02-07-2025
Potential Medicaid Cuts Demand Action, Here's How CIOs Can Step Up
WASHINGTON - APRIL 21: U.S. Sen. Hillary Rodham Clinton (D-NY) (L) and Michigan Governor Jennifer ... More Granholm participate in a forum
The Senate's approval of more than $1 trillion in Medicaid cuts over the next decade puts severe pressure on healthcare systems, and CIOs can't afford to stay in the background. With CMS and Medicaid budgets on the line, IT leaders must step up and collaborate with CFOs to streamline operations and maximize every dollar. CIOs must rethink the tech stack in both the front-end and back-end revenue cycle processes, where more innovative technology can deliver a real financial impact.
Front End Revenue Cycle
Incomplete and incorrect data collection at the front end of the revenue cycle process, such as pre-registration and patient registration, has a significant impact on the finances, leading to claim denials and errors in patient eligibility. According to the Experian State of Claims report, 67% of the patient data gap is in demographic information.
CIOs need to automate identity verification, starting with third-party lookup databases or system integrations. While not a complete fix, it's a critical first step to reduce manual effort and improve efficiency. To strengthen the front-end revenue cycle, CIOs must deploy strategic solutions that ensure accurate patient identification and streamline financial workflows to enhance operational efficiency. This includes implementing strong identity verification at registration to prevent fraud and duplicates, automating eligibility checks and prior authorizations, and enabling secure, user-friendly digital payment options.
Patients who lose Medicaid coverage often regain eligibility quickly—what disqualifies them this month might change by the next. Life situations change rapidly, and healthcare organizations must keep pace. By utilizing the tech stack to monitor and reassess eligibility in real-time, teams can help patients secure coverage as soon as they qualify again. This approach reduces unnecessary write-offs and recovers reimbursement for care that may become covered in the future.
When CIOs prioritize data accuracy and automation from the start of the patient journey, they reduce claim denials, expedite collections, and enhance the patient's financial experience.
Back End Revenue Cycle
The push for autonomous medical coding has gained traction as a way to speed up claim submissions and reduce AR days. While these solutions support—rather than replace—medical coders, CIOs are also moving forward with Agentic AI to streamline operations and drive greater efficiency across the board.
For example, after medical coding is completed, CIOs can implement an AI agent to perform a final review of each claim, checking it against the specific requirements of the insurance payer. If the claim meets all criteria, the agent automatically submits it. After the claim submission, if the payer rejects the claim, the agent identifies the denial reason code, pulls relevant claim and patient data, and corrects the issue. It also analyzes the root cause to prevent repeat errors. Over time, the Agentic AI learns from each interaction, continuously improving the accuracy of claim submissions. By orchestrating these intelligent, self-correcting workflows, CIOs can reduce denials, speed up reimbursements, and build a more resilient revenue cycle.
CIOs can transform the healthcare revenue cycle by embedding Agentic AI into workflows that still rely on manual tasks. To ensure success, they must build strong partnerships across internal teams, such as IT and operations, as well as with external vendors. When applied strategically, automation and AI in the revenue cycle deliver measurable ROI and drive lasting efficiencies.
