Revenue Cycle Management & AI: Working Together to Keep Hospitals Healthy

Posted by Shyam Sunder and Chandler Tarr on Thu, Feb 07, 2019


An Unconventional Business Model

The business of healthcare is unlike any other business. The primary objective of a health system is to provide best in class services, rather than to maximize profits. Most people would agree that this is a good thing. It’s also a rare thing in the competitive world of business. The admirable commitment to “patients before profits” puts every health system’s cash flow at constant risk. A health system has more control when it comes to providing services, but relatively little control over collecting payments for these services. Inefficiencies in collection processes and missed charges result in significant lower revenues and directly impact the bottom line.

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Topics: Healthcare, revenue cycle management, Artificial Intelligence, Revenue Cycle AI, Payment Integrity, Revenue Commander

CMS Chooses Opera Solutions for Analytics — Again

Posted by Sarah Anderson on Tue, Nov 17, 2015

Once again, we are pleased to announce that CMS, the Centers for Medicare and Medicaid Services, has chosen Opera Solutions for a three-year, $28 million contract that will enable Opera Solutions to provide the operational analytics that drive the Health Insurance Marketplaces of the Affordable Care Act. In this role, Opera Solutions will continue to build on the strong foundation it has built in the first three years of this relationship, adding more advanced analytics and ensuring data integrity across the widespread, diverse data environment within CMS.

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Topics: Healthcare, Press Releases

Analytics in Healthcare: How to Survive the ICD-10 Transition

Posted by Sarah Anderson on Thu, Oct 01, 2015

Is now the right time to add machine-learning analytics into your charge-capture management system?

ICD-10 is here and chances are, as a provider, you’re as ready for it as you can be, knowing there could be some hiccups and impact on revenues. Most predict that the impact will be confined to inpatient revenues, driven by significant adjustment issues in grouper methodologies. But what if the impact extends well beyond that, to outpatient revenues?

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Topics: Healthcare, Machine Learning

Data Science As the Panacea for Healthcare Fraud, Waste, and Abuse

Posted by Daniel D. Gutierrez on Thu, Jun 12, 2014

Edited by Yan Zhang

Many pundits speaking about the state of the nation’s healthcare infrastructure routinely point to fraud, waste, and abuse (FWA) as major reasons for many of the problems the public witnesses every day – increased healthcare costs and the resulting increase in insurance premiums. The net effect is an annual loss of billions of dollars, and these losses affect the public in very real ways. 

The size of the healthcare sector, the enormous amount of money involved, and the lack of surveillance and monitoring mechanisms across the healthcare ecosystem make it an attractive target for FWA. According to the Office of Management and Budget, in 2010, about 9%, or $47.9 billion was lost to fraud in Medicare alone. It is therefore imperative to develop effective FWA technologies and solutions for reducing the costs associated with our healthcare system.

Data science and its primary enabling methodology of machine learning represent the country’s best chance for detecting FWA to avoid extraordinary sources of loss. Data science possesses the facilities to make a significant difference healthcare industry budgets and their impact to the public. Opera Solutions is the industry leader in applying Big Data technologies to the most challenging and significant business problems. We are the company charged with developing the analytics to identify fraud for the Centers for Medicare & Medicaid Services (CMS) on the health insurance exchanges. Here’s a look into just how big this challenge is — and some of the approaches we’re taking to overcome one of the costliest burdens in America.

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Topics: Healthcare, Big Data, Data Science, Machine Learning

Data Science and ICD-10 Team Up to Benefit Healthcare

Posted by Daniel D. Gutierrez on Mon, Mar 31, 2014

Switching to a new medical coding system won’t be easy, but when combined with data science and machine learning, ICD-10 presents enormous potential benefits for both the financial and the clinical sides of healthcare.

