AI vs. AI: The Next Generation of Revenue Cycle Management — A Conversation with ModMed's Rob Ware
Download MP3Well, hi, everyone, and welcome to the MGMA Insights Podcast. I'm Daniel Williams, senior editor at MGMA and host of the MGMA Podcast Network. We're back with another episode today, and we are joined by Rob Ware. He's senior vice president and general manager of Revenue Cycle Management at ModMed. Rob has more than twenty five years of experience helping healthcare organizations improve operational and financial performance.
Daniel Williams:Now he's tasked with integrating AI and all these other technology platforms as well. We're going to be talking about how that's reshaping revenue cycle management. Rob, welcome to the show.
Rob Ware:Thank you. It's great to be here. Thanks for having me, Danielle.
Daniel Williams:It is so good to have you here. So I'm going to ask you a few background questions first that are going to set the stage. So first of all, just tell us about Rob Ware, what your background has been, any kind of career highlights you want to share with us that get us to where you are right now?
Rob Ware:Yeah, interesting enough, I started my career in operations consulting. I actually worked in manufacturing and logistics environments, which is a little bit different than healthcare, but to to be honest, not all that different from Revenue Cycle because it's a big operation and it's all about sort of the challenge of, you know, getting to that end goal. So I did that for a number of years. I did a little bit of strategy consulting in technology businesses, and eventually found my way into Revenue Cycle, and I've been at it for a number of years now, and enjoying the challenge of it.
Daniel Williams:That's really cool. I know that we're gonna talk a bit about AI. It's almost impossible to have podcast now unless we're talking about detaching from technology and we're going to go have a retreat somewhere. So were you well versed with your manufacturing background and now in healthcare in the technology world? Do you consider yourself a techie, an early adopter?
Daniel Williams:Where would you place yourself there?
Rob Ware:It's a good question. I think in you know, I would say early in my career, maybe a little bit less so. You know, I went to college and, you know, computers were just blossoming in that day. You know, I took coding classes in college, but I wasn't a computer scientist. So I've always, I would say, dabbled, you know.
Rob Ware:I had an iPhone early on, and, you know, I've always, you know, used used, I would say, technology. I think what's interesting, I would say, is as the capabilities have increased, my lean towards technology has also increased because I think as we all recognize more and more, if you're, you know, if you're not utilizing it, you know, you're you're sort of wasting time and falling behind. And so I think as things have advanced, you know and when the iPad came out, remember being a little skeptical, and now when things come out, I'm like grabbing at them. So That's
Daniel Williams:that's a great way to do it. I have shared this with the audience before, but I'm somewhere squarely in the middle of technology, but definitely very curious and like you wanting to adopt. I remember my parents calling me to program the VCR. Why is the light flashing? Why can't I set the thing to record?
Daniel Williams:And then I'm sandwiched by a daughter who's in her twenties now who just says, dad, give me the phone so I can get to what I need to get to. So I feel like I'm advanced and know nothing at the same time.
Rob Ware:I'm you. I'm with you. My daughter you know, the thing notice difference I notice, I use technology, but I still type and my daughter does everything with voice. So that's I'm feeling the same thing.
Daniel Williams:That's incredible. Alright. The second question is, tell us a bit about ModMed and how it is positioned to help medical practice leaders who are our listeners today.
Rob Ware:Yeah, I think ModMed as a whole, I think is positioned in several ways. ModMed started its life as an EHR, and so we've got a very, very strong, you know, clinical EHR in the specialties that we serve. And then on the financial side, we've got a strong PM and revenue cycle business. And so for specialty practices, you know, ModMed, I think provides a very technology forward EHR, PM, RCM, patient engagement platform. And we're very invested, you know, in AI, which I know we'll sort of get into, but we've, And I think the fundamental difference in our approach has been that we wanna make sure everything that we build is very, a lot of people would like to use this word native and I would argue very few of them are actually native because they obviously started before AI existed.
Rob Ware:And so to say it's AI native is like a little bit disingenuous, I would argue. But I would say that as we think about AI, we wanna make sure it's as fully integrated and taking advantage of the data as much as possible. Because I think as you implement it, that's really the biggest challenge, and therefore that's where we think we have the ability to start to differentiate.
