Full Transcript

Q+A with Surya Ravulaparthy, VP Revenue Cycle at Marshfield Clinic.

Introduction

Ben Reigle: Surya, welcome to the show. Surya is the VP of revenue cycle at Marshfield Clinic, an entrepreneur, and former consultant.

Surya: Thank you, Ben. Thanks for the opportunity, and I'm excited to have this conversation today.

Background

BR: Why don't you just give us a quick background, how did you get into revenue cycle?

SR: I've been in the revenue cycle space for a little over 15 years. Part of it is personal. Part of it is just like the career driving me here. When I moved into moved to the US back in 2000, I worked as an engineer, but also had some personal issues with healthcare. I found that the financial experience and the clinical experience were very different. I had a great clinical experience, but very tepid financial experience. And at the same time, I was thinking about going to business school and thinking about what to do next with my career. And I was like, oh, this looks like ripe with opportunity.

So that's how I got into healthcare and revenue cycle. I've been fortunate to play different roles. A lot of my career was being a consultant, focused on revenue cycle strategy and operations. Then I was a technologist and also a vendor for some time.

BR: When you say technologist, what do you mean?

SR: Core EMR implementation was my first foray into technology and then in the automation space. So towards the latter part of my Deloitte career, I was more on the automation side of things, delving a little bit into AI, which was at very early stage at that point.

BR: How did you end up taking job at Marshfield? Like what, how did that transpire?

SR: It was just the next step in the career, right? So I experienced all these different roles and phases, if you will. And what was missing for me was like just really getting into the mindset of an operator.

For me as a consultant or a vendor, my responsibility was always to an organization. I was always focused on how to make the organization better. Even though there was this secondary thing of ultimately impacting patients, the patients were not my first client. It was always the organization.

Part of my decision making and my experience over the last 14 months being in the operator role is that my primary responsibility is to the patients and the community. Which is entirely different. That's what I was kind of missing and why I wanted to make that transition.

BR: As I've gotten into this role for longer, there's like a lot of other stuff involved that, as a consultant, you just don't see. When I was a consultant, I always thought - these guys move so slow. But I realized that hospitals are a big ship. Trying to move quickly is hard. There's a lot of other factors involved.

SR: Yeah, totally agree with you and what you said. And one of the points that's important is that doing projects is one thing, but as an operator every patient is important, right? So you have this diversified responsibility of every small thing matters, even though you have these strategic things you're focusing on. So you have to split and prioritize your time appropriately.

BR: I'd be curious to know from your perspective, what is it like being on the side you're on now and knowing what you know now. Would you have done things differently as a vendor?

SR: I don't know if I would do things differently, but I would be more patient now. I’ve been in different roles but the most recent was in sales. I would always think, wait, I sent this contract recently. Why are they not responding? I used to think they weren’t doing stuff. But now I know.

Priorities

BR: What are the things that are keeping you up at night? What are the things that have been tough, or something you’ve just been really focused on?

SR: When I think about it, the core problems in revenue cycle haven't changed from what they were 15 years ago. If I went back and thought about my first ever project in revenue cycle as a consultant, I was talking about the same things. And I'm sure somebody that's done this for 30 years would probably say something similar.

The number one problem is getting my denials down - prevent the revenue leakage. There's definitely an increased acuity to that problem now, especially over the last few years in a post-COVID world. I believe the technology is improving and payers are getting smarter on how they adjudicate claims.

BR: And how would you characterize it now versus pre-COVID? Would you say that it's changed?

SR: I think there's certain types of denials that have increased. Payers want more information before they process the payment. That seems to be definitely one area where we're seeing a lot of spikes post COVID in my experience.

Clinical denials are another area. As payers put more rules in place for authorizations, we are seeing some of the clinical denials go up.

Payors

BR: And how have you seen like your relationships with your payers evolve? I'm just curious, I as this is a common theme we've been hearing: clinical denials and additional information requests has changed dramatically. What are those conversations like?

