Navigating the No Surprises Act: Technology, Strategy, and Revenue Cycle Transformation with Macedon Technologies

Hi everyone, this is Lucas Vos with Becker's Health Care. Thanks so much for tuning into the Becker's Health Care podcast series. It's great to have you. We're going to talk about the No Surprises Act and the impact of the No Surprises Act on Revenue Cycle Management for Health Care providers. Very excited to be joined by two guests today, Rami Fortea President and Chief Operating Officer of Neuromonitoring Associates, NMA, and Seth False Graph Healthcare Client Director at Macedon Technologies. Rami and Seth, thanks so much for being here today. Appreciate it. Thanks for having us. Yeah, absolutely. I want to start with introductions here really quickly. Rami, why don't we start with you? Could you just introduce yourself and share a bit about your work in health care? Yeah, absolutely. My name is Rami Forte. As you said, President Silo of Neuromonitoring Associates, which is third party health care service, or we provide something called Interoperative Neuromonitoring. I've been working in this industry for over 20 years, started on the ground floor as one of the technologists in the operating room, and through time and experience, have been able to rise the ranks into more leadership. So most of my experience has been delivering health care directly to patients, but as a third party too, the general health care system. Seth, over to you. Yeah, you bet. Thanks for having me. Luke, I appreciate it. Again, Seth False Graph and I lead our health care automation strategy here at Macedon Technologies. Macedon, we specialize in deploying bespoke or custom software applications that help providers intelligently automate critical and what I would refer to as high friction, business processes or workflows, especially in revenue cycle management, but lately that's been focusing a lot of our time and effort heavily on the no surprises act. So great to be here. Look forward to the conversation. Yeah, there's certainly a big topic and something that a lot of people are concerned about or are addressing right now and we want to make it a topic for today as well. And again, the no surprises act is designed to protect patients from unexpected out of network medical bills. There's new operational demands for providers though that it has introduced, which certainly changed the landscape. I'd love to start with your perspectives on how this legislature legislation has affected sort of the day-to-day realities of revenue cycle operations and some of those key challenges or opportunities really that have emerged throughout this whole process. Ronnie, why don't we start with you on this one? Yeah, absolutely. It's a great question. I mean, I think on the surface, it completely changed how you do revenue cycle management. I think now we talk about traditional revenue cycle management versus now with arbitration and NSA involved. What used to be a very still laborious process that was more about how strategically you are about the way you appeal claims and submitting bills cleanly and ensuring that you don't miss deadlines, etc. It's now changed to a very laborious process that requires multiple steps in a very short windows that are initially handled manually, but now that we're everyone is looking to kind of automate, it's required a bunch of people initially. And now it's been more about finding technologies to kind of handle the workload that's come across. I think it's definitely been a challenge, but we have risen through that. And now it's allowed us to be a lot more strategic about how we're crafting our positions, how we're approaching open negotiations, and which is one of the key components of the total no-surprise act process, and also how we're bundling arbitrations versus taking them independently by CPT code. I mean, I think there's a lot of things that have come about that technology is like Macedon has helped us kind of realize the potential for, but it's definitely a big shift, and it has certainly turned us up on the side of our head and glad to finally be in our feet. So yeah, you certainly landed on your feet there. And yeah, no, I think that's what you mentioned too is this because it is this multi-step piece and there's so much involved that just takes a little bit of getting used to. And Seth, I'd love to come to you on this as well. Obviously, some of the challenges that were described there, and then also are there opportunities that have emerged as a result of all of this. You bet. Yeah. I mean, I think it's a great question. Maybe it may be if we rewind the clock just a bit back to 2022 when the no-surprise exact first came into play and the dispute process started opening up in Q2 of 2022. Really, if you think about it again, rewinding the clock a couple of years, many providers at that time weren't even sure if they were going to participate in the NSA dispute process or if the legislation was going to even going to stick around over the course of the next 12 or 18 or even 24 months. And as a result of that, most organizations, again, at that time approached managing this no-surprise exact and this dispute process very manually using tools that they had available to them, tools like Excel or smart sheets to manage kind of, again, what we call a very complex, a very high friction workflow process. Why I'm making that point is if we fast forward to today and you take that idea of, you know, we're not sure if we're going to participate or participate heavily or is this legislation going to be around? I'll add that whether even whether or not you are even eligible to participate or are not, I think there was a question of whether or not this applied to each individual kind of industry