The healthcare industry is undergoing a seismic shift, driven by the need for operational efficiency, improved financial performance, and better patient outcomes. Nowhere is this more critical than in behavioral health, where low reimbursement rates and administrative complexities often strain resources. On October 8, 2024, at the BHB INVEST conference, Heather Martinez, Director of Specialty Solutions at NextGen Healthcare, and Brian Wheelan, CEO of Transformations Care Network, sat down to discuss how innovative technologies, including AI and automation, are transforming Behavioral Health Revenue Cycle Automation.
The Challenge of Adopting Technology in Behavioral Health
Heather Martinez, who has over 25 years of experience in the revenue cycle space, highlighted a common barrier to progress: resistance to adopting new technologies. “There’s a big resistance, especially in larger organizations,” she explained. “Staff often say, ‘Only I understand this; there’s no way to automate this.’ But we need to challenge that narrative.”
While clinical adoption of technology has made strides, RCM lags behind. Martinez emphasized the importance of leveraging tools that can streamline operations, reduce errors, and improve financial outcomes. She noted that many organizations are hesitant to invest in Behavioral Health Revenue Cycle Automation due to the perceived complexity of their revenue cycles. However, as the healthcare landscape becomes increasingly complex, the need for scalable, efficient solutions has never been greater.
Transformations Care Network’s Success Story
Brian Wheelan shared how Transformations Care Network, an outpatient mental health provider with nearly 1,200 clinicians across 60 locations, has successfully integrated AI and automation into its RCM processes. The organization, which handles over 1 million claims annually, faced growing complexities as it scaled.
“We went from touching 86% of claims to now touching only about 15%,” Wheelan said. This dramatic reduction was achieved through the adoption of RCX Rules, a robotic process automation (RPA) tool that handles repetitive tasks like claim submissions, eligibility verification, and payment posting.
Wheelan explained that the decision to invest in Behavioral Health Revenue Cycle Automation was not an easy one. “It’s time, it’s talent, and it’s painful,” he said. “But at the end of the day, RCM is that important. We had to go to the big leagues, and that meant spending money to get it right.”
The Role of RCX Rules and AI
RCX Rules automates the tedious, error-prone tasks that previously required manual intervention. For example, it ensures that the same 35 data points are accurately entered into various payer systems, despite the fact that each payer—whether Blue Cross, Medicaid, or Medicare—has its own unique requirements.
“We went from 400,000 to over 1 million claims a year, and RCX Rules scaled with us,” Wheelan noted. However, he cautioned that automation is not a cure-all. “RCX Rules won’t fix bad processes. RCM starts at intake and continues throughout the entire patient journey. If your processes aren’t clean, Behavioral Health Revenue Cycle Automation can only do so much.”
Wheelan emphasized the importance of addressing inefficiencies at every stage of the revenue cycle. “If you’re not clean end-to-end, RCX Rules can help you cover some sins, but it’s not a panacea,” he said. “You’ll wind up trying to rule your way out of problems that started at the front desk or in documentation.”
Operational Efficiency and Financial Impact
The adoption of RCX Rules and other AI-driven tools has had a profound impact on Transformations Care Network’s operations. Wheelan shared several key metrics:
- Reduced Denial Rates: Initially, denial rates spiked as the team resubmitted previously denied claims. Over time, denials dropped from 11-12% to 4-5%.
- Improved Payment Accuracy: Automation has enabled the organization to better track whether claims are paid according to contract terms.
- Labor Savings: The need for manual claim touches has decreased significantly, allowing the organization to reallocate staff to other critical areas like credentialing and payment accuracy.
Despite these gains, Wheelan emphasized that implementing Behavioral Health Revenue Cycle Automation is neither cheap nor easy. “It requires deep subject matter expertise and a commitment to continuous improvement,” he said. “But when you get it right, the results are transformative.”
The Human Element: Staffing and Training
One of the most intriguing aspects of automation is its impact on staffing. Wheelan explained that while some roles become obsolete, others evolve. “About a third of our team moved into new roles, like bot management or payment accuracy analysis,” he said. “Another third continued their work but with fewer manual tasks, and the final third were roles we likely would have phased out anyway.”
Wheelan also highlighted the importance of retaining institutional knowledge during the transition to Behavioral Health Revenue Cycle Automation. “The people who understand your revenue cycle inside and out are invaluable,” he said. “You need their expertise to configure the rules and ensure the system works as intended.”
Martinez echoed this sentiment, noting that automation allows staff to focus on higher-value tasks. “It’s about working at the top of your license,” she said. “Instead of spending hours manually sorting through claims, your team can focus on resolving exceptions and improving processes.”
Looking Ahead: The Future of RCM in Behavioral Health
As the conversation turned to the future, both Martinez and Wheelan emphasized the importance of continued innovation. “To remain financially viable, you have to adopt these technologies,” Martinez said. “Your clinicians will demand it. No one will want to type out notes anymore—they’ll want to record conversations and let AI handle the rest.”
Wheelan added that surveillance tools are critical for ensuring no claims fall through the cracks. “You need to know whether all your recorded claims make it to submission and payment,” he said. “The leakage is shocking if you don’t have the right systems in place.”
He also stressed the importance of staying ahead of payer changes. “Payers are constantly updating their systems and requirements,” he said. “If you’re not proactive, you’ll wind up with a backlog of denied claims. Behavioral Health Revenue Cycle Automation helps us spot these changes faster and adapt accordingly.”
The Bigger Picture: Sustainability in Behavioral Health
Wheelan painted a sobering picture of the financial challenges facing behavioral health providers. “Our margins are tight, and our payroll is big,” he said. “It takes us 1,200 clinicians to generate $150 million in revenue. If we were an orthopedics practice, we’d need maybe 30 people to do the same.”
This reality underscores the importance of operational efficiency in behavioral health. “Without Behavioral Health Revenue Cycle Automation, it would be hard to imagine a scaled outpatient platform surviving, let alone thriving,” Wheelan said. “Automation allows us to take costs out of the system and ensure that more of our revenue goes to supporting our clinicians and patients.”
Final Thoughts
The discussion underscored a universal truth: technology is not a silver bullet, but it is an essential tool for navigating the complexities of modern healthcare. For behavioral health providers, where margins are tight and administrative burdens are high, solutions like RCX Rules and AI-driven Behavioral Health Revenue Cycle Automation offer a path to sustainability.
As Wheelan put it, “This is what allows us to stay in business. Without these tools, it would be hard to imagine a scaled outpatient platform surviving, let alone thriving.”
For organizations looking to improve their RCM processes, the message is clear: embrace innovation, invest in the right tools, and ensure your team is equipped to adapt. The future of behavioral health depends on it.
By leveraging Behavioral Health Revenue Cycle Automation to streamline operations, reduce errors, and improve financial performance, providers can focus on what matters most: delivering high-quality care to those who need it most.