SR: The way I look at it is that we're all in this ecosystem and we all have a part to play. I guess the short answer to your question is that it varies. We have some payers that are extremely collaborative, and we work with them very well, and some where we have to continue to work through all the layers of communication. But it’s a continuous challenge because we live in this complex world of reimbursement.

BR: I like the use of the word “Ecosystem” because relationships will vary by payer and market. It’s one reason why providers struggle. Insurers have a national footprint. They know exactly what's happening in all these different markets. And that's where providers just don't have enough scale to affect change.

SR: Yeah, I agree with you. And to have a good data-driven decision-making approach, providers are disadvantaged, right? Providers are regional, and typically looking at just our data, whereas the payers are coming in with a lot more volume of the data. So they are able to make decisions made based on a much broader data set than providers.

BR: Yeah, I had this crazy idea. This thing came up at forum last year. This is idea around just creating some standard contract language that providers can enforce with payers. What we started to hear from people was that there's just all these different little things that get into contract somehow. You're just like, how did they get that in the contract? But I also think, to your point about scale, is let's have the same contract language or some parts that are the same.

SR: No, it's not a crazy idea. I was at a HFMA executive council session where we were talking about these topics. HFMA brought in some experts around contract language. For example, what are the things that should be the baseline expectations from a provider side of things. What are some of the big no-no's, etc. So yeah, it's definitely a valid thought and a direction that we need to go. Because as a provider organization, you know what you know, and unless you rely on your cohort, it's hard to get a good understanding of what else is happening outside in the industry.

BR: Yeah, I just think it probably goes on this point of the fact that providers typically don’t have a united front. Especially saying no to certain things. For example, providers didn't invent the copay or the residual balance. Hospitals certainly didn't invent it, right? But providers got stuck with it somehow.

Cybersecurity

BR: Let's take a question. Kevin asked a good one about being more specific about this current state we're in: “Due to the recent change health breach, is Marshfield evaluating their cybersecurity policies?”

So not just trying to figure out the clearinghouse issues, but in general, on the cybersecurity front.

SR: Yeah, they are definitely heightened, but I don't know if we're fundamentally changing much. Our legal and compliance team have been strong throughout this process. There's a lot of these things internally that we do, it's not just the business owner that's making the decision. Our team is thinking through all these other elements. For example, our IS security team is making sure their data requirements that get passed through are safe. Legal and compliance is ensuring the right checks and balances in place in case something like this happens, right?

Our teams did a great job like this whole change healthcare issue. We were very fast to respond initially. We were very fast to get some backups in place.

So I wouldn't say we've changed fundamentally. There's definitely a heightened sense of concern, but we’ve had the right checks and balances in place the entire time.

BR: If I'm a vendor and need to connect to something, or I have data from you there is obviously going to be a different level of scrutiny. Do you think that contracting takes longer?

SR: Yeah, I would say just understanding the level of risk has changed in the marketplace. As we go through more of this data being out there, how are providers and the vendor partners managing that risk? For example, in a typical contract there's always liability clauses. What are the vendors bringing to the table now that we acknowledge there is a bigger risk now than there was in the past. I think that'll determine the speed at which some of these partnerships move through.

BR: Are you asking for more cybersecurity insurance for the vendor, or did you already have a high amount? I'm curious if that's changed.

SR: I don't have particular numbers in the post change health cyberattack era, if you will. I just know that our legal teams already had it in place.

AI Governance

SR: As we were going through this transformation into more automation and AI, one of the things we had done at Marshfield was set up an AI governance committee.

Essentially, it’s a cross-functional team that has clinical, revenue, finance, legal, and compliance. We're looking at these challenges from the perspective of not only vendors coming in and the risks they present, but also fundamentally how we should be thinking differently in this new world where more data is being put out there for different purposes, etc.

BR: I'm curious about your AI committee. Are you guys looking at vendors and use cases you’re excited about? There are some practical uses in my everyday life, but its limited.

From a healthcare perspective, are people concerned that they could implement something that has unintended consequences? For example, the risk of implementing something the organization thought was gonna be really helpful, but it actually steered us in the wrong direction, or we're making bad decisions because of it. Is that what the committee's intended for?