individually as well. 100%, yeah, 100%. And so, you know, I think and certainly Rami can attest as well, you know, this process for revenue cycle operators and operations in general, it's become a very significant and very much a permanent part of their operations, of their organization. So, I mean, you can look back at the CMS data if you want to look at 2022, at that time when the initial legislation was launched, CMS projected that roughly, no, I don't know, it was roughly 18 to 20,000 disputes would be submitted on an annualized basis. And if you fast forward to full calendar year 2024, CMS saw 1.5 million disputes initiated. Obviously, a far cry in almost a, you know, 65, 70, 70 x increase in the number of disputes. And so why am I saying this, like, what's my point and kind of back to your question, Lucas, in terms of, you know, challenges and opportunities, right? Some of the challenges that those providers face, and I definitely turn it over to Rami and he can add to this is, is when you think about managing this process manually versus the scale in which the process and the number of disputes are at today, having that exponential scale increase comes with major challenges. And we could talk for hours about what are the challenges that providers face, volumes of email and communications, first providers and idea identities and type timelines and deadlines and managing the negotiations, managing legal documentation, so on and so forth. But the net net is what we saw three years ago in 2022, where organizations were building processes and managing those manual tools, those manual tools just simply couldn't scale to the volume that we're seeing now. And so that's where Macedon, that's where myself, we stepped in, we have, we saw the opportunity to partner with folks like Rami and normal monitoring associates and the other healthcare providers work with to build these custom software applications to automate really that end-to-end NSA dispute process, helping reduce operational burden and of course driving both top-line revenue and bottom-line cost savings. Yes, I'd love to go a little bit more into detail on some of those operational pieces that you just mentioned in terms of the pressures, again, that are on top of everybody right now. What are some of those strategies and process changes specifically in terms of technologies itself, right, that you're seeing organizations leverage to strengthen compliance while also, again, preserving that revenue integrity piece as well. Yeah, you bet. I'll give you a couple and then love to love to hear Rami's take on it as well in terms of operational challenges that he saw and then strategies and things of that nature. But I mean, big boulders that we've seen, it's significant in terms of the amount of just sheer email communication that has to go back and forth between payers, providers, and these arbitrators, these IDR entities. And being able to keep up with this volume of emails, understanding, is this an email I need to pay attention to, is this an auto-generated email, how do I log this for auditability, purposes later on down in the process when providers maybe challenged, did you go through each process, specifically the open negotiation process, before initiating the dispute resolution with the IDR entity. So email is huge, which sounds a little silly, but at the end of the day, it's significant, it's significant challenge to understand and digest all of that communication. And then you go through, for some organizations, the open negotiation process, just isn't a thing for other organizations, it's a massive, massive differentiator in terms of being able to negotiate a settlement prior to going through the dispute resolution process. And there's reasons why different organizations are different in that regard. And then you go through from a strategy perspective, and this may be the last one, from an arbitrator selection perspective, which arbitrators right now there's and Rami correct me if I'm wrong, I believe there's about 15 IDR entities. Yeah, 13, I think there's two pending, right? So yeah, so I think I think people are adding into it, but for the last four years, it's been 13. And so you think about which arbitrator do we want to select, what are our wind rates based on the arbitrator, how fast are they turning around their awards, how fast are they reimbursing us, are the things that we have to pay them, things like that. So there's a lot of strategy involved between pairs and providers in terms of what is the arbitrator that we're going to request, and how do we go about selecting that, and then how do we stack rank those IDR entities? Are we doing it manually, are we doing some intelligence around it, are we using information and data in order to reprioritize our IDR entity selection process. So those are a handful of things, kind of the big boulders, if you will, some of the big pieces that weren't helping organizations manage smartly and intelligently. But again, let me turn over to Rami, I'd love to get his take as well. Yeah, Rami, what does this look like in practice in terms of, can you share a couple of examples or outcomes that speak to this, what is this, what's working in practice, what does this look like? Yeah, so in terms of like a fully automated system that we built with the mess down, what it looks like is what we were doing before was manually adding payments to a spreadsheet or a smart sheet, and attempting to track all the specific times and dates that things were due and creating forms that were needed to be submitted within like a three day timeline, and then opening what they call IDR submission, where you have to log into a portal, and having to track all this, thousands of claims and thousands of different IDRs dispute