Latest / Becker’s Healthcare Podcast / Deborah Greer, MD, System Lead for Advanced Appeals and Settlements, Denials Management and Prevention at CommonSpirit Health

Transcript

Deborah Greer, MD, System Lead for Advanced Appeals and Settlements, Denials Management and Prevention at CommonSpirit Health · Becker’s Healthcare Podcast

• 0:02
  - There's a small circle of people who truly
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  - Becker's fourteenth annual CEO and CFO roundtable
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  - workforce strategy, and the leadership questions that don't
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  - Join us November second through the fifth in
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  - Chicago.
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  - For the agenda and event details,
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  - visit beckershospitalreview.com
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  - and click on the events tab in the
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  - upper right.
• 0:51
  - This is Laura Dierdo with the Becker's Healthcare
• 0:53
  - podcast. I'm thrilled today to be joined by
• 0:55
  - doctor Deborah Greer, system lead of advanced appeals
• 0:58
  - and settlements, denials management, and prevention at CommonSpirit
• 1:02
  - Health. Doctor Greer, it's a pleasure to have
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  - you on the podcast today.
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  - Thank you for having me.
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  - I'm Deborah Greer. I'm family medicine by training,
• 1:11
  - and I practice for over twenty years before
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  - moving into family
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  - physician advisory work.
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  - Now I'm a physician advisor and the system
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  - lead for advanced appeals and settlements, denials management,
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  - and prevention with our internal physician advisory service
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  - or iPASS at CommonSpirit Health.
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  - So my work sits at the point where
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  - clinical care meets,
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  - health plan coverage,
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  - making sure patients are in the right status
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  - and taking up the conversation with health plans
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  - when there's a disagreement about that.
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  - And, again, thank you so much for having
• 1:42
  - me.
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  - Yeah. Absolutely. And it's fascinating to hear your
• 1:46
  - background and how you went from the clinical
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  - family medicine side into what you're doing now
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  - with revenue cycle and everything that goes along
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  - with it. What's it been like making that
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  - transition?
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  - You know, it is actually
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  - very, helpful.
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  - I have actually
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  - done the whole entire,
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  - pretty much gamut of, health care. So I've
• 2:07
  - been a hospitalist.
• 2:09
  - I've been primary care.
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  - I have, worked in post acute care, as
• 2:14
  - well as urgent care. So that's given me
• 2:16
  - the experience, the well rounded experience to understand
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  - when I went into revenue exactly what the
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  - journey of the patient is,
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  - and what the health plans are expecting.
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  - So it's actually been really helpful, and it's
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  - been a great journey for me.
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  - That's awesome to hear. Yeah. Thank you so
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  - much for sharing, and I'm excited for our
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  - conversation, especially given your background in so many
• 2:37
  - different areas of the health system.
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  - So I guess let's start off. Could you
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  - give us a quick state of the union?
• 2:43
  - What's going well this year, and what are
• 2:44
  - you focused on for the rest of 2026?
• 2:47
  - Sure. So physician advisory is growing, and it's
• 2:50
  - in better shape than it was a year
• 2:52
  - ago.
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  - Now let me start with what physician advisers
• 2:56
  - actually do because it's not their role of
• 2:58
  - hospitals.
• 3:00
  - So when a patient comes into the hospital,
• 3:03
  - someone,
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  - decides what kind of stay it is. Is
• 3:06
  - it an inpatient stay or is it observation?
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  - That is they're in a hospital bed, they're
• 3:10
  - getting care, but they're classified as outpatient. There's
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  - also outpatient in a bed,
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  - and that's what we call status determination.
• 3:18
  - It's based on clinical treatment of the patient.
• 3:21
  - Now it's a clinical call,
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  - a clinical call determination by the treating physician,
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  - but it also drives how the stay gets
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  - paid and what the patient may owe.
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  - So a physician adviser makes sure that the
• 3:33
  - determination fits the care the patient is actually
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  - getting.
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  - And when a health plan disagrees, we're the
• 3:39
  - ones who take up that conversation.
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  - Now it matters to patients. For example, observation
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  - days do not count toward the three inpatient
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  - days traditional Medicare
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  - requires before it'll cover a skilled nursing facility
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  - stay.
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  - So a patient can spend days in the
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  - hospital and still not qualify for the rehab
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  - they need, which may which means that they
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  - might go home with home health, which might
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  - not be ideal for that patient.
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  - So why is the field growing?
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  - I point to three things. First, criteria.
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  - These decisions get measured against standardized
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  - criteria. For example,
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  - Interqual,
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  - MCG, or a plan's own internal criteria.
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  - They're evidence based, and they give both sides
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  - a common reference point.
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  - But patients don't always fit them. For example,
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  - someone with multiple chronic conditions
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  - may clearly need to be in the hospital
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  - and still not meet a specific requirement on
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  - a specific day.
