Latest / Becker’s Payer Issues Podcast / The Path to Payment Accuracy: Tackling Billing Errors with Payment Integrity

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The Path to Payment Accuracy: Tackling Billing Errors with Payment Integrity · Becker’s Payer Issues Podcast

• 0:00
  Hi, everyone. This is Lucas Voss with the
• 0:01
  Becker's Healthcare podcast series. Thanks so much for
• 0:04
  tuning in today. Very excited to have you.
• 0:07
  And I am excited and thrilled to be
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  joined by Mark Johnson, senior vice president at
• 0:12
  Saris, who will talk to us about payment
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  integrity. Very important topic. Mark, thanks so much
• 0:17
  for being here today. Thanks for having me,
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  Lucas. Appreciate it. Mark, we'll start off with
• 0:21
  introductions here. If you just wanna give us
• 0:23
  a quick introduction to yourself and just your
• 0:26
  your background in health care and your career
• 0:28
  so far.
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  Absolutely. I've been with,
• 0:32
  Cirrus now for a little over five years,
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  but my background, you know, is around thirty
• 0:36
  years experience in the health care space. I've
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  been in patient care at the bedside,
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  into medical billing, payment integrity, insurance.
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  Really, I've I've led significant product improvements in
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  that thirty years at Cirrus. We're part of
• 0:51
  the CorVel Corporation.
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  I've been at Blue Cross Blue Shield in
• 0:54
  Minnesota.
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  I had a stint at UnitedHealth Group as
• 0:57
  well. My background includes patient care,
• 1:00
  payment integrity,
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  vendor management,
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  regulatory
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  compliance.
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  I've done some international
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  operations startups as well.
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  Educationally, I've got a bachelor's degree in physiology
• 1:12
  from the University of Minnesota
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  and an MBA from Regis University.
• 1:17
  Go Gophers
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  in in that case. Go Gophers. Go big
• 1:21
  10. Yeah. Ex exactly. We'll we'll go with
• 1:24
  that.
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  Well, again, Mark, it's it's great to have
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  you, and this is an important topic today.
• 1:29
  I was doing research for this podcast, and
• 1:32
  and this stat just really stood out to
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  me. There's an estimation that up to eighty
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  percent yes. You heard that right. Eighty percent
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  of medical bills
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  contain
• 1:43
  errors, which is staggering.
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  As leaders in the payer space increasingly
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  look to really optimize
• 1:50
  processes, we know that's happening, especially around billing
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  and payments.
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  What's the role of payment integrity
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  from your perspective, and why is it so
• 2:00
  important?
• 2:01
  Yeah. Payment integrity
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  in the payer space is incredibly important. It
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  just ensures that claims are accurately
• 2:08
  processed
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  and more importantly, accurately reimbursed
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  to the providers.
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  It helps prevent errors, fraud, waste, and abuse.
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  Really, this is crucial
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  because it helps maintain financial stability, not only
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  for the payer, but for the providers being
• 2:24
  impacted.
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  It also enhances the trust between the payers
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  and the providers.
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  And, you know, lastly, it ensures that the
• 2:31
  health care dollars are being used appropriately.
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  That's why payment integrity is so important.
• 2:37
  Yeah. It's sort of a I view it
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  sort of as a as a foundational
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  piece. It's really the foundation that a lot
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  of things stand on. And if that foundation
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  isn't there,
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  then there are going to be problems as
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  you've outlined.
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  And
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  the process is is really key to this
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  to this area,
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  the process around,
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  around everything that you've touched on.
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  How can changing the process
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  around payments
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  reduce some of these numbers of errors, right,
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  80?
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  And what strategies have you found beneficial?
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  Do you have any examples that that stood
• 3:12
  out to you and some of the results
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  that that you see that that make a
• 3:15
  difference?
• 3:17
  Sure, Lucas. I'm I'm trying to think over
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  thirty years, payment integrity really didn't exist thirty
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  years ago. Right? And it's going through a
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  lot
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  of transition right now, a lot of growth.
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  I can think of maybe four or five
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  key strategies that payers might wanna contemplate.
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  The first would be
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  to centralize their payment integrity strategy.
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  Take a centralized approach that integrates your prepay
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  editing reviews,
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  your post pay auditing capabilities,
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  and as well as your innovation teams, your
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  r and d teams in order to streamline
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  processes
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  and try to reduce those errors,
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  especially prepayment.
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  Secondly, I would say
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  when you're thinking about artificial intelligence
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  and machine learning, those are big buzzwords
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  lately,
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  really think about it as a complement to
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  the clinical teams that you have deployed in
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  your payment integrity space as well as your
• 4:12
  certified coders.