Daniel Williams:Okay. That is great. That's a great way to really set the stage for what we're going to be talking about today, everyone. We're really going to be looking at that billing cycle, revenue cycle management, and technology's role in it as well. We traded a lot of information back and forth, Rob, you and me and your team.
Daniel Williams:One of the things that was shared was billing processes really haven't changed significantly in decades. However, y'all shared with me that you believe that we're really at an inflection point. So talk about that. What is that inflection point? What do we need to be on the lookout for?
Rob Ware:Yeah, and you know, it's interesting. I would reflect back to when I first got into RCM because I remember, you know, was a little naive. Like I said, I had this manufacturing background. I came in and what surprised me was everyone talked about RCM as if it was an art. Like you had to know all this magic, it was a black box, you know?
Rob Ware:And I thought, you know, it should be a science, right? You follow the rules, you get paid. And as you get into it, you recognize well, it's not that easy and what makes it complicated. From my perspective, it's really about the number of variables and the fact that they're constantly changing. So if you think about the number of payers and plans and obviously combinations of codes that you can have, It's just impossible for any one person to know all those things.
Rob Ware:And even if you sort of manually try to document and create your rules in your system, you're always behind, right? And so, you know, the payers are constantly adapting and so that's been sort of the process that we followed for a long time. Most of revenue cycle relies at least to some degree on human expertise, right? And to know these scenarios. And so it's a tough game to play.
Rob Ware:The reason I think we're at an inflection point now is you think about those number of variables that a person, an individual can never keep up with, obviously machine learning and AI gives you an opportunity to actually take all those variables into account and come up with the right answer, hopefully every time. And so that's where I think we really are at an inflection point. It'll be, you know, I think we're just stepping into it and I think a lot of people see it and a lot of people are trying to figure out how to use it. And I think some of us are starting to to show success, but I would also argue no one's, like, fully cracked it yet. So I think we're, you know, we're sorta early in this journey.
Daniel Williams:Okay. I'm gonna tick off several challenges that are gonna sound really familiar to all of our listeners, to you as well, Rob, practices today. They face rising costs, stagnant reimbursement, increased administrative requirements, and a lot more. But those are three big aspects of it right there. So how are these pressures affecting medical practices and the operations right now?
Daniel Williams:What is happening as you just feel this increased pressure there?
Rob Ware:I mean, think the reality is what it means is every dollar just counts more, right? And so you don't have the luxury of being able to accept, you know, missing out on certain pieces of your collection. And so maybe at some point in history you would say, oh those, you know, that claim is small dollars, or you know, I can not chase as hard after that. I think now we're at a point where physicians can't accept that because as you point out, reimbursements are not keeping up with inflation essentially and so they're getting squeezed. So I think that's, particularly from the revenue cycle lens, think that's what we see.
Rob Ware:And so practices big and small, you know, in hospitals and everywhere else is saying, okay, what else can we get from the revenue cycle? If my NCR is at 96%, how do I get it to 98%? Like how do I eke out those extra dollars?
Daniel Williams:Yeah. That's what I keep hearing as well, that literally every dollar counts. There might've been a time when maybe, how hard are we going to chase for that one or that one? But now with the capability, the technology, the data points, yeah, every dollar counts. So, one other aspect that I found really interesting when I was sharing information back and forth with your team.
Daniel Williams:One thing that came back was fighting AI with AI. And so I wanted you to help elaborate that phrase. What does that mean? I mean, we get we all have an idea. I'm thinking of stuff like the Terminator 2,000 and I'm going real sci fi here.
Daniel Williams:But when we're fighting AI with AI, what are what are we doing? What does that look like?
Rob Ware:For me, the surface, it's certainly the payers we know are using AI, right? They are running first pass denials with AI. They would be foolish not to, as every business is trying to figure out how they make AI work for them. Payers are certainly doing that. And so from our perspective, it does mean we're seeing things move faster in a way that they used to in terms of denials and things are more dynamic.
Rob Ware:And we see this with our clients every day. Hey, this this was paying before, this is not paying now. What's going on? And I think, again, going back to the how many variables there are, I think AI is really the only chance you have to sort of keep up with that, to be able to respond, to see, okay, this is the new trend that's coming. Historically, people would do data analysis, right?
Rob Ware:You'd look at your month end reports, your quarterly reports, what's trending with my denials? We're trying to keep up with it faster. And so that's where I see the AI fighting AI is if they're implementing AI to create denials or to put more checks in place, we've got to implement AI that can see that quickly and react and respond and help us make better decisions more quickly in the revenue cycle.
