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 beckershospitalreview.com.