In this episode of 'The Efficient Care Podcast' we are talking about the domino effects of adopting automations in a healthcare practice's revenue cycle.

Our host, Shruti Mehrotra, is joined today by Niobis Queiro. She is a veteran in revenue cycle management and has worked in the healthcare industry for more than 30 years, Nio's background in revenue cycle, finance, and technology allows her to continue helping healthcare organizations evolve their digital and hyper-automation ecosystems using strategic transformational models. She was one of Modern Healthcare’s Top 25 innovators in 2021, where she was recognized for developing novel ways of improving patients’ access to care during the pandemic of 2020.

Listen on to hear as they discuss why good communication with your patients is at the heart of implementing patient transparency, change management strategies you can bank upon when you're transitioning to newer RCM technologies, why healthcare revenue data is important and how automations will create new opportunities in healthcare in the coming decades. She talks about her new book 'Joy Notes' which is a must read for business leaders across the board and offers rare life lessons for women in healthcare and beyond.

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Listen to the full episode here: https://www.aarogram.com/the-efficient-care-podcast

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Transcript of the full episode:

Shruti: Welcome to the podcast, Nio. You've been working in the healthcare industry for the past 30 years. What initially drew you to the industry and how has your perspective on your core mission evolved over time? Tell us a bit about yourself.

Nio: Absolutely. You know, nobody says to themselves when they're little kids, Oh my God, I want to get into revenue cycle or I want to get into the financial side of their, actually in my case, having a glimpse of health care as a young child, shepherding my mother through the health care system because we came to this country when I was four years old from Cuba, and my mother didn't have a mastery of the language, so I was her interpreter, and my mother was going through a catastrophic health care issues, and going to the treatments and being the one speaking for her, and also seeing the disparity in the finances and the disparity in the equity because of someone that couldn't speak the language, and getting the care that they deserved.

I said to myself, I will do something in my future to change this. And that has been my passion and my dedication. And it has evolved, you know, as life, as you get more exposed, I mean, you started with biochemistry and look what you're thinking and you're doing now, because as we get exposed, we evolve and we get into different things.

But it's a lifelong journey, to focus on health equity and financial solvency and literacy for patient. That's very important to me. And at the same time, making sure providers are solvent so that they can reinvest and also be paid. Equally, so that they can actually continue in the healthcare environment. We lost so many providers during the pandemic. It was devastating. Because for the work that they were doing, and they didn't have.

Shruti: When you say solvent, when you say that providers are not solvent, what do you mean? Like, do you mean, is that is there cash crunch faced by providers?

Nio: Absolutely. Unfortunately we're in a situation that providers margins are so low that they're barely making it. We're seeing more providers, from the positions that just retire because they can't do it anymore. Denials are high, AI is being used as a weapon, by the payers against providers, in the sense that they have greater mastery of, the data science of usage of AI, being able to use large data analysis and,, understanding and, being able to direct.

That information, those findings to, provide denials to the payers to change the ecosphere. So it's harder for them to get paid for the services that they provide. That is causing a true, impact in the industry, and unfortunately, what's happening is we have a great. Void. In between the provider on the pair and the only way that this is going to get better is if we bridge that chasm and if we say we both have AI, let's figure out how to use it responsibly and let's get paid for the services we provide and make sure that our patient outcomes are truly the focus and not how much money do we, garnish for care.

Shruti: Going back to your story and your journey, you've been recognized as a healthcare innovator, and can you share a bit about the automation you introduced for which you received this award?

Nio: You know, it was a team effort. I did not take and. Full credit for this event, but we were in the middle of the pandemic, and I had just joined, Tufts, medicine, as their SVP of revenue cycle and when, I joined that 1st day.

An article comes out, in Boston Globe and actually hit CNN also. And it was lines of people waiting for, COVID tests. And we had such an inefficient means of getting people registered and seen. And the reason for it is nobody was prepared for anything of that magnitude. So we had a very clunky system and it was a great opportunity to take people that were out in the sun and rain and horrible weather from waiting an hour and 15 minutes to just be seen, not even get their COVID test, just get to registration point.

