How Automation Enhances Revenue Cycle Operations

Automation offers game-changing advantages that are much needed in today’s healthcare industry. While the term is sometimes used interchangeably with artificial intelligence (AI), automation is a type of software that works with data to do things automatically without human intervention – and it can be found everywhere. Automation can include AI, because it works with data, whereas AI understands data, using it to simulate the way humans think.   

Clinical applications of AI tend to attract the most attention. However, revenue cycle operations are one of many administrative areas where AI and automation can transform processes and efficiency.

Let’s take a closer look at how automation enhances revenue cycle operations. We’ll start with a brief definition of revenue cycle operations (RCO) in healthcare.

Defining Revenue Cycle Operations

RCO, which is also called the revenue cycle process, focuses on: is the patient in the right status at the right time, ensuring the correct reimbursement. RCO encompasses the following for providers like hospitals and health systems :

  • Prior authorization to align medical services with payer requirements ahead of the medical visit
  • Utilization management and patient status alignment
  • Claims processing and denials resolution management
  • Payer and patient billing for patient care — in other words, medical billing
  • Collecting funds owed to the provider

RevCycleIntelligence supports “The [revenue cycle management] process consists of identifying, managing, and collecting patient service revenue.”

RCO includes both administrative and clinical functions, and AI can offer benefits that support both types of employees. After all, there are no claims to submit and nothing to bill for without the work of doctors, nurses, and other clinical staff. 

The Healthcare Financial Management Association highlights the importance of communication in RCO. It notes providers must effectively communicate with insurance companies, government payers, and patients alike. Initial ways to improve communication among these entities is deploying a payer communication layer and a more strategic way to deliver a patient encounter visit synopsis (clinical picture). In addition, Precision Utilization Management further tightens communication gaps by delivering payment agreements more efficiently between providers and payers. 

Why Automation is Valuable in RCO

An abstract concept image representing automation and AI in healthcare operations.

When it comes to healthcare RCO, automation plays a crucial role for strategic providers.

Automation, and especially AI, in healthcare can be delivered in real-time, providing analytics that drive staff efficiencies and strategic outcomes in several areas:

  • Taking care of important but tedious tasks, leaving staff free to focus on other duties
  • Generating analysis and forecasting that guides crucial decisions and strategy development
  • Predicting patient status that provides real-time notifications when there are appropriate conversion opportunities 
  • Sharing the most relevant patient data with payers, improving communication and streamlining the approvals process

AI can never fully replace the clinicians and other skilled professionals who work in RCO in healthcare each and every day. However, automation can make those employees even more effective at their jobs, augmenting the quality of their work. I like to say that AI allows clinicians to truly be clinicians and “do great work” because they’re not caught up in EMR deep dives – the right technology allows them to start their day in the driver’s seat and build confidence with their clinical validations. 

AI-driven workflows optimize operations, cutting down on inefficient communication and delays in decision-making seen when there are denials and peer-to-peer review processes for claims that could have been first-touch approvals. Learn how AI helped nurses at United Health Services Binghamton reduce administrative burden and spend more time focusing on patients. In addition, Payer organizations like Humana similarly benefit from AI with time savings and data transparency.  

This leads to opportunities for improved financial efficiency. The time and money once spent when providers and payers are misaligned on patient status or medical necessity documentation can now go toward administrative and clinical improvements. That could mean everything from giving clinicians more time each day to spend with patients, focusing on clinical initiatives, to updating IT infrastructure.

The reporting generated by a dependable AI solution for RCO can even supply context about relevant strengths and opportunities. Robust reporting capabilities and increased data transparency ultimately empower leaders to make effective and evidence-based adjustments that lead to sustainable improvement.

XSOLIS is proud to offer an automated utilization management solution driven by AI and predictive analytics called CORTEX, which offers shared views and a framework for automation and better collaboration between both providers and payers. The icing on the cake? The Clinical Engagement Consultant who manages reporting and provides proactive support to promote clinical best practices, revenue retention, and client satisfaction through the life of each XSOLIS customer’s engagement. We support clinicians and RCO-focused staff alike, saving money and optimizing workflows. 

Learn more about XSOLIS for your organization.


Kelly Layton BSN, RN, ACM, is Senior Director, Clinical Engagement at XSOLIS and has over 30 years’ experience in healthcare, serving in corporate compliance and care coordination technology roles, and as a former director of case management at Penn Medicine Princeton Medical Center, Saint Barnabas Medical Center, Saint Peter’s University Hospital, and Union Hospital.