Part of why the healthcare industry is such a notorious laggard in jumping on the Big Data bandwagon is that every attempted change faces a huge domino effect, rendering many good ideas useless until everyone — and everything — is ready. One big step in the right direction, however, is an important upgrade to the computerized codes used for electronic medical records (EMR), which will take hold in the next year or two. These codes, known as ICD or International Classification of Diseases, determine what ailments patients have and how much they and their insurers should pay for a treatment. The set of codes, currently called ICD-9, is scheduled for its 10th revision this fall (but there may be a year-long delay). The updated codes, called ICD-10 codes, improve on the previous standard by adding more descriptive capabilities that will help healthcare professionals better categorize and keep track of patient disorders and treatments. Through the use of machine learning and other data science techniques, this increased granularity is expected to open up patient treatment analytics along with the ability to better monitor public health threats.

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Topics: Healthcare, Big Data, Data Science, Machine Learning

Retail Clinics and Their Financial Impact on Hospitals

Posted by Sarah Anderson on Wed, Feb 12, 2014

Since retail clinics started gaining popularity in 2007, healthcare professionals have been worried — for all sorts of reasons. Will patients still get the care they need? Will they visit their doctors less? How will these clinics impact patient volume in nearby emergency departments?

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Topics: Healthcare

Predictive Analytics Curb the Cost of Healthcare — An Hour at a Time

Posted by Sarah Anderson on Wed, Sep 04, 2013

Predictive analytics–based staffing solutions can save hospitals millions.

While we wait to see how insuring more of the population affects healthcare costs for patients, hospital groups are also working hard to reduce the cost of healthcare. Some hospitals are reducing unnecessary department labor costs — in some cases staff hours have been reduced by up to 8% — by using solutions that analyze Big Data to predict patient inflows. With accurate patient forecasts, hospitals can optimize scheduling to better match supply (nurses) to demand (expected patients). Not only does this reduce costs, it makes their hospitals more efficient and even increases patient satisfaction.

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Topics: Healthcare, Big Data

Obamacare: Predictive Analytics Promise Healthier Exchanges

Posted by Bob Knox, Jr. on Mon, Jun 17, 2013

While some users are just now getting their footing in Big Data, two — healthcare management and fraud prevention experts —are already successfully using predictive analytics to deliver unprecedented results. And so it makes sense that the Centers for Medicare and Medicaid are turning to Big Data predictive analytics solutions to prevent fraud and enhance operational controls in the new health insurance exchanges that form the centerpiece of the program.

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Topics: Healthcare

Opera Solutions Selected by the Centers for Medicare & Medicaid Services to Provide Operational and Fraud Analytics

Posted by Todd Higginson on Thu, Nov 15, 2012

NEW YORK, N.Y., Nov. 15, 2012 — Opera Solutions, LLC, a leading global Big Data science company, today announced that it has been selected by the Centers for Medicare & Medicaid Services (CMS) to provide advanced analytics to enhance operational controls and prevent fraud in federally funded Health Insurance Exchange Operations (“HIX”) managed by CMS’ Center for Consumer Information and Insurance Oversight (CCIIO). Opera Solutions will apply its unique healthcare claims data anomaly detection experience, in tandem with its extensive origination/eligibility and fraud detection expertise, to support CMS’ rollout of the Exchanges that begins in January 2014.

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Topics: Healthcare, Big Data, Press Releases

Opera Solutions Launches Advanced-Analytics-Based Capability to Help Hospital Systems Improve Charge Capture

Posted by Todd Higginson on Wed, Jun 20, 2012

NEW YORK, N.Y., June 20, 2012 — Opera Solutions, LLC, a leading global Big Data predictive analytics company, today announced the general availability of its Revenue Cycle Management solution.

Already in use in more than 60 hospitals, the solution helps hospitals significantly increase profitability and operating efficiencies by identifying missing charges and reducing audit expenses. Based on industry profitability averages, hospitals using the solution can increase their operating income by 10 percent or more.

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Topics: Healthcare, Machine Learning, Press Releases