Daniel Williams:Let's add on to that question then. How does a practice remain competitive? Where is that competitive advantage? How do they leverage the technology that's out there and be really smart with it? Because as we know, holy moly, there's a lot of tech out there right now.
Daniel Williams:So part of it is parsing through all of it to figure out which one's the right one for my practice, the one I'm in. So let's think about that. How do we leverage technology as a practice? How do we remain as competitive as humanly possible when we're looking out at the landscape of other practices out there?
Rob Ware:Yeah, I think, so obviously, you know, coming from a EHR PM system of modernizing medicine, have a little bit of a bias, but I think sort of fair in that I think your best bet is if you can have sort of a fully integrated solution, right? Because I think, you know, you're able to get more direct access to your data and your information, that makes AI more powerful. So I think, you know, at the very least you need something that's very well integrated into your core systems of record that you're operating with. If you've got something that has to exist outside and do a lot of data transfers, I think it's just gonna be tough for it to be as efficient. So that's one.
Rob Ware:Think it's just making sure you've got like a good fully integrated solution or a solution that can be fully integrated with what you're using as your core systems in your practice or in your business today. And then there is some level of analysis of trying to understand where do we think the leakage is coming from, Is it a charge capture issue? Is it a denial issue? Is it a authorization issue? You know, and I think that that depends for different practices.
Rob Ware:And so based on those pain points, you know, I do think, you know, today there are a lot of what I would argue, you know, sort of point solutions in place, and I think for certain tasks, it's probably, you know, okay. But I I I think the more you can have, you know, integrated and sort of centralized to your to your core system of record, the more successful you'll be down the road. I think that's the one mistake I have seen is looking for something that just sort of solves a problem in general as opposed to solving a specific problem. And so that's what I think I would encourage people to think about is like, okay, where is my like real pain and how can I, gonna buy something, how can I make sure that I know exactly what this is gonna solve so it doesn't just sort of feel like we're getting better, but we can measure what you know, what success actually is because we know what metric we're trying to improve or we know what process we're trying to improve?
Daniel Williams:Yeah. Do you have an example then of getting that specific laser focus going in that you know this is the data point or this is the KPI that we need to improve on, and then really applying a technology to really examine that and better it.
Rob Ware:Sure. I mean, the way I tend to think about it is, you know, if you look at, for instance, I think there's two ways you can approach it. You can look at what are my top denials and is there something I could put into, you know, solve that on the front end or work them more effectively. And so I think about like if you've got a lot of authorization denials for instance is one that comes up a lot. You know, is there a tool that would help me with my authorizations either in terms of identifying the right visits or helping with the process of getting the authorizations and making sure they're on the claim?
Rob Ware:And there's there's sort of several steps there to, you know, to authorization. So that's that's one very distinct one I think that we see a lot. You know, there's a lot of point solutions around doing other specific tasks like writing an appeal letter. I think there's also people today probably just putting that in chat GPT. Yeah.
Rob Ware:I hope careful with their PHIs.
Daniel Williams:Sure. That's a good point. The protection there, the compliance aspects as well. One thing that y'all sent me that I've been kind of mulling over, just trying to get it into my head here, you've talked about predictive revenue cycle management. Hand raised, I think that's the first time I've ever heard predictive and revenue cycle management converging there.
Daniel Williams:How can practices use data and use AI to identify denial risk before claims are even submitted?
Rob Ware:You know, a lot of practices, I think, have historically done some level of data analysis and then tried to write rules. I mean, that's sort of the way that we've fought this in the past. I think what we're trying to do is actually make it so that you don't have to sort of after the fact do some analysis and then try to manually or in some other way put some rule in. That, you know, that works. That's been how we've approached this for a long time.
Rob Ware:I think it's tough to keep up with, it hits a limit. And so what we're trying to do is bring that knowledge of, hey, these are the scenarios that deny to the right point in the workflow. Because the reality is, you know, when we talk about being preventative and predictive, it's not just about the person who's about to submit a claim and hey, is this claim gonna get paid? Because the reality is, they might need more information from the physician and they, you know, depending on the setting, that can be hard information to get. Or they need information from the patient who's no longer in the office, right?
