The Winning Edge for Revenue Cycle Policy Readiness

Over the next couple of years, health systems will face an unprecedented convergence of federal regulatory shifts and policy mandates.

From the sweeping changes to Medicaid and coverage introduced by H.R. 1 to the stringent new prior authorization and API requirements under CMS-0057-F, revenue cycle leaders are under immense pressure to adapt their operations.

During a recent Ascent Health webinar, revenue cycle leaders Bill Stone, EVP of U.S. Healthcare at Ascent Health; Samantha Evans, Assistant Vice President of Revenue Cycle at AnMed; and Ken Hogue, Chief Revenue Cycle Officer at United Health Services (UHS), discussed how healthcare organizations can prepare for these changes rather than simply react to them.

This article highlights key insights from that conversation, along with additional perspective from Stone on the regulatory, operational, and technology challenges revenue cycle leaders should be preparing for now.

Read on to learn:

• Strategies for transitioning from reactive to proactive policy readiness
• How to strengthen front-end eligibility
• How to hold payers accountable
• Why putting patients first is the path forward

H.R. 1 is here. And it has everyone talking.

Ascent Health Executive Vice President of U.S. Healthcare Bill Stone recently found himself ensconced in nonstop discussions about the sweeping new bill, with providers discussing the stricter Medicaid work requirements and re-determination timelines. Namely, they reviewed how adapting front-end patient access workflows can prevent coverage gaps.

What he and others noted were the ways in which proactive advocacy will matter more than ever. The obvious element is an expansion of advocacy by not-for-profits. But more generally, providers will need to be advocates for patients.

“Often in healthcare, it falls on us to help interpret the rulesets and guide patients through the process.”
– Bill Stone, EVP of U.S. Healthcare, Ascent Health

Samantha Evans, also on the webinar, agrees.

The Assistant Vice President of Revenue Cycle at AnMed, Evans shared that patients won’t always know their way around the new rules. That means patients and providers won’t always connect when they should.

“Let’s say a patient lost coverage in June,” Evans said in the webinar. “I don’t know that, because they haven’t come to see me yet, and I don’t have a claim for them. They haven’t needed services.”

If she can help that patient get their coverage back, then when that patient does need services, everyone is ready.

“And so I think the biggest thing that we need to focus on is closing the gap: focusing on the patients that we’re seeing today or we’re seeing next week, but also focusing on the patients that we possibly could see moving forward because we’ve seen them previously,” she said.

The way to close that gap is to be proactive, especially with your patients.

The number-one word Evans uses when thinking about this new normal? Proactive.

“Being proactive and knowing that the patient is at risk of losing their coverage, or has already lost it, matters,” she said.

Revenue cycle leaders must adopt that mindset. Why? They need to identify coverage risks early and help patients navigate changes before they create barriers to care. Organizations that take this approach will be better positioned to protect patient access, reduce revenue disruption, and improve financial performance.

Ken Hogue, Chief Revenue Cycle Officer at United Health Services (UHS), shared how his organization has put that philosophy into practice. As Medicaid eligibility rules changed, his team focused not only on identifying patients at risk of losing coverage, but also on helping them understand their options and connect with available resources.

“As the hardships happen, we’ve proactively looked at things outside of traditional financial counseling and patient financing.”
– Ken Hogue, Chief Revenue Cycle Officer at United Health Services (UHS)

“We are very blessed to have a strong team here at AnMed,” Evans said. “That is number one. Their processes, their ability to help these patients through the unknown is very important.”

More broadly, revenue leaders must be ready to work with all of their partners in a proactive manner to deliver the help that patients need most.

“We are working with partners and looking at reports two or three months out, essentially looking at coverage like a sponsorship,” Hogue said. “We work with a few vendor-related partners to be able to help pay and secure the insurance premium.”

“We want to educate people on what they may have missed on the front-end, while on the backend, offer them tools to help them overcome their hardships,” Hogue said. These steps could include helping patients receive grants, referring them to mobile food banks, or even just giving them utilities assistance.

For example, a patient might just be $5 over the threshold for help and still really need additional assistance to make their marketplace payment.

“As the hardships happen, we’ve proactively looked at things outside of traditional financial counseling and patient financing,” he said.

In other words, Hogue sees patient advocacy as extending well beyond financial counseling. It means anticipating challenges, connecting patients with the right support, and helping them maintain access to care even as coverage rules evolve.

That effort also requires thinking beyond Medicaid eligibility alone. Many patients fall into coverage gaps that leave them without Medicaid while also making it difficult to afford marketplace plans or other coverage options.

“We’re focusing on additional resources, because while Medicaid remains our number one priority for those patients, sometimes they don’t fit in that box or fit in our financial assistance,” she said.

As such, providers must put a lot of resources into helping patients navigate the system even when they don’t have Medicaid.

As Evans, Hogue, and Stone look ahead to the next 24 months, they are focused on the capabilities that revenue cycle leaders must prioritize today to prepare for the regulatory and reimbursement environment ahead.

Stone sees regulatory guidance as largely silent on the treatment of AI, such as billing procedures for automated clinical workflows, because current compliance frameworks were developed for human-driven workflows.