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  - So when that happens, the chart has to
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  - make the clinical thinking clear.
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  - And a lot of the time, the disagreement
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  - isn't about the medicine at all. It's that
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  - the documentation didn't tell the story that actually
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  - happened.
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  - Second,
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  - where a Medicare patient
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  - where Medicare patients are enrolled.
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  - So back in 2007,
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  - about nineteen percent of eligible beneficiaries were in
• 4:57
  - a Medicare Advantage Plan.
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  - Today, it's fifty five percent, and that's more
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  - than thirty five million people.
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  - Now Medicare Advantage reviews these cases in ways
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  - traditional Medicare largely doesn't.
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  - In 2024
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  - alone,
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  - plans issued close to 53,000,000
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  - prior authorization determinations.
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  - So the same patient with the same clinical
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  - picture is now in a program where status,
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  - length of stay, and where they go after
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  - discharge will all be reviewed.
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  - Third
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  - and very important is compliance.
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  - So getting status correct isn't just a financial
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  - question.
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  - It's a compliance question when it comes to
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  - government plans.
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  - If a stay is submitted as inpatient when
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  - it should have been outpatient and there's a
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  - pattern to it,
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  - that may be false claims act
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  - fines and settlements can run into tens of
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  - millions of dollars.
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  - So a big part of this job is
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  - protecting the organization and the treating physicians from
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  - being out of compliance with CMS.
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  - Now the big change in the last year
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  - or two is AI.
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  - It moved out of conference conversations and into
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  - real workflows
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  - on both sides of these determinations.
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  - And the field started working on guardrails at
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  - the same time instead of afterwards.
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  - So I believe
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  - AI can help prepare the argument, but it's
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  - a physician that makes the clinical determination and
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  - owns it.
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  - Okay. For
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  - the rest of 2026,
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  - there are two priorities.
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  - One is consistency.
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  - The same clinical question should get the same
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  - answer whenever it comes up.
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  - And two is capacity.
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  - Physician advisers are the subject matter experts, and
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  - knowledge takes years to build. So this field
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  - gets to grow significantly.
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  - And there's one more thing I'd like to
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  - see. When a case is denied, we learn
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  - exactly what questioned and why what was questioned
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  - and why.
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  - And that's far more useful to the provider
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  - documenting in real time than it is to
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  - us, the physician advisers,
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  - reading it months later. So if that information
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  - got sooner,
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  - there'd be fewer denials to begin with.
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  - That's really helpful to understand. You know? It's
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  - such a a complex process when you think
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  - about the billing system revenue cycle within health
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  - care and then throwing in the different,
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  - scrutiny on, as you mentioned, Medicaid or Medicare
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  - Advantage or all of those different types of
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  - things from the government programs,
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  - that differ from,
• 7:27
  - the the regular Medicare and then looking at,
• 7:29
  - commercial plans as well. It's a lot to
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  - keep track of the input together. So,
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  - I can imagine your team definitely has its
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  - work cut out for you.
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  - As you're looking ahead, what are some of
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  - the headwinds that you're keeping your eye on
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  - and preparing for?
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  - Yeah. So the honest answer is volume.
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  - The number of determinations and redeterminations
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  - moving back and forth between hospitals and health
• 7:52
  - plans has gone up a lot,
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  - And organizations are hiring to keep up with
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  - with that demand,
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  - but it eats a tremendous amount of clinical
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  - time, and that's time and money both of
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  - us would rather spend on patients.
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  - So the headwind,
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  - I'm watching most closely, is AI because it
• 8:10
  - cuts both ways.
• 8:11
  - So on the helpful side, it's real. It
• 8:14
  - can pull a long complicated chart together quickly.
• 8:18
  - It can flag a documentation gap while the
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  - patient is still in the bed, which is
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  - when it actually matters.
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  - And it can find patterns across thousands of
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  - denials that no person would ever see.
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  - But what concerns me is speed without judgment.
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  - Because if automation moves a determination
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  - faster without a clinician actually looking at the
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  - case, then all we've done is remove the
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  - judgment and keep the speed.
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  - So the guardrail I keep coming back to
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  - is that the decision has to stay with
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  - this physician who can be accountable for it.
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  - And a related piece is that adoption in
• 8:54
  - health care is slow, and, honestly, it should
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  - be.
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  - These tools are new. The validation standards aren't
• 9:01
  - settled, and there's no agreed upon benchmark for
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  - what good performance even looks like in this
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  - work.
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  - So you're being asked to move quickly on
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  - something that's largely untested in an environment where
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  - being wrong has consequences for patients
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  - and for health care organizations.
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  - So the governance is still being written, and
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  - it has to catch up with what the
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  - technology can already do.
