence.
AI is really starting to play a a
really critical role, honestly, in addressing that complexity
by helping to standardize the contract
terms
in a way that they're the way that
they're, like,
essentially interpreted
and then, of course, how we analyze them.
So instead of reviewing each contract manually
and and trying to track down
dozens of reimbursement
logistics and and look at different spreadsheets and
documents,
AI can take that information
and extract it and normalize those contract terms
into a consistent structure.
This enables providers to be able to see
side by side
how similar their services are and how similar
their those services are reimbursed across different agreements
and identify where terms might be misaligned,
with their clinical or operational realities, so what
they're actually doing.
And this is just as important as how
a standardized sets the stage for future planning.
So as payment models evolve,
as we see fee for service
move to more value based, bundled, or perhaps
even in some cases some hybrid models,
providers really need to understand
not only how they're being paid today,
but how those terms could shift in the
future.
AI can help simulate that. It can tell
us what the impact is going to be
of different contract structures,
based on the provider's unique patient population and
service mix.
So at the end, it's you know, really
by building a a standardized view
of existing payment terms and modeling how future
contracts could perform,
providers gain a much clearer path forward.
It supports stronger financial forecasting,
more informed negotiations,
and ultimately ensures that payment structures align again
with both that clinical priority as well as
long term sustainability.
And, Erica, if I can, I mean,
appreciate everything Lori's saying and and
so true, but I'm just gonna comment on
AI as a whole briefly here
on this? So, yes, AI can do all
this, and it's interesting when we talk to
providers
and we say, you know, all of this
is possible with AI. Everybody's extremely hesitant right
now. We heard it at the conference as
well with people saying that they're starting to
introduce AI, and it's how accurate is it.
And it is accurate, and I think it's
just important that it's gonna be a period
of time and a phased approach to organizations
accepting,
this incorporation of AI. It very much so
can do it. Laurie and I see it
with our own hands at the Crane Ware
Group, what it's capable of doing,
but it's getting comfortable because it's not a
human
completely
sort of there. At least that's what people
perceive it to be. But in actuality,
it very much incorporates
human that's driving the AI
and training it to do the things that
Lori has been referencing here. So it's absolutely
fascinating from my standpoint what it's capable of
doing as long as you have the right
people behind it building it to do the
items referenced
by Laurie.
It's such a such an important add on,
Brian. I completely understand where you're coming from
saying how at Becker's annual meeting just a
couple weeks ago, we we certainly hear a
lot of excitement around AI in in the
reimbursement
and payment space, but also, of course, hesitation
concern at the same time. So
I appreciate that clarification there.
And I wanna shift just a bit here
to talk a little bit about Medicare Advantage,
another topic that at the conference,
certainly, no
no shortage of topics and conversations
around MA. But
as we see shifts or potential pullbacks in
Medicare Advantage
in certain markets, especially, what are the implications
for hospitals and patients, especially communities that are
relying on managed care
models? Oh my goodness. This is
certainly an emerging and very important issue.
As as you said, we heard it at
the conference,
in several sessions.
But
as we look across our our makeup, our
our footprint of of our providers,
and in several markets, especially in those rural
areas or even the underserved
urban regions,
Medicare Advantage has filled a a very critical
gap, by providing managed care structures that help
patients navigate the system,
you know, coordinate care,
and really access services beyond what the traditional
Medicare
might offer.
And when we talk about Medicare Advantage going
away or plans
exiting specific geographies, we're not just talking about
a shift in payor mix.
We're really talking about the potential of unraveling
of local care,
the the management infrastructure.
So from a hospital perspective,
the change or disappearance even to an extent
of Medicare Advantage Plans can certainly
disrupt the long established patterns,
care coordination programs, and even
preventative service models. And many hospitals,
particularly those smaller or safety net facilities,
have invested care teams and outpatient supports that
are tied directly to how those Medicare Advantage
plans operate.
So, you know, if those plans exit,
hospitals
find themselves managing a more fragmented patient population
often with fewer resources
and less predictable
care pathways.
For patients, especially
those with chronic conditions,
the loss of managed care can mean losing
access
to disease management programs,
perhaps some transportation services, or even
simple appointment reminders.
The downstream
effect is often a return to the emergency
room
for those unmanaged or preventable issues.
And that's a real concern
in the markets that have already seen a
strain on acute care settings.
What we believe the industry needs to be
doing right now is scenario planning.
Understand where Medicare Advantage participation
may be unstable,
assessing how that affects those local provider networks,
and identify what safety nets or even policy
levers can be put in place.