We were able by using QR codes, by using AI automation to shrink that down from the point of presenting to the point of walking out the door to 13 minutes and it was a team effect. It was actually a multidisciplinary effect because we had to put the nurses in the rooms, the doctors in the rooms and really say, what is your process and. Create a very agile approach to how we use those spots to do a push and pull through the clinical system and the administrative system so that the patient ended up with a seamless event.

And left out of there with their test. And and knew that they were okay. So that particular, project was the beginning of innovation for Tufts Medicine, and we created an innovation lab, and I'm proud to say that even though I've moved on, they are continuously innovating and doing great creative things that Mary.

The clinical and the financial together to do great outcomes.

Shruti: Thank you for sharing that use case with us, you have a successful business, providing strategic consulting services on establishing revenue cycle and operational efficiencies, The Queiro Group. In your experience, what have you discovered about what works and what doesn't work when it comes to operational efficiencies?

Can you please also share a success story as well as a time when you made a mistake and then you learned in hindsight that you could do something better?

Nio: Absolutely. You know, it's really funny. It all comes down to communication. We have incredible systems. We have incredible talent, however, hurts us and stops us from flourishing is really communication.

And, what I've been able to do is help organizations have full awareness when they are creating use cases. Or projects or trying to do a reengineering and it all starts with listening and being open to everybody in the room and acknowledging that they have a true case. It doesn't mean you have to agree with it.

It doesn't mean that one is more important than the other, but at least when you understand how everything impacts each other, then that is the starting point. For whatever project I'm doing, you know, I've had the great opportunity to work with companies that are interested in, adding revenue cycle services. And we started with the poor education. It's a great idea. We have millions of great ideas, but if we don't really understand the idea and understand the impact and the dependencies associated with the idea, it just stays an idea. So, when we started from that, and we were able to sit down together and make sure that everybody knew and everybody that needed to be in the room was in the room.

Then we could do the RFP to find a partner. And we treated the partner in the same lens, gave them full transparency. They gave us full transparency and it's a wonderful partnership that has moved on. And then a bad story. Bad stories happen when we actually make that miss of making the assumption that we know the answer.

Before we go in, and I got to say that the 1st,, project that I had, when we started the company was with this firm and they had some revenue cycle issues. And I basically leaned in to what the CFO's version of their issues was. So, we came in and we were ready to, address only those points of view.

And what we found out, that there was an array of things. That were really the cause of those issues, and if they weren't taken care of, we could not ever have any success with what he was worried about. So, that's where the foundation came that we start with communication on every project. We are very much not only due diligence, but we also create a communication plan for the organization for every project that we do.

We have to be on the ground level. We need to be in touch with the real problems before we start solving them. Right? Yes. And we have to listen and we have to have full awareness. And, you know, I had the white experience, which, by the way, is the best.

And the way it teaches you the interview process and so on, but it's beyond that interview process. It's actually understanding who the influencers are understanding the voices behind the scenes and having a communication process that goes. Up and down at the same time. So it's a very different methodology. But it's the differentiator.

Shruti: As a consultant, you are an outsider to the process. Do you think someone who's managing RCM in house, do you think they might have biases towards seeing the problem?

Nio: You know, I will tell you. I think that what helped me a great deal is that I've sat in that person's seat, and I know that 99 percent of the time, the person sitting in the seat knows what their problem is.

I'm not coming in giving them this magical awareness. Maybe I can quantify it, qualify it in more succinct manner than they can. Because I have the tools to do that, but they know their problem. What I believe the magic is working beside that person, elevating their knowledge, making sure that their leadership knows that they know and they are willing to fix.