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  - And the last headwind I'd name is experts
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  - in the field. Physician advisers need full credibility,
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  - and they need to know the regulations, and
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  - they need to be able to build and
• 9:35
  - work.
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  - So that can be a real hard combination
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  - to find, and it takes years to develop.
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  - So you can't hire your way out of
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  - all your problem quickly as a result.
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  - And that's fascinating to hear. You know, certainly,
• 9:49
  - those things that you've mentioned are top of
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  - mind, I know, for so many executives and
• 9:53
  - leaders within hospital health systems across the board
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  - and knowing how important not only the physician
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  - adviser role and, clinical guidance is within the
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  - organization, but also thinking about that revenue cycle
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  - side too,
• 10:06
  - to make sure you've got the financial,
• 10:09
  - foundation for the health system to do what
• 10:11
  - it needs to do,
• 10:12
  - on the clinical side. So I think especially
• 10:14
  - when you look at, as you've been talking
• 10:16
  - about technology, AI, and and figuring out how
• 10:19
  - to, bring that on smartly and thinking about
• 10:22
  - the governance and, then, you know, the the
• 10:24
  - people and the clinicians that are working with
• 10:26
  - it as well.
• 10:28
  - How have you seen it work well, and
• 10:29
  - is there any lessons that you've learned over
• 10:31
  - the past few months or or will be
• 10:33
  - applying as you go into the future,
• 10:36
  - in with,
• 10:38
  - you know, identifying additional technologies or figuring out
• 10:41
  - ways to make sure you're optimizing the technologies
• 10:43
  - you already
• 10:45
  - Yeah. So, I would say probably,
• 10:48
  - looking all of at all of that, we
• 10:50
  - have an opportunity, and the biggest opportunity is,
• 10:52
  - moving from recovery to prevention.
• 10:56
  - So,
• 10:57
  - appeals works. It's on the best information anybody
• 10:59
  - in the organize organization has about why stays
• 11:03
  - are denied reimbursement for lack of medical necessity.
• 11:07
  - So we, we know that, what the plan
• 11:10
  - is actual what actually asks for. We know
• 11:13
  - what was missing from the record. And, historically,
• 11:16
  - when a denial was upheld at peer to
• 11:18
  - peer and came to us, that information stayed
• 11:20
  - with us because that's where the case, pretty
• 11:22
  - much ended up.
• 11:24
  - So the opportunity is getting that information to
• 11:26
  - the front end. So the case gets documented
• 11:29
  - correctly the first time.
• 11:31
  - And every denial we prevent is worth more
• 11:34
  - than one we overturn because it never costs
• 11:36
  - anybody
• 11:37
  - the time and money on either end when
• 11:39
  - it's never denied in the first place. So
• 11:42
  - that's better for us. It's better for health
• 11:44
  - plans. And most importantly, it's better for patients,
• 11:48
  - because they may face consequences including a bill.
• 11:51
  - So why does this become possible now? It
• 11:54
  - would definitely be because of AI.
• 11:56
  - AI is definitely changing everything.
• 11:59
  - So we already look at these patterns across
• 12:01
  - our denials,
• 12:02
  - but we basically do it by hand,
• 12:04
  - and it's cumbersome, and it takes time. So
• 12:07
  - this is exactly the kind of problem these
• 12:09
  - tools are suited for.
• 12:11
  - Finding patterns that scale and showing us where
• 12:14
  - physicians' time actually creates value.
• 12:17
  - And with that same guardrail I mentioned, it
• 12:20
  - supports physician judgment. It doesn't replace it, which
• 12:23
  - is really, really important.
• 12:25
  - And then the last thing I'd hope for
• 12:27
  - is more transparency
• 12:28
  - and more shared standards between health plans and
• 12:31
  - hospitals
• 12:32
  - because a lot of the friction in this
• 12:34
  - work comes from two sides looking at the
• 12:36
  - same patient with different information
• 12:39
  - and different assumptions.
• 12:41
  - So if technology closes that gap instead of
• 12:44
  - widening it,
• 12:46
  - then that then that's the version of the
• 12:48
  - next few years I'd wanna see.
• 12:51
  - That's amazing to hear. And you're definitely painting
• 12:54
  - a vision of where growth, in technology and
• 12:57
  - AI
• 12:57
  - can really come together and help the organization
• 13:00
  - serve more patients, provide better care, and and
• 13:03
  - truly a better experience for the providers too.
• 13:06
  - So thank you so much for sharing that.
• 13:07
  - Very inspirational and exciting. Is there anything else
• 13:10
  - you want to touch on when you think
• 13:11
  - about growth in the next two, three years
• 13:13
  - or so?
