Navigating Disruption: What CFOs and Their Teams Need to Know Now

The health care field has entered a period of disruption, from sweeping coverage changes to the rise of artificial intelligence (AI)-enabled tools. The Congressional Budget Office is projecting millions of individuals will become uninsured over the next several years, and experts warn that increasing labor market instability, driven in part by AI, may further exacerbate this trend. In addition, rising costs on the individual market and expected regulatory changes are likely to increase the number of underinsured individuals, including those with catastrophic and/or skinny coverage (e.g., short-term, limited-duration health plans). Together, these changes will have significant implications for hospital finances, as many newly uninsured and underinsured individuals will struggle to afford their care.

At the same time, health care consumers — including patients, employers and payers — now have access to rapidly evolving AI-enabled tools that provide new opportunities to interact with health care pricing data and aid in billing and payment disputes.

With these changes in mind, hospital finance and revenue cycle leaders should consider the following actions.

Audit and ensure compliance with uninsured/self-pay good faith estimates (GFEs). Hospitals are required to provide all uninsured and self-pay patients with GFEs for scheduled care. Patients who receive a final bill that exceeds their GFE by $400 or more can engage in a dispute resolution process. Given the anticipated increase in uninsured and underinsured individuals, hospitals should expect to provide an increasing number of GFEs in the coming years.¹ Hospitals should audit their GFE process now to ensure compliance with the uninsured/self-pay GFE regulations and ability to handle the increased demand. In addition, hospitals should assess the accuracy of their GFEs and make any necessary changes to minimize excessive patient disputes. 

Consider implementing presumptive eligibility for charity care. Experts expect hospitals will experience a significant increase in uncompensated care due to the growth of uninsured and underinsured individuals who may not be able to afford their care. Hospitals and health systems are increasingly incorporating presumptive eligibility screenings for charity care into financial assistance programs, which involve analyzing readily available financial and other data to approximate a patient’s financial need. Implementing these presumptive eligibility screenings could be even more critical moving forward, for both the patients receiving financial assistance and the hospitals seeking to avoid excessive administrative burden. 

Monitor Price Visibility. While hospitals and insurers have been required to post their negotiated rate data in machine-readable files for several years now, utilization of the data has been relatively low. However, as the data quality improves in the coming year and as individuals become more comfortable using AI, exploration and use of the data is likely to increase. Hospitals should regularly check the leading publicly available tools to understand how their data may be presented to patients or employers.

Develop an AI Action Plan. One of the most promising areas for AI deployment is in administrative tasks, including interactions with payers to ensure appropriate reimbursement. Electronic medical records, for example, are developing AI solutions to support billing and claims processing, including tools to generate appeals letters for claims that are inappropriately denied. Other administrative and/or clinical AI-enabled tools may help alleviate some of the growing financial pressures felt by hospitals. In this period of significant resource constraints, hospitals should consider how they can leverage these new technologies to streamline operations.

Disruption is inevitable — but with careful planning and action, hospitals can make their operations and patient relationships more resilient.