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How AI can improve documentation practices to boost revenue: 5 insights

Artificial intelligence technologies can help ASCs alleviate revenue and resource challenges spurred by the COVID-19 pandemic by optimizing workflow and improving revenue capture.

Panelists at Becker's ASC Virtual Event on Oct. 2 discussed how AI can drive appropriate reimbursement and improve provider satisfaction through solutions aimed toward simplifying documentation practices.  

The panelists were:

- Lucian Newman III, MD, chief medical information officer at Nuance Healthcare
- Ken Kolenik, director of product management at Nuance Healthcare
- Matthew Thom, MD, urologist at DCH Health (Tuscaloosa, Ala.)

Five takeaways:

1. Clinical notes are critical to reimbursement. While technology has evolved, clinical note taking methods like Dictaphones or voice-to-text templates don't always cover every aspect of the surgical or clinical encounter. It’s critical to present the complete patient story to third-party payers to achieve appropriate reimbursement and quality  scores.

2. Challenges ASCs are facing today. From a budgeting and cash flow perspective, many elective surgeries were delayed and continue to be postponed due to COVID-19, which has had a direct effect on operational budgets and resource constraints. Burnout also continues to be a problem for physicians and surgeons.

"We've learned that surgeons are more strapped today than before due to COVID-19. They have to be more flexible with scheduling and take on additional responsibilities within the organization," Mr. Kolenik said. "A lot of organizations are analyzing their operations to understand what they can do to get back to so-called normal operations."

3. Artificial intelligence combined with speech recognition technology creates accurate clinical notes in shorter time. Dr. Newman said Nuance's surgical CAPD solution uses built-in AI to compile accurate report patient and event data.

"We do not want to focus on event versus patient, but on understanding all of the information necessary to present the right workflow to capture all of the necessary specificity and details," Dr. Newman said. "Those details are saved so they can be reused the next time the procedure is performed and helps speed documentation."

4. Simplify insurance reimbursement claims process. After implementing Nuance's surgical CAPD software across his practice, Dr. Thom was able to complete his notes within about 90 seconds after surgery — significantly faster than using transcription.

"It has revolutionized our documentation process because there’s no draft mode; we don’t have to re-review our notes to make sure everything was transcribed correctly. We sign the note right away and it’s sent to billing so we can be paid more quickly," he said. "Documenting in real-time in one setting has been a big time saver from an efficiency standpoint."

5. AI checks clinical note taking. With AI working in the background, Nuance's software learns a surgeon’s documentation habits. It guides surgeons through the documentation process, automatically prompting them when clarifications are needed to capture the required level of specificity, to quickly and easily document the appropriate level of care.

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