And, Eric, I'm gonna chime in here again
and take it from a different sort of
not a different completely, but just piggybacking on
some of the things that Laurie was saying
here, but adding to it a little bit
and referencing some of the things that,
we both heard, Laurie and myself and maybe
yourself, Erica, at the conference, the the recent
payer conference.
Beyond just Medicare Advantage, the payer as a
whole
is also looking to potentially shift
maybe the types of plan offerings that they
provide and put on the table in front
of the their consumer, which is technically the
patient that's signing up for the coverage just
like Medicare Advantage.
So either one, either of those avenues,
when you go backwards a little bit in
terms of sort
of, not so much, I mean, well, Craneware
Group does
help providers
and moving away from the payer side, what
this means with this shift
is these patients
that Laurie was referencing
that maybe don't have the coverage,
where do they end up?
They end up going to the emergency department
within the providers. So they don't they don't
have the insurance that they need that puts
them on those necessary plans, which ultimately raises
and increases the cost to the provider to
provide that care because you're coming in as
maybe as a self pay.
Maybe you're a sicker patient.
So then
the care that you need at that point
in time, because you haven't been going along
the path with coverage and getting the care
along the way, you're sicker, you go in
and the cost to provide that care is
much higher,
then that burden is shifted to
the provider to take care of that. How
do they make sure that they are remaining
profitable
from a provider standpoint? Remember, yes, all these
organizations are not considered not for profit, but
at the end of the day, organizations
still need to make money to continue to
provide the care that is necessary
for the market that they serve. So if
these shifts happen that we're talking about, about
the Medicare Advantage maybe shifting and maybe pulling
back a little bit, that's gonna shift to
provide more cost in the organization and sicker
patients that they're taking care of that ultimately
can
lead to an impact on the provider's bottom
line.
Mhmm.
I really appreciate how you both outlined that
so clearly.
What a significant domino effect that is,
both to your points about, you know, how
this ultimately impacts a provider organization, but more
immediately patients as well.
So so really appreciate you both outlining kind
of the the potential consequences of some of
these shifts we're seeing in Medicare Advantage.
And I wanna stick with just for one
more question, I wanna stick on the payer
side for just a moment. You know, we're
seeing growing availability of payer transparency data. So
how do you recommend providers
think about using that information to really generate
meaningful insights and also to support decision making
with their services?
Oh, boy. Erica, there's been a lot of
data put pushed out there at the fingertips
for for everyone, not only the consumer,
but also the,
I guess, vendors,
the government.
There's access to both the payer side, the
hospital side's pushing data out there. But with
the release of this TIC data, what is
transparency
in coverage, what is what people call TIC,
that's on the payer side,
where they had to put out all the
the reimbursement
information in terms of what how they pay
the providers across the country.
It really put it at a whole different
sort of level from a standpoint of visibility
into
what those rates have
what they've negotiated,
across the health systems.
So now, as I was saying, so many
people have access to an overwhelming
volume of raw
rate files from payers
published to comply with federal transparency
regulations.
Although that's a major step forward in our
industry that we're in,
the real opportunity lies in what providers do
with that information.
And how can it be used to support
more constructive,
data informed conversations with payers?
So I will say, yes, it's out there.
But one of the things that that is
so important
to know is how that data is laid
out. And when I say laid out, how
it's been pushed out in files,
it doesn't necessarily
completely align with how maybe a payer contract
is structured.
So it does require,
some, I guess,
additional scrubbing to
almost normalize it and make it so that
it's usable,
for individuals to go back and then try
to figure out what is this saying, what
does this mean.
But what it does drive
is, in my mind, and is a better
partnership, and we and we heard that, I
think, at the payer conference as well.
It's no longer should be looked as an
enemy. You know, I'm either on the payer
side or I'm on the provider side.
This publishing of data is requiring
or leading us in the direction that they
actually truly work together
because
one can't survive without the other. So they
can't
be one-sided and and kinda going against each
other, which is in a way
how the industry has,
I guess, gone
to date.
And and both myself and Lori have been
in the industry for many years and we've
kinda seen it evolve,
in that way to a certain extent. So
that that's what I would say around this.
It's it really ties to
what are we gonna do with that data?
It's out there. So how
how do you you actually use it and
put it to good?
So I don't know, Laurie, if you wanted
to add anything to that.