numbers, and did you pay here, or have you not paid this one yet, and have you been reimbursed here, and oh, did we get an award on this? That's what it looked like at the start to what we have now, which is payments flow directly into our Appian platform, that massive on bill for us. They are filtered and vetted into the appropriate buckets, emails that Seth talked about, the thousands of emails that are received, I think last year, for our arbitration team, they received over 250,000 emails in regards to our specific claims, or tag automatically, and auto kind of assigned to our team members. Once we kind of filter out the claims into our open negotiations portal, we clip open negotiations, the form is created for us automatically, it's submitted to the appropriate entity appropriately, and really what we're doing now is just being more strategic about how we're handling, like what our decisions are. Do we want to open negotiations on all of our payments? Do we want to be strategic about how our position statements are worded, and how do we support our documentation? I think to kind of flip back to the start of the beginning 2022, we were just trying to get payments through and not lose claims, because the reality is if you miss a deadline or you don't open negotiations, or if you didn't pay your invoice, the chance for revenue is dead, it's gone. You failed, and that's spillage, and no organization. So what went from us just trying to meet all the deadlines and try to accomplish all the tasks that needed to happen. It's really turned into a very automated, streamlined platform that all of our team members are working in the same system that they know what's happened with each claim that we are now thinking on an elevated level. Do I want to bundle my arbitrations? Do I want to pick this IDRE, as Seth mentioned, based on what the insurance type is, or what procedure code we're building for? It's allowed us to, again, like you said, you asked about where that strategy comes in. It's really been much more easy to kind of implement strategy, now that we are not so induated with, it'd be open negotiations on this, or have we submitted our invoice for this, or have we paid this, it's done for us, and it's been a really, really impactful to the organization. I think if we talk about old RCM process before the NSA was started, as an out-of-network provider, which I've always lived in an environment of being an out-of-network provider, if there's just not really an avenue for neural monitoring companies to become in network, it's not been a thing that providers have wanted to do, our insurance carriers have wanted to do. We never had a voice with the insurance companies. We would just submit bills, and we'd get paper documents back, and they would tell us why we're denied, or why we're not medically necessary, and we kind of just had to live with it. So every day was really a crap shoot on whether or not we were going to get paid, and we used to track things like zero paper sentence, because that's how often we weren't getting paid, and you flip that to with an open negotiations period, which has been really positive, I think, for providers in general, to actually have a voice and actually have an independent third party to kind of assess fair market value for the services we're provided, to the important services for our patients. So it's really been a positive for us. It was really difficult at the beginning to be able to kind of handle all these deadlines and tasks, and the workload to create position savings was overwhelming. And then really vetting payments as to whether or not their NSA eligible is a whole other topic set that we haven't really brought up. Now that we've done this, and we've put this all in this automated Appian platform that masks it on so massively put together, we're thinking strategically as you talk about. We are being we are picking idearies based on insurance carrier. We are picking, you know, whether we bundle these arbitrations together or not based on kind of the procedure and who the healthcare or the healthcare insurance provider is. So lots of opportunities to be strategic and really elevating the type of work that our team is doing, you know, instead of becoming a task master and just kind of make sure you get to the day. Now they're actually able to be spotting trends and identifying where we are able to improve our our outcomes. And again, like you said, you're just being being strategic is has been really really okay focusing on the important things, which is which is key. So where's this where are we going next then? So I want to pose that question to you both really on on what are as we're continuing this process continuing to adapt rights. Where's this conversation heading? What are some of those other focus areas that you're looking at that might potentially come up? What should leaders keep in mind? Seth, I'd love to start off with you on this one. Yeah, he bet. And so I mean, what we're seeing, I mean, the no surprises act for our work with healthcare providers has been has been a catalyst. It's it's put it in its pushing providers to think more strategically about how they can handle, not only the NSA, but other high friction workflows across the revenue cycle. I mean, NSA is just one of many and we're on me contact this as well. But many administrative processes that kind of suffer from this really the same root cause with the manual processes, fragmented systems, and manual workarounds that kind of put compliance in and revenue at risk. So to answer your question, Lucas, a little bit more specifically, where are we seeing organizations? Once we have a framework in place for automating the NSA, where are they going next? So examples of this are we're working