SR: I'd say over my 14 months, this is one of our crown jewel type projects. I feel like we are on the cutting edge at thinking through some of this. As an example, one of the things we're looking at are the ethical considerations? So when people are putting these models and AI solutions out there -what testing has been done so the outcomes are what we expect and we don't have unintended consequences.

So initially when we were asking these questions, a lot of vendors would say, well, we don't take any patient demographic data, so you don't have to worry about these ethical considerations. But that's not the question. The question is how do the outcomes really come from the model? Have you tested against them?

We've definitely seen the growth in our partners that are coming in with better answers to those types of questions. Some partners have done more of that type of testing and understand what outcomes their models will produce.

BR: I'd be curious to see how that changes over time. Especially as you get inundated with things that are changing. Because we're certainly in the curve right now where there's going to be a lot of failures. So, like anything, everyone's going to be super excited. Whether it's the internet or a cell phone. There is this initial excitement from companies - they're going to use this, it's going to change everything, etc. But then we see this crash because it took a while actually to figure out what the valuable use cases are. So we're in that period right now where there's a lot of excitement, but there's going to be a bunch of failures.

It's good that you have a committee because I think that is helpful for evaluation and getting consensus on decisions.

SR: Yeah, that is absolutely right. As we're thinking through partners in this space, a few things are important for us to understand, right? AI is a tool, right? Ultimately our objectives haven't changed (better patient experience, better financials for the organization) So whether that happens through me clicking a button a hundred times, or AI doing it, or automation doing it, it doesn't matter. Ultimately, the outcomes are the most important thing.

As we're going through this, the biggest thing we're looking for are teams that are really capable of implementing these solutions in a nimble manner. The technology is important, but the team that comes along with it is also important.

BR: I like to say, you've got to walk before you run. I hear people be like, well, we got to get AI in there. I think, okay, what does that even mean? Let's get real for a second.

SR: Yeah, I absolutely agree. Solving the problem should drive what solution we use, right? And there's are very good use cases for tested technologies. RPA for example. And just because AI is here, doesn't mean the RPA use cases have gone away completely.

Rural Healthcare

BR: What are you most excited about? You've been in revenue cycle a long time. Is there anything that, besides AI, is something you're excited about?

SR: Marshfield is a rural healthcare system. We primarily serve the central Wisconsin and portions of Michigan from a rural health perspective. I fundamentally believe every healthcare provider is an extremely important entity to the community and I specifically I really value our role as a rural healthcare organization. So for me, being in a position to improve our patients experience is what really excites me.

Similar to other provider organizations, we have financial challenges. Now that we are in 2024, we are seeing the improvements we started in 2023.

Seeing the future state is really what excites me. And the ability to rely on this ecosystem of vendors, partners, payers, everybody to make that happen.

BR: And do you think you can remain independent? Or is it something where it’s like we've got to merge with somebody else to make this whole thing work?

SR: There's definitely much smarter people in our organization that are making those decisions. The scale of organizations is an important factor in our ability to serve our patients. So, I'm sure there's teams within our organizations that are continuing to look at what's the right.

Generative AI Use Cases

BR: What generative AI use case has garnered the most excitement at Marshfield?

SR: We have one around provider messaging. For example, how can we help our clinicians, with their time that's spent answering inquiries and things like that. We're doing a use case there, which is in the early stages, but we are making some good progress.

Back to my point about solving the problem. We need to look at the entire thing, right? It's great if we have Generative Ai responding to these inquiries, but we are also looking to understand if providers should be responding to this message in the first place. Why are we getting this many messages in the provider inbox? We are taking an end-to-end problem solving approach where Generative AI is not the single solution.

Offshoring work / Global workforce

BR: What are you looking to try new or pilot in operations?