Yeah. I I think that when we think
about this massive amount of data that's available
at our fingertips and to Brian's point, you
know, however it's used, it's gonna be used
in in different formats and different things and
interpreting it. But at the end of the
day, it's about looking at what's been
published or what's what's out there for for
folks to to absorb and ingest or whatnot.
And it really needs to be looked at
in the sense of it's not just to
compare rates. Right? We're not looking at just
to, say, well, this one pays more than
this one.
It's really there to help both the payer
and the provider understand
and and get the why behind the numbers
so providers can really approach payers with more
clear evidence based questions. So coming to them
and saying,
well, you know, where are the rates not
aligned with the market or service intensity or
maybe even looking into how can we ensure
reimbursement models reflect clinical realities
and operational investments.
So when really when this information
is used thoughtfully,
the data becomes a tool for collaboration, like
Brian mentioned, and and helping to identify those
shared goals
across access,
quality, and
even sustainability.
Mhmm. So as health care systems benefit, when
we're looking at both the provider and the
payer, when they're working from that common set
of facts, if you will, you've got more
information about
what do we have available to us and
how can we work together to strengthen
those relationships.
Shifting the conversation from reactive disputes to more
proactive alignment.
Mhmm.
Yeah. Laurie, Brian, I really appreciate these insights,
and it sounds like the data is there.
It's just perhaps not in a perfect format
yet, but it's going in a direction of
supporting this more collaborative relationship between
providers and payers.
And and I think that we're seeing that
in other areas too, especially
value based care payment models. You know, there's,
of course, payers and providers alike are interested
in the in the outcomes and the benefits
of those models.
And so my final question for our conversation
today, you know, as we're thinking about value
based care and how it continues to grow
and evolve,
how should providers be foe what should they
be focusing on to succeed in those models?
And how can better analysis and partnership
to both of your points play a role
in that success?
Yeah. So
value based payment,
This has been talked about even back when
I entered,
different forms of it back when I entered
the industry.
Still have a ton of fee for service
that's out there, although it's shrinking. But when
you look at value based payment,
it it really isn't new because, again, it's
been talked about for many years, but what
we're really seeing is a broadening and deepening
of these models
extending beyond primary care. So it's no longer
just about hitting a few quality metrics or
reducing readmissions.
For providers,
that means a shift in focus.
As value based care expands across more services
and patient populations,
providers are under
increasing pressure
to balance,
let's say clinical outcomes
with financial
sustainability.
It's no longer enough to manage a revenue
cycle efficiently.
Health systems now need to understand the true
cost of care to maintain competitive,
to remain accountable under these models.
And and that's a key piece. So one
of the things that they heavily talk about
with value based payment is the payment
and making sure you're hitting the quality metrics,
making you sure you're hitting all the different
levers
to actually receive the payment. But in all
actuality,
there's there's a fundamental
piece that's being missed.
That's great that you, as a provider, you're
getting the payment and you have this model.
But if you're not managing the overall
margin management,
which you're looking at the revenue piece with
the payment, but if you're you are not
factoring in the true cost of care that's
in that model,
that that's great that we've gone to value
based payment.
Hospitals are gonna sink because they're not managing
their margin and making sure that they're also
paying attention to the cost to provide that
care there. And it no longer can we
rely on the standard RCC model, the ratio
of cost to charge model, which is a
true is more of an estimate of what
it costs to provide the care.
You need to get down to a true
cost of care or what would also
cause it's not because it's not like a
manufacturing
industry, healthcare.
We've lived in a whole different realm
today
and still do for the most part. There's
very few organizations
that you could go to and say, I
understand my true cost.
It's an estimate off of a ratio of
cost to charge. So it is absolutely fantastic
that the industry is moving towards
value based payment. And I'm not sure what
the numbers are in terms of lives covered
under a value based payment model. I know
it's growing to your point, Erica. It is
definitely going up.
I think it's still a a ways away
because
people have to get that understanding of what
that cost is in that model. And I
think that's a missing component to really
springboard us forward in these payment models.
Yeah. Fantastic points, Brian. Thank you. And, Laurie,
before we close, just wanna check-in with you.
Any final thoughts on value based care or
anything else from our discussion?
No. This has been great. I appreciate the
opportunity to be able to dig into these
very near and dear topics to our hearts.
And it so this has been really helpful
to be able to talk through.
Yeah. Fantastic.
Well, Brian, Laurie, it's been great having you
both and your expertise on the podcast today.
So thank you so much again for being
here. And, of course, we'd like to also
thank our sponsor for today, the Crane Ware
Group.
Listeners, be sure to tune into more podcasts
from Becker's by visiting our podcast page at
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