To learn more about these matters, we asked Stone to expand on several of the issues facing revenue cycle leaders — from H.R. 1 and CMS-0057-F to AI, workforce transformation, and the future of policy readiness.

Here’s what he had to say.

Q: Many organizations feel they are constantly reacting to regulatory changes. What are the biggest challenges providers face in moving from compliance firefighting to true regulatory readiness?

STONE: Governance and workflow are often the biggest obstacles to transitioning from a reactive to a proactive compliance posture. From a governance perspective, leadership buy-in is essential to foster top-down development while also building a culture of distributed accountability.

For an organization to proactively address compliance concerns, a compliance-first mindset must extend across the entire organization — not just the compliance department. That doesn’t mean every team member must share the same perspective as the Chief Compliance Officer. Rather, it requires recognizing that a strong compliance focus may create tension between different teams (e.g., compliance and revenue optimization) and fostering a willingness to address that tension constructively.

Furthermore, there must be an appreciation for the complexity of operating in an industry where compliance is a foundational element of the business, while also building a compliance team that is viewed as a trusted partner rather than an adversary. These considerations become even more important in private equity-backed organizations, whether due to limited experience with regulated industries or a general deprioritization of compliance.

Based on experience with both the utility and healthcare industries, I would argue that repeatable processes are a necessary foundation of any proactive approach, whether compliance-focused or otherwise, because they create predictable outcomes and establish standardized baselines. In an environment with ever-changing requirements such as healthcare compliance, these baselines can serve as a launching point for addressing new requirements when new regulations or guidance layer on top of the old.

Q: With H.R. 1 introducing stricter Medicaid work requirements and redetermination timelines, how are you adapting your front-end patient access workflows to prevent coverage gaps?

STONE: Many of our clients have designated teams to assist patients in this process. Often, the patients are confused as to the new requirements and are seeking counseling. Many of the non-profits continue to invest in this process as laws and requirements are changing.

Q: What strategies are proving most effective in identifying coverage issues earlier and reducing preventable denials?

STONE: A structured benefit verification process is critical to managing controllable denials. Leveraging technology throughout the process to prompt the user can simplify complex specialties such as infusion, oncology, behavioral health, and dental where controllable denials often happen.

Q: CMS-0057-F sets strict prior authorization turnaround times for payers. How are you preparing to track payer performance and hold them accountable to these deadlines?

STONE: Technology is the cornerstone of tracking and payer accountability. The challenge, however, isn’t prior authorization itself. It’s what happens when payers request additional documentation after authorization has already been granted. Was the documentation sufficient to ensure final payment for the services for which prior authorization was granted? CDI, guided by clinical guidelines and payer policies, will be key to ensuring first-pass payment for services that receive a request for additional information.

Q: Many organizations are investing heavily in automation and AI. In your experience, what operational changes must accompany those investments to achieve meaningful results?

STONE: AI alone does not solve operational challenges. Without process transformation, AI alone is not the solution. Without an organizational commitment to repurpose individuals in the revenue cycle as AI replaces or enhances their work, most organizations will fail to realize the full value of these investments. Many promising AI solutions have failed to deliver value because organizations never fully transformed the underlying processes needed to support them.

Patience is also another critical factor. AI requires continuous training, refinement, and oversight. Organizations often mistake it for a plug-and-play solution rather than an iterative process.

Q: Given the potential for significant Medicaid funding cuts and subsidy shifts under H.R. 1, how are you adjusting your financial modeling and margin-protection strategies?

STONE: Our clients are focused on optimizing reimbursement from commercial payers in anticipation of reductions in Medicaid funding. There is a strong emphasis on maximizing the net collection ratio (NCR), with revenue cycle executives targeting an NCR exceeding 95%. Retaining the best people, partnering with the best organizations, and continuously refining processes remain core priorities.

Q: Revenue cycle teams are being asked to manage increasing complexity while dealing with staffing shortages and burnout. How are organizations adapting their workforce strategies to meet these demands?

STONE: Success still comes down to people, process, and technology. We continue to partner with healthcare organizations to deliver Global Capability Centers (GCCs) that focus on retaining the best personnel domestically and globally while amplifying their abilities through technology. Process transformation continues to be difficult for healthcare organizations, and our GCC model allows organizations to scale and change in a structured format. The goal is to improve the process and then deliver technology that amplifies the human-in-the-loop.

Q: When you think about the next 24 months, what capabilities should revenue cycle leaders prioritize today to prepare for the regulatory and reimbursement environment ahead?

STONE: It’s almost trite at this point, but I think the ongoing evolution of AI poses a significant challenge for healthcare compliance. Compliance regulations and corresponding compliance frameworks necessarily lag behind rapidly evolving technologies. Regulatory guidance remains largely silent on the treatment of AI, such as billing procedures for automated clinical workflows, because our current compliance frameworks were developed for human workflows.

The development of new regulatory requirements is a matter of when, not if. Maintaining organizational flexibility to address these changes may create a competitive advantage by enabling organizations to adapt more quickly as regulatory requirements evolve.