Rob Ware:And so, what we wanna do is actually bring that prediction all the way forward into the workflow to where you can do something about it. So when the front desk is sitting there with the patient or when the physician is actually with the patient, what's the extra information that you need? Because we know we're going to need that to produce a clean claim.
Daniel Williams:Okay. Furthering on the prediction conversation, I wanted you to predict, or this might be found this might be knowledge you have right now that you know applications that are either in the works or need to be in the works as they relate to the revenue cycle. What are some apps that should be implemented or will be implemented over the next several years?
Rob Ware:Yeah. Well, think, I mean, so to prediction, I mean, I do think that's something that everybody's gonna be looking for to some degree. And I would argue, really people want more than prediction. They want, you know, prevention, So applications that can actually do something about it, not just tell you this might be a problem, but actually help you solve the problem. I do think, you know, there's a lot out there of AI usage in the coding space.
Rob Ware:The, you know, the apps that I've seen to this point, I'm not seeing great efficacy. You know, some getting to like the sort of 50% range, but still having to bring a lot back to coders. I think that will continue to be the case. So I think, you know, that's something that some people have found efficiency with, but I think it's still not where it needs to be to be, you know, to really bend the curve in a lot of scenarios. So I think again, as a practice, if you have a big enough operation, a big enough revenue cycle operation, can, I would say right now, take it off, you know, point solution by point solution?
Rob Ware:You can buy something that writes appeal letters for you, for instance, and that's out there. I think ultimately what people will want and need is something that's solving the problem more holistically for you. And so, you know, I think that's the way I would encourage folks to think about it because if you end up with, you know, eight point solutions to drive your revenue cycle or 12 more, you know, it's gonna get a bit clunky and you're probably gonna end up in the end with more expense and issues because the data's not transferring right. So that's, I think that's the thing I'd encourage people to think about is are they buying something that will extend and be able to, you know, to solve all the problems that they think they will want to be able to sort of get to down the road.
Daniel Williams:One of the challenges that just won't go away is staffing. You may know this. I think many of our listeners do because I bring it up every episode. This is MGMA's one hundredth anniversary, 2026. So got established in 1926, and staffing is one of those challenges that's ongoing along with much of the billing side of things.
Daniel Williams:When we look at staffing as a challenge, what are some of the options? How and how is that shaping decisions around outsourcing and also bringing in strategic RCM partnerships? What are you seeing in that space?
Rob Ware:Yeah. It's it's interesting. I mean, will say from my perspective, really, I to your point, staffing's always been an issue. You know, post COVID world, we saw a lot of challenges, you know, with with people being able to to staff appropriately, a lot of turnover. I think it's improved slightly since that initial, you know, sort of burst and challenge, but it continues to be a challenge.
Rob Ware:I think we've seen, from our perspective, more and more, you know, there's obviously been consolidation in the healthcare space, and I think, you know, we're seeing a bit of a shift from where organizations felt, hey, I need to own my revenue cycle, I need to have, you know, my employees sitting in my office doing the work, to where they say, hey, if we wanna continue to scale this business, is it really feasible to continue to hire the right people? And therefore, do we need to continue to consider, as you say, you know, sort of an outsourcing partner? And so we see, I would say more and more of that people thinking strategically about about partnering. I think, you know, what I see as as generally holding people back from that is a concern about losing control, right? Like if it's my person, I can go down the hall.
Rob Ware:I can, you know, call, I have more control. I have, you know, I have more impact. And so I think what we're seeing is with technology, we can have more visibility, you know, with more real time tracking, we can provide more insight into, you know, how are things moving? Where exactly is the money? And I think that, you know, that enables people to have the comfort that, okay, maybe working with a partner is okay, as long as I can keep an eye on it.
Rob Ware:And then I think, you know, the other piece that I do think will help the industry overall is, I think some of this technology will enable you to hire potentially someone who doesn't have, you know, thirty years of experience and can get up to speed faster because you can utilize technology to bring information to that person a little bit more effectively. So I think that's where it's going. But that that that's still and like I said, on that one, think we're still, you know, we're still on the journey and there's still still takes a lot of people who know what they're doing to get the work done.
Daniel Williams:Right. I love that. Couple more questions here. One thing that you shared with me is you emphasized that net collection rate is a key measure of practice health. Explain why that's a thesis or theme that you're focused on.