And working as a partner. That's when consulting becomes a fixer or a additive to success. If you go in there trying to shame the other leader, you're not doing anything good for that organization

Shruti: My question was more about the fact that a practice manager or a practice owner, let's say at an independent practice might not be aware of the problems, although you are saying that they are, I'm talking about the operators. Most of the operators know what's wrong. Some new, if you're talking about a new practice, a younger practice. They may not know, and we do discover things that they don't know.

Nio: want to make sure that you create an ally. You want to make sure that you create a partner. And you want to also educate. Education is so important. You know, those operators and those owners, are so busy on the day to day that they don't have the ability to do what we have, which is research.

They don't have the ability to go and sit with CMS, to go and sit with the payers, and have conversations, go to all the different activities that consultants are able to do. So yeah, there is a great value with us bringing our knowledge, which is great connections to the table that is something that we pride ourselves in.

Perfect example, right now I'm working with an organization they're building their a CO and PHO and I'm able to connect them with a successful one so that they can hear others, successes and actually, issues that they had when they went and set their own. So I'm able to connect to organizations to help each other that a single provider. Someone that's just starting, they don't have those connections. So those are the good things that happen when you do bring consultants and they can bridge those gaps that you may have.

Shruti: Integrating automation with existing systems can have both technical and non technical challenges, as you may know. How can a provider ensure a smooth integration process with their EHR systems as well as getting it accepted by their staff? How do you deal with resistance to change to ever evolving processes?

Nio: Well, change management is everything. You know, we go back to awareness, you know, I'd love the app car, model and it's awareness. Then you do discovery and the discovery is the best part because that's when you really define your use case. And I think that the biggest problems that providers have is that their use case is so large that they are not focused.

So here's the deal. For the last 50 years, we have been doing waterfall implementations, meaning everything but the kitchen sink. Has to be implemented at one time. Reality is, when you think AI, it is about a Scrum approach, an Agile approach, where you take small bites of the apple, make sure the bites are settled, and then you go to the next level.

So, when you start with the awareness, you start with discovery, and then everybody knows. That's the end. Okay. They know, and they make the decision that the use case is limited. So no more than three things to fix at that use case. It doesn't mean you're not going to have other use cases to support the model.

No more than three things. Now everybody has clear defined expectations of what success is going to look like. And then you can build. With the technology that you have to support it. I think if you do that, and then you modify and you go back and you add more to the use case, right? You add the things that you wished for that we're laying on the side.

And if you use that model. You will be successful. Mass Brigham in Boston is a perfect example of a place that has been using the Scrum approach and has been so successful in everything that they do in ai. They have an incredible AI team, and the reason they're successful is because they understand it's small bites.

Now, here's the issue that we are having though. The big issue that we're having is that our large EHR companies, Epic, Cerner, and so on, they are nervous about AI. They are nervous about the layover systems that are looking for APIs and are looking to link into their system in order to create dynamic change.

And they are blocking us. And that is something that makes it very difficult for us to be able to get to the level that our payers are at, because you see our payers have our data, but we can't even use our data because we have blocks that are happening in our data. With our EHR companies. So that's an area that we need to further investigate and spend more time in understanding how we can create models that the EHR company can understand that there, things that they don't need to do for us.

There are special things we need to do for ourselves and they should collaborate with us to let us be able to change the way we do business so health care is not as clunky and cumbersome.

Shruti: Quite ahead of the game with their use of AI implementations because theyinsurance companies have been doing a lot of claims denial using automations anyways for the past five years already. And so the situation that you described really calls for EHRs to rethink the way they are building their technology and how it's going to be useful for practice owners going forward.

Thank you for sharing that. It's a very important point. RCM systems generate a wealth of data. What kind of data do you think health care providers should focus more on, while collecting it or integrating it with the decision making process.

How can practices use this data to gain actionable insights and optimize the revenue cycle?

Nio: You know, it's really interesting that question in asked, let's say, 10 years ago would be a question that would have just stayed in the financial realm. Of using it, to understanding, creating a payer scorecard.

