Speaker 1: Denials are still a problem for a lot of health care providers, despite all of the investment that's been made over the last many years in revenue cycle efficiency, because of the constant changing nature of health care reimbursement. You know, if we think about where claims management was 10 or 15 years ago, while those are still core problems of, did my claim get where it needs to go, did it get to the right place on time, the adjudication logic has really evolved quite a bit, and with focus now on clinical accuracy, more complicated networks for patients, there's just a continuing change in really the rules, and that really speaks to a lot of things we've heard from our customers and from the market, that continuous challenge in maintaining good understanding of what the rules are, so that they can bill claims appropriately and expect proper reimbursement, is really one of the big persistent challenges in health care. Denial problems can definitely be attributed to the front end or the back end, but in our experience they're usually not that cut-and-dry, so it's important to have good end-to-end visibility, because while a problem may have been caused by something on the front end, like missing information, if it wasn't caught in the middle or the back end, or during other pre-billing operations, then it really has multiple causes because of the situation, so through tools that look at the end-to-end quality of revenue cycle, as well as powerful analytics, there's really significant opportunity for organizations to move beyond front-end back-end thinking and think about revenue cycle in a totality. We get a lot of questions if inpatient and outpatient denials are really the same, and they're very significantly different. I think the outpatient denials are most often a factor of both volume, as well as discrepancies in the order process and the variations in services that are actually performed, or simply an issue about being in the right place to have a test done or a scan completed. Inpatient care is much more complicated now. We have admission management, utilization management, review processes on both sides of the organization, and while it's definitely complicated further by varying lengths of stay and levels of service, they really are different animals in terms of how the causes are, what the causes of denials are relative to inpatient and outpatient services. The top pain points from a perspective of providers on authorizations really boil down to transparency and having good understanding of the rules for a given service at a given location for a given payer, and often even having to know plan level specificity to understand if a service requires an authorization and under what criteria. So the the problems around authorization really do begin at the very beginning to understand is an authorization even needed? Is an authorization appropriate for this patient at this place of service with this particular service to be performed? And then once that answer to that question is known, yes or no, provided it's a yes, it opens up a whole new set of questions. Is this the right location? What are the dates? How many times can we do that service? What was the specific authorization number? Really the tracking number for that authorization. So understanding that end-to-end and applying that information, ensuring it's integrated back into the EMR and ultimately makes its way to the claim process, really highlight a lot of the elements of complexity and challenges with authorization today. The other big overarching problem is the manual nature of understanding those things. Payer portals are all different. They're all highly fragmented. It could be a real challenge for providers to know who's responsible for starting the authorization process. Is it the referring physician? Is it the rendering provider? And once those things are known, how do they change over time as the rules change for authorization? So much like claims where the rules change constantly, claim scrubbers and edits are constantly being retooled and sharpened to keep up with claim adjudication processes, the same philosophy has to be brought to bear on authorization given the constant rate of change. The most important innovations that we've heard from the market and from our customers around authorization and medical necessity really focuses on a couple of key areas. The first is transparency, to understand the ground rules, to know what requires an authorization, what's it take to meet medical necessity in more inpatient settings, and how does an organization go about collecting the information to hit those criteria. The second major challenge is understanding if an authorization has been obtained, tell me about the authorization. How do I get details on it? How do I monitor the status of that authorization in case it changes or in case some variable in the delivery of care changes, like a place of service or the rendering physician? Another big challenge downstream is reconciling what the authorization was for versus what was actually performed. A very common example is MRIs that may or may not have contrast. So if an auth says you didn't have one but you decide to add contrast, that can effectively break the authorization and send you back to start where you have to begin the game again. And then lastly downstream is the management of that authorization for patients who may be in recurring services. If I have authorization for ten units of outpatient physical therapy and I'm at number eight, it's time to get started on the renewal if additional care is needed. And so having that visibility and having tools that are integrated into the provider's workflow to help them have visibility, both from a pre-service scheduling and getting the patient ready for care, as well as the downstream management and really in a sense working against that authorization, add a lot of complexity because many core EMR systems don't have that capability inherently and organizations need to find tools to support that workflow. Change Healthcare, we're really focused on in helping organizations improve denial rates from the beginning of the revenue cycle to the end. In areas like authorization, we're working with our payer partners to bring transparency to the authorization business problem and to help organizations understand the status of authorizations, to initiate authorizations, and to make sure that they're performing care in alignment with that authorization. On the downstream side, we've always focused on getting claims right and getting claims delivered the first time, and we're now bringing more analytic capabilities to the party to really let organizations see the revenue cycle end-to-end and not think about it as a front-end, back-end problem, but look at it as an end-to-end problem. Patient access workflows in the hospital have really been changing a lot in the last five to ten years and continue to evolve pretty significantly today. The change in patient responsibility and patient out-of-pocket really is a big driver for that, so as health plans have changed and you and I have significantly higher deductibles than we did, it's causing our behavior to change and make us more focused on cost, which has driven providers to focus more on setting the right expectations and help bringing transparency to the patient experience there. It really continues to evolve in becoming more proactive, to bring more direct communications to patients to help them understand and be ready clinically and financially for their care, and ultimately is the first opportunity to make a good impression with a customer, and I think that's really been one of the core drivers in the evolution of patient access is that customer service mindset really has to be an important part of the process. Revenue cycle and utilization management are increasingly coming together to work on problems like authorization and medical necessity in a collaborative fashion. They really are links in the same supply chain. How do we prepare a patient clinically? How do we make sure that we're making the right clinical decisions? And once those answers are known as to the clinical plan, the utilization management approach, then it becomes a patient access problem often to say where will that service be done, how will it be performed, under what time frame, and in what other characteristics of the administration of that care. So there really is a very complementary role in the utilization management revenue cycle function. We've seen some organizations align them under the same leadership, which has really I think helped bring more consistent goals and consistent execution, but fundamentally you have this combination of clinical readiness with administrative readiness, and they both have to work for that care to be delivered appropriately and to help fight the denial engine.