with providers on how we can look at their denied claims and how we can automate the appeals process. And this is everything from gathering information to consolidating documentation that may live in a number of different systems. This could be the explanation of benefits and other medical records. And then how we can use next generation technology, which we probably shouldn't say next generation technology when we're referring to artificial intelligence. That is not next generation. That's this generation technology. But leveraging things like artificial intelligence to intelligently summarize documentation, extract the salient arguments within that documentation, and then write a draft of the appeal. And be able to spit out that appeal and fast forward your health care providers appeal process for maybe weeks or months to days or even hours. So that's a big piece of what we've seen where organizations are kind of taking this this program and where they go next. But there's other things, you know, patient experience and portals for patients to be able to log in to submit information to fast track, recycle operators in order to submit claims, do it on time. To things like Macedon, we're a big proponent of the HFMA conferences. And one of the biggest conversations that we've seen at HFMA over the past six months are workflow processes around pay or contract negotiation management. I am more specifically around the strategy and the internal strategy for managing those pay or contract negotiation or renegotiations. How are we going to do that? What are we going to ask for? What are the payers going to ask for? Do we have executive buy-in and sign off? Should we want to give to get? And then what's our strategy if we end up going from in network to out of network? And all of that is typically managed in very manual processes, Excel, email, Slack messages, Microsoft Teams. We're helping organizations govern that process, consolidate the right information, and quite frankly automate aspects of those tactical workflows in these types of processes, really again, to drive both top line and bottom line cost savings. Making things easier, as Rami said, making things easier for folks, improving workflows, getting there. Rami, really quickly too, what's next for you? What do you think or some of those things? What are the things that you're thinking about? What do you think other leaders should be thinking about in this space? And what do you focus on? Absolutely. I think for neuromontory associates or NMA specifically, we jumped on the automation AI train early even prior to the NSA process. We were very mindful of our patient intake process. And scheduling system, we were having lots of difficulty with lots of different customers 1300 hospital partners across the country. And we were receiving scheduling information in a very interesting way from each of them. And so we wanted to kind of be easy to work with. And so we kind of built our systems in a manner to kind of collect that information, no matter how our customers wanted to. But I think where we're headed next is aligns with what Seth talked about, a patient portal that we think is very important. In addition to that, right now we are operating in multiple systems and doing our RCM, our traditional RCM in one system in our EMR platform and another. And now our NSA process is in happy and with massive on. I think we're going to look to kind of consolidate a bit and try to bring in some of the automation and AI we've already built with existing vendors and try to consolidate that down. I think there's a lot of value in what your traditional RCM team is doing with their billing and coding team and the traditional AR team is doing can impact what the NSA and arbitration teams are doing. And so we're going to try to get into one system where there's like this cross-departmental communication happening and really start to leverage that automation throughout the whole front end process and start to use that strategy. We talked about earlier across our entire Revenue Cycle Management process as opposed to just focusing on the NSA. Again, I think it's a great place for people to start. I think it's probably the lowest-hanging fruit and really will give the biggest upside in ROI. But as we continue to scale the business and look out to kind of grow, we think that there's a lot of value in bringing our systems under one house and under one name and allowing us to kind of be strategic and communicate within the same platform as opposed to trying to build pipelines and API connections that aren't always the most reasonable. And to be candid, I mean, I could have went out and found some out of the box NSA platform or use my EMR to kind of build something like what we wanted. But we were really focused on getting something custom and making sure that we controlled those processes. We felt like we knew what we wanted to do and what we knew it would work best for our team. And so it was important for us to kind of to do it from from our vantage point and not necessarily from what some third party has already put together. So yeah, I think that's what's coming for us. We're going to head down that path. It was very exciting. And I think again, you've mentioned both of you, so many great insights throughout the conversation. I feel like we have to have this conversation again with more of those newer trends and newer innovations that are coming up. Ramiya and Seth, thanks so much for your time, both of you for your insights. Thanks for being here. Really appreciate it. Absolutely. Thanks. Appreciate it. And we also want to thank our podcast sponsor, Mastodon. You can tune into more podcasts from Becker's Healthcare by visiting our podcast page at Becker's Hospital Review dot com.