That still stays. , that is something that is essential for providers to understand how their payers are behaving. A scorecard could tell them, you know, how quick are they to pay. What are they denying? What are the patterns of styles that they seek? What are the data requests that they always have for X type of claim?

Those are important, but I challenge them to also start thinking beyond that realm, into the social, economic, and population health space, and understand how the care is differentiated With insurance, for different social economic, levels. And also, what are the trendings that happen with a patient based on race?

Based on gender, so start looking at the person as a whole person and that will give us the ability to really serve our patients. So, as much as I love revenue cycle, as much as I love making sure that our providers are getting the reimbursement that they need. deserve for the services that they're providing.

I also want to make sure that they look at that patient. That patient AR or responsibility is important, but it's important to make it so that they can afford their care so they don't avoid care because they can't afford it. And we have a great opportunity now with AI to be able to give them a path. To being able to afford care by giving them insights to all the benefit, packages that are available privately, government wise, state wise and locally.

So, it's not only insurance, there are great grants out there. There are also, different programs that pharmaceuticals have. And I think that having the data that we have now, we can assist patients in being able to get into those programs. So going beyond taking care of the provider, we are now to spread our wings into that customer financial solvency.

So we're looking at both of them and taking care of both of them. And it's a win win. You know, we're going to have healthier patients and we're going to have providers that are well reimbursed with the work that they do.

Shruti: The healthcare industry also faces a grave staffing crisis. What are your thoughts on healthcare practices, leveraging AI effectively for RCM tasks without fearing job displacements, how can automation address these challenges and empower existing staff?

Nio: You know, I always laugh that. You know, people get so scared when they think of technology. And if we go back to, our history, you know, technology has changed everything.

When we first started, billing, you know, I've been in this business 30 years. So I was here when we had paper claims. You know, we had young ladies typing claims. Can you imagine the volume of typing that was going on? And then the computer hit, and then they were typing in the computer. And then little by little, we got EHRs and we got administrative systems, and we were able to get the X 12 and have an administrator.

When that happened, everybody's like, Oh, everybody's going to lose their job. Nobody lost their job. What we have is new skills. New work. This is an exciting time. Now Revenue Cycle truly has the ability to have data analysts, to have experts that can actually direct the machine learning. That can direct the outcomes and create new programs so that we can get better so that we can cue things and make them automated so that I got this denial.

I need this information. Here's my letter that the machine learning has created, and I can put it out, but the human is the one that has the skill set to actually do the thinking as to where are the differentiations, where are the variances, you need the human, the human is never going to disappear, I'm finding that humans have more context than AI, and they always will.

And always will. And you know what I'm doing with my clients is I'm teaching them how to upskill their workforce. I'm teaching them how to do it without breaking the bank. There are over 20, 000 courses. And you can actually get your employees to get the Scrum certification for free, you know, the Agile certification for free, understanding AI 101 for free.

So this is a great opportunity to not only give them skills, but empower them to become critical thinking people it's a time to really skill up your health workers. And the other thing that's very important is our. Revenue cycle, people are aging out, so we need.

To have a newly skilled workforce to attract the younger set to come into revenue cycle. So it's a win win. This is not a negative.

Shruti: I wanted to really talk about the book. I was deeply impacted by reading it. And I'm not done reading it and I want to read it slowly because it's an amazing book.

I don't want to finish it too fast. How did the idea of the book originate? And how did the book transform you? What were you before you wrote the book and after?

Nio: You know, the book is 20 years in the making. It goes back to when I had my first near death experience. I knew at that time in my life, it was so much about survival.

It was so much about being, in a state of perseverance and resiliency that I knew it wasn't the time to write the book, but I knew the book was coming. When I had my next, you know, situation in 2021 that I had to cardiac arrest, I came out from, the coma, uh, the, the induced coma. And I knew, this is the time that you have to help others, because you're going to go through a transformation of life and you're going to have to really face everything that you have put on a shelf in life.