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  Utilizing AI,
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  machine learning for real time analysis of claims,
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  proactively
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  identifying high risk claims,
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  and really helping your clinicians and your coders
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  identify,
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  those claims quickly can significantly
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  enhance your accuracy and as well as throughput
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  for the teams working those claims.
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  Third strategy,
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  contemplate a second pass claims editing process.
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  A second pass vendor, second pass process, or
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  even a final filter on claims
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  can really help catch errors that are missed
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  in primary editing phases.
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  Just, again, reducing inappropriate payments from going out
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  the door.
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  Fourth, and this is a big one,
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  coordination of benefits.
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  Mhmm. We really need a strong coordination of
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  benefits program. You may want to consider adopting
• 5:06
  a pause and pay approach
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  with advanced analytics again, right, to ensure you're
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  correct payment responsibility,
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  eligibility validation before the claims are even paid.
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  Just reduce that overpayment from going out the
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  door
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  and all of the overhead associated with the
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  pay and chase model.
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  Lastly,
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  quality assurance programs.
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  Establishing a robust
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  QA program
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  to conduct pre billing audits can really catch
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  errors early and then just improve overall billing
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  accuracy.
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  I guess with these strategies,
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  you know, health care payers
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  can really enhance their payment integrity program and
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  reduce those errors, really ultimately
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  improving overall financial performance.
• 5:52
  Yeah. Absolutely. And just as a as a
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  quick follow-up to that, should this be a
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  a holistic approach as in we're focusing on
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  all of these strategies, we're incorporating them all,
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  or is there one focus area from the
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  things that you just mentioned that that, organizations
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  should look at?
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  I all. I would I would be looking
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  at all of these right now. If you
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  had to prioritize,
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  something, I would I would try to centralize
• 6:19
  your payment integrity strategy.
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  You may have payers may have post pay
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  services, prepay services,
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  clinical utilization
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  management services, all under different
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  leaderships
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  Mhmm. Or strategies.
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  And some of those strategies may be at
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  odds with each other. Make sure you're all
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  aligned
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  first.
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  And then you then you can really start
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  digging into
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  solutions,
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  vendor partners,
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  like Cirrus
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  or any other,
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  technology play.
• 6:52
  Yeah. Absolutely.
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  Which leads me to my next point, and
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  this was one of your your strategies or
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  one of the pieces of that you've mentioned
• 6:58
  that are really important right now. The modernization
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  efforts
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  efforts that are happening in the payer space.
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  They are all over. You've mentioned the buzzwords.
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  Right? AI. It's it's all over the place.
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  Again, touch on how you see technology
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  evolving and really making an impact on reducing
• 7:13
  errors and enhancing
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  payment integrity.
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  What are you looking forward to right beyond
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  those buzzwords, and how should organizations prepare?
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  Wow. That's it's such a big area. The
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  technologies are just evolving
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  so rapidly.
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  I would say that if if you have
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  an AI strategy,
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  excellent. If you don't, get one quickly.
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  Innovations such as artificial intelligence,
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  digital payment systems,
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  finance solutions, just embedded finance solutions are really
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  transforming health care payments. Mhmm. Providers
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  themselves
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  are starting to look at these these technologies
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  as well to help them with their revenue
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  cycle.
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  So while this these technologies
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  I mean, all of this tech play
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  can really help automate billing processes and reduce
• 8:08
  manual errors and just improve that rev cycle
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  for both payers and and providers.
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  It's still going to be important to have
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  that
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  human
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  touch, that clinical
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  overview, that coder overview.
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  You don't want to get caught
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  automating your your edits, automating your your solutions.
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  Technology can help,
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  but you shouldn't put all of your eggs
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  in just in that baskets.
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  You know, adopting advanced payment technologies,
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  making sure that that cash is flowing
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  smoothly and accurately between the payer and the
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  provider. And I think that's that's really where
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  you're gonna wanna be focused.
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  Yeah. Absolutely.
• 8:51
  Well, Mark, thank you so much for sharing
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  all of your insights here. Again, thirty years
• 8:55
  of experience. We really appreciate you taking the
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  time today. Thanks for being here.
• 8:59
  I appreciate it, Lucas. Thank you for the
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  time. I I really do.
• 9:03
  Yeah. Absolutely. Thanks for sharing everything. And I'd
• 9:06
  also like to thank Suresh as well for
• 9:08
  sponsoring this episode. And you can tune in
• 9:10
  to more podcast from Becker's Healthcare by visiting
• 9:12
  our podcast page at beckershospitalreview.com.