• 13:15
  - So I think that AI is, definitely,
• 13:18
  - there. I think also,
• 13:21
  - that,
• 13:22
  - ultimately,
• 13:23
  - if
• 13:24
  - we want to be able to as far
• 13:26
  - as growth is concerned,
• 13:28
  - we wanna be able to say again, it's
• 13:31
  - all about really just preventing,
• 13:35
  - the, the denials in the first place. When
• 13:38
  - you think about it, you think about all
• 13:39
  - of the money that comes in into our
• 13:41
  - or, into, into health care and where can
• 13:44
  - we use it. And we really wanna be
• 13:46
  - able to use it, for patient and patient
• 13:49
  - care.
• 13:50
  - And so anything that is, you know, that
• 13:52
  - is required is great, but anything that isn't,
• 13:55
  - we wanna be able to reduce.
• 13:57
  - So,
• 13:58
  - for growth in this industry, being able to
• 14:02
  - use that,
• 14:03
  - use the,
• 14:04
  - funds for,
• 14:05
  - for patient care,
• 14:07
  - ultimately is what we really would like.
• 14:11
  - Got it. That makes a lot of sense,
• 14:12
  - and it's helpful to really see what's behind
• 14:14
  - all of those efforts and then tying it
• 14:16
  - back to the bigger mission and vision of
• 14:18
  - what's happening in the health care space.
• 14:21
  - Before we wrap up, I wanted to ask
• 14:23
  - you about leadership too. Who is a leader
• 14:25
  - that you admire really from any industry and
• 14:27
  - why?
• 14:30
  - So I say,
• 14:32
  - captain Sully Sullenberger.
• 14:35
  - And for a specific reason, that's close to
• 14:37
  - what I do.
• 14:40
  - When flight fifteen forty nine, hit that flock
• 14:42
  - of geese,
• 14:43
  - he and his first officer went to the
• 14:45
  - checklist, which was exactly right. That was what
• 14:47
  - they were supposed to do. That's what the
• 14:49
  - training says.
• 14:50
  - But the dual engine failure checklist had been
• 14:53
  - written for a failure above 20,000 feet,
• 14:56
  - where you have time and altitude to work
• 14:58
  - through it. They were at about 2,800
• 15:01
  - feet, so they never got past the first
• 15:04
  - checklist page.
• 15:05
  - The checklist even called for a relight speed
• 15:08
  - that they just couldn't physically,
• 15:10
  - reach.
• 15:10
  - So the checklist wasn't wrong. It just wasn't
• 15:13
  - written for the situation.
• 15:16
  - And what he did was start the auxiliary
• 15:18
  - power unit, which wasn't the next step in
• 15:20
  - the procedure.
• 15:22
  - So the NTSB
• 15:23
  - later credited,
• 15:24
  - that with keeping the aircraft's flight protections working
• 15:28
  - all the way down.
• 15:29
  - And that came from experience, not from the
• 15:31
  - page.
• 15:33
  - So what I admire is that he didn't
• 15:35
  - treat it as a choice between the protocol
• 15:38
  - and his judgment.
• 15:39
  - His first officer kept working the checklist the
• 15:42
  - whole way down.
• 15:44
  - Stopped covering him and filled in the rest.
• 15:47
  - So where where it stopped covering him, where
• 15:50
  - it stopped covering him. And, and that's the
• 15:52
  - job that physician advisers do. We work with
• 15:55
  - evidence based criteria,
• 15:57
  - and they're good, and they're right for most
• 15:59
  - patients. But they're written for the typical case,
• 16:01
  - and some patients aren't typical.
• 16:04
  - So somebody has to recognize when the standard
• 16:06
  - doesn't reach the situation
• 16:08
  - and be able to explain why.
• 16:11
  - And that's not going around rules. That's just
• 16:13
  - knowing them well enough to see where they
• 16:15
  - end.
• 16:16
  - And that's why he stays with me. He
• 16:18
  - knew the checklist better than almost anyone, and
• 16:20
  - that's exactly why he knew,
• 16:22
  - where it ran out, and that's what expertise
• 16:25
  - is for. And that's how I what I
• 16:27
  - consider as physician advisers as well.
• 16:31
  - I love it. Deborah, thank you so much
• 16:33
  - for joining us on the podcast today. This
• 16:34
  - has been a really fun conversation.
• 16:37
  - We covered a lot of ground and truly
• 16:39
  - inspirational to think about what you're doing at
• 16:41
  - at CommonSpirit. So I appreciate your time today
• 16:43
  - and look forward to seeing you as well
• 16:45
  - in person at our ITRCN conference coming up.
• 16:47
  - So so it's great to see the folks
• 16:50
  - that we're talking with and be able to
• 16:51
  - meet in person in Chicago.
• 16:53
  - Alright. Thank you so much, Laura. I really
• 16:55
  - appreciate your time.