And that's what something catastrophic does for you. It is a very interesting healing methodology. It teaches you how vulnerable you are. And the power of vulnerability, and it teaches you that you can do anything. Fear becomes something that you just don't recognize as part of your life. So the book was a call to action for me.

It was how can I take stories, not only my story, but the stories of others and share them with some practical wisdom, so that people know that they can make it. And while I was going through it, one of the things that happened as I started writing the book, I realized how music was so powerful. In my transformation and throughout my life, and I started doing research about how music heals and research about how music also empowers.

And I wanted that to be a major force in the book so that people would understand that even when you think you have no more to give, you can just reach. And re energized by listening to a song, listening to a tempo and understanding, yeah, you can do this. The words speak for you. So, you know, when I sign books, I always say when the words fail, music speaks and it's the truth.

So that's why music is so much a part of the book. And I put a playlist to go with the book on Spotify and every chapter has its own playlist. And it's because. Yes, you can be at your lowest, but music can make you rise up. So I'm so happy that you're enjoying the book.

Shruti: I'm discovering new artists as well, along the way. It's been a very enjoyable experience reading the book. You're a role model for women in healthcare leadership.

What advice would you give to aspiring female readers in this field?

Nio: My advice is You truly are unstoppable. Never limit yourself. Do not let anyone put you in a box. There's nothing that you want to do that you can't do, but you've got to put in the work and you've got to practice every day. Every day you have to get a little better than the day before. That's the practice, you know, amateurs practice, To get it right once professionals practice to never get it wrong.

And reality is you must continue to grow. Don't have expectations. That it's going to be given to you, have expectations that you're going to fight for. And if you're willing to do the work, there's nothing you can't do.

Shruti: Those are some powerful words. Thank you for that. And thank you for writing the book. At Aarogram, we believe that being efficient in your business also means providing more patient-centric care. Therefore, we asked us to every guest on our podcast, and this is a fun one. What's the most ingenious, ridiculous, or witty way in which you've solved a workflow problem in a healthcare setting?

Nio: Workflow problem. Okay. So we had a situation that, we had our call center. So came into work beautiful day, and I get a phone call that 40 people in our call center gave their resignation all at the same time. And it happened because this is during the pandemic, a competitive gave them. A great deal of money more than they were getting paid.

So they all left and they did not give notice. They just left. So we had 40 people less in our call center in one day. And I remember we said, how are we going to fix this? So what we did was we did gig economy. We went put together a script. Uh, we had another team put together painting material. All videos, and we hit all of the major colleges in the area and talk to their deans and focus on the medical students, nursing students, people that were doing MPH, programs and, also business administration students.

Talk to, you know, their deans and we flooded on social media. That we had opportunities for gig work in one day, in one hour, we had 300 applicants. And we did group interviews on zoom, you know, we had 50 people on zoom and we picked from the 50 people 2 weeks. We stood up a whole equivalent of those 40, we actually added 10 more.

And it was ridiculous because nobody had done it. And it was so much fun. And you know what ended up happening? We created this whole online community that we never had. And the students, they said, you know, we really don't like your training. They redid the training for us. And we had a blog that they used to ask questions, manned by the supervisors 24 hours because we didn't care what time they worked, as long as you were in your gig, four hour, and time slot.

And it was fun. It was fun because all I said to my team was be creative. We got to fix this. So if you let people fly and have fun, you can do crazy stuff and you will laugh about it. Uh, you know, and did we keep it? When I left Tufts, it still was in place. When the new person came that replaced me, he was able to, he wanted more.

Balanced situation and he replaced it with actual full time employees, but he saw the value and he understood the concept of the power of the leaders that he had in his house. That they are capable of doing extraordinary things.

Shruti: What a brilliant solution, Mio. That, that was brilliant. I'm so glad that that story is, it's amazing. Thank you so much for your time. And thank you so much for being on the show today.

Nio: My pleasure. It was truly a pleasure.

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