Rob Ware:Yeah, I think for me, net collection rate is the ultimate barometer because it's meant to tell you of the dollars that are available, how much did I get. Right? I mean, one of the you know, everybody talks about health care being such a unique business because a a physician, you know, sees a patient and they don't know how much they're gonna get paid for that. Right? I don't know like, hey, what's my contract with Blue Cross and therefore like what's the adjustment gonna be?
Rob Ware:So you've gotta take all that into account, but net collections rate is meant to account for that, right? So it's out of, you know, out of what's allowed, how much did I actually get? And so to me, that's the ultimate barometer. The challenge with it is that, you know, it takes a while to get there. It takes a while to get up to your 95, 96%.
Rob Ware:Right? You know, you're probably a couple of months out. So it can be a bit of a lagging indicator, but I do think ultimately that tells you, you know, the the real performance of your of your revenue cycle and whether or not you're you're getting everything that you can.
Daniel Williams:We've covered a lot of information here today on the revenue cycle. So for our listeners, what should they be doing today, whether it's one step or a few steps to prepare for themselves to be healthy in that revenue cycle over the next several years?
Rob Ware:Certainly, taking a look at the way that you're executing it today, the way that you're structured in your practice, trying to understand where you feel like you have pain. So like I talked about at the beginning, is there revenue leakage? Can you identify where that is? You know, there's obviously organizations that'll help you with that kind of analysis. There's a lot of consultants out there.
Rob Ware:Some of them are very effective, think, at coming in, just helping you run some analysis and get an understanding. A lot of practices can do that themselves and say, okay, here's here's the leakage. I think from there, you need to make sure that you've got your sort of data in your system of record. And so what I would say is if you know you're in a situation where things are just moving from system to system and all over the place, it's gonna be hard for you to bring in technology that's really gonna solve that. Like you need to you need to think about what is what's my sort of unified, I hate to say like data strategy, but it really is.
Rob Ware:I mean, think the less shifts you have to make with your information, the more likely you are to be successful because you can't really fully harness, you know, the power of AI and some of these other technologies unless you've got clean information in a centralized place. And so those are the sort of the foundational things. That's where I would start. And then from there, can start to think about, okay, what's the tooling that I might bring in? Do I need a solution for auths or or, know, can I build that on top of of my system of record?
Rob Ware:Obviously, I have a bias that if you've got a, you know, a core system that can do all these things for you, that you're gonna be, you know, in the best place. And I think, you know, for folks who are fortunate enough to have that situation or to be able to evaluate that situation, you know, I think that's what I would think about and test what's there.
Daniel Williams:All right. That concludes our core analysis and examination of Reb Cycle and what's going on there. What we like to do for the last question is just one more question to get to know the guest a little bit better. When you're not honed in, zoned in on Reb cycle, what do you do for fun? What brings you joy?
Daniel Williams:What's a passion that you have you wanna share with the audience?
Rob Ware:Yeah. I mean, I'm an outdoors guy, so I, you know, I really enjoy getting outside. I I road bike and mountain bike quite a bit when the weather's alright, and so I I have a good fortune to be a part of a group that a lot of Friday afternoons, we get together, and we go have a really hard mountain bike ride, and then we sit around a fire pit and have a beer and and and just have a little bit of community. So that's that's probably one of the things, I should say, in addition to spending time with my with my lovely family, wife, kids, but from a from a athletic pursuits perspective, I love to love to get out and ride.
Daniel Williams:Yeah. What part of the country are you in? What mountains are we talking about?
Rob Ware:Yeah. So mountain biking is not always on the mountains. It's gonna be where I am. I'm I'm in the outskirts of Boston. So we do a lot of riding through sort of public forests around here.
Rob Ware:There's a lot of lot of up and down, though not technically technically mountains. We gotta get up to New Hampshire and Vermont to really get, really get into that.
Daniel Williams:That is wonderful. Rob Ware, it has been a joy getting to talk with you, learn from you today. Thanks for joining us.
Rob Ware:Thank you. I I really appreciate having you. I love I love talking about it, so thank you.
Daniel Williams:It is very apparent. And everybody, this is we've been talking with Rob Ware of ModMed. In the episode show notes, we're gonna share resources, direct links where you can plug in and learn more about Rob, learn more about Mod Med, and how they can help you with your practice. Until then, thank you everyone for being MGMA Podcast listeners.