SR: Solving for our staffing challenges. How can we get all this work done with the staff we have? One of the things were looking at is using a global workforce. A lot of outsourcing vendors already offshore work through a global workforce for cost efficiencies. The question we are trying to solve for with our pilot is: can our teams work closer with the global workforce teams without the vendor, so we can achieve those same efficiencies.

BR: Cool. Are you guys doing your own captive, like going direct, or are you just kind of working like a different model to work directly with your vendors that are offshore?

SR: Right now the pilot is just a different model working with offshore resources. Depending on this pilot, we may have different opportunities that we will explore in the future, but the initial pilot is just understanding how the operations will work. For example, just hiring the global teams and getting them closer to our teams.

BR: Yeah, one thing I funny about the offshore thing is that 15 years ago it was taboo. And now it's like, oh, you haven't done that yet? Which I always find fascinating.

SR: It's interesting, right? Some of this is simply that unknowns are scary to people. I had a conversation with one of our team members and the first question was - will they understand what I'm saying? I say, well, these people are not from Mars. It’s very similar to the way we work in a remote capacity. I sit in Dallas and our health system is in Wisconsin.

So getting through the change management, and creating a mindset that these (offshore) people are not any different. They're capable people that we can work with directly. But yeah, some great success initially. It's an interesting conversation initially for some of our staff to just get there.

BR: The hard part is that they're really smart. Many folks are college educated and fast. They're doing stuff like at another level, but they don't have Susie who's been working billing for 20 years. So the knowledge transfer is very important and getting teams working as an extension. I think was always like a huge gap for us, where it's initially it's like, we'll throw it over the wall and good luck. You're supposed to be doing this now. And I'm like, you wouldn't do that to anyone. You'd be more inclined to work as a team if it was anyone else. Back then (this is a long time ago)we had daily calls with everybody. We're helping these new teams learn. Because if we don't this is never going to work. It took 18 months, but I would say that was game changer.

You can't just replace 20 years of knowledge by putting it in a SOP and think everything's going to be fine.

SR: The other thing I would say when we talk about offshoring, it's the concern of jobs going offshoring. What I remind our teams is that this is work that was getting done offshore already. Like we are throwing work over the wall to a partner or vendor who is using offshore staff.

Right now, we just cannot find the people to do onshore. Especially when we talk about just the account receivables or some of the prior authorization work. With our pay scales, it's hard to find the volume of people that are needed to get the work done. So it's really focusing on what should be done offshore and getting some of the middlemen out of the process and let's get there ourselves.

Future of revenue cycle management

BR: I'd be curious to know your thoughts on this. 10 years from now, we're in 2035. What is the job description of a biller, or what is the profile of a biller look like?

SR: The technology has a long way to go from where we are today, but I think it will get us to a place where we don't have a billing department like we have today. It will be more like a leadership team that's working exceptions with support from automation and a global workforce. I see a future that is highly automated and globalized.

BR: Yeah, I don't think that it replaces people completely. There are enough decisions that are unique. It feels like you'll need people that are almost like data analysts and can build their own automations that will make them more efficient. Perhaps using AI to replace the yellow sticky notes, which everyone knows those are everywhere around someone's computer screen. Rather, staff are using tools to keep them super efficient.

Trying to get to a place where it is the right person looking at the right account at the right time. Tt feels like that person still is going to need knowledge to be able to make a decision, but they should be able to make lots of those decisions over the course of a day. If I work on 30 accounts a day, my sense is they should be able to do 130, because they're only having to make decisions and they're not making the phone calls for us.

SR: Yeah, I agree with you. The type of work you do changes. I can take an example of a prior authorization person. For example, there's a lot of manual work that's done today just to submit these prior authorization requests and all of these things. But all of that could be automated. And I see parts of that getting automated today, but it’s a journey and we're not anywhere close today. 10 years down the road I could see it.

The need for that person still exists because I need to prepare my patients for the surgery versus just getting this administrative prior authorization. There's more meaningful work that our teams would be able to do as bandwidth gets created by automation.

Closing

BR: Good stuff. Surya, thanks so much. I think this has been great.

SR: I appreciate the opportunity. Thank you.