Revolutionizing Claims Accuracy and Efficiency with Steve Sutherland, the Senior Vice President of Information Systems at CERIS

[00:00:01] This podcast is produced by Outcomes Rocket, your healthcare-exclusive digital marketing agency. Outcomes Rocket exists to help healthcare organizations like yours to maximize their impact and accelerate growth. Visit outcomesrocket.com or text us at 312-224-9945.

[00:00:34] Hey everyone, welcome back to The Beat Podcast here live at the Health Conference in Las Vegas. Today I have the pleasure of recording this podcast with the outstanding Steve Sutherland. Steve is the Senior Vice President of Information Systems at CERIS. He's been with the organization since 96 and has 30 years of industry experience.

[00:00:59] I'm excited to have him here to talk about what they're up to in the healthcare industry. Steve, thanks for joining me. Thank you. Glad to be here, Saul. Yeah. So, Steve, what brings you to help? Yeah, so technology, really. I mean, we're in the healthcare space. We're a payment integrity vendor, but we always try to be at the forefront of technology. And so this is a technology conference. So, yeah, we want to be here and be a part of it and meet some new partners and see what's out there. That's awesome. Well, it's a pleasure to have you guys here. Let's get into it.

[00:01:27] What is the role of artificial intelligence and machine learning in addressing payment integrity pain points? Yeah, sure. So there are really endless use cases for these technologies in the healthcare space in general, but also in the payment integrity space, which we're in, working with payers and providers. So most of those use cases are going to revolve around payment processes, claims adjudication processes,

[00:01:52] automating those processes, adding an AI assisted, reduce the number of touches. At the end of the day, you know, reduce administrative costs, which, you know, overall impacts the healthcare costs. Yeah, that's big. And 4.3 trillion a year. That's a lot of transactions. That is a lot of transactions. You are correct. So you guys are doing important work. In your experience, you know, working with payers,

[00:02:17] what specific benefits have partners realized in applying the tools that you just mentioned to claims processes? And do any success stories or case studies come to mind? Yeah, sure. It really kind of ties into the last question, right? It's where, you know, we've seen several use cases, both some internally that we have built ourselves, some solutions and processes that we have put in place internally, but also with our partners and our payers. Everybody out there is looking at these technologies and how can they use them? How can they implement them?

[00:02:45] How can they automate their processes, make things more efficient, more automated? So we've seen many, many use cases on both internally and with our partners and that we partner with. Yeah. And so, you know, as you think about payment integrity, it really does play a key role in healthcare. Ensuring that claims education is accurate and healthcare organizations are properly reimbursed for their care delivery. There's so many pain points. I was at an HFMA, the national conference.

[00:03:14] I mean, hearing all the challenges that are happening is crazy. Talk to us about how you guys are making a difference here and complexity you guys are dealing with and just ways to get results for people. Yeah, sure. So I did a panel discussion yesterday on the same topic. And one of the things at the very forefront of any of these kinds of technologies is security and compliance. It's a big hurdle.

[00:03:36] It's a big challenge to be able to implement these technologies, but also in a secure way and to keep up with your compliance regulations and requirements. So I would say that's at the forefront before, you know, any of us who are handling healthcare data partner with an external party and we're sharing data. Security and compliance is really a big one. And then having access to quality data, right?

[00:04:00] So, I mean, there's a lot of data out there, but having quality data and accurate data and being able to build models and AI solutions around that data can be a challenge just for the sheer mass of the data. And again, identifying really use cases. So everybody wants to get into this space and implement these tools and AI is the buzzword and really the world right now in every industry. But being able to dive in and say, OK, we want to do some work in this space. We want to build some solutions. How do we start?

[00:04:30] And sometimes it's difficult to figure out, you know, what's the right use case? You know, build a proof of concept, start small and then build on to that and you'll have some successes. You'll get some wins. You'll get some buy-in. You'll get some excitement from your teams and people start to trust it, right? I mean, there's a lot of folks, you know, in healthcare, especially on the provider side. I mean, doctors and nurses may not want to trust AI, right? All the time. And it's the same thing. We have nurses on staff who do our audits and reviews and kind of the same thing.

[00:04:58] So you build up some confidence with those folks that this is accurate and we are still using the human to validate and verify. So I think that's part of, you know, a challenge is getting people's buy-in on this. Again, data, data governance rules. So having strict rules around how you're going to use the data. There's data use agreements as a third-party vendor in the space. So we don't own the data, right? We work for the payers. So the providers generate the claims, the payers receive those claims to pay them.

[00:05:25] And then we're on the back end helping review and audit those claims. So we don't own that data. So there are very strict requirements and governance around data use and what we can and can't do with that data, who we can and can't share that with. And we have to trickle those down. So it's a big challenge there as well on, you know, who we can partner with. We can't just go partner with some very small company who has not gotten their compliance up to standards.

[00:05:52] And then I guess education and transparency again, you know, getting folks buy-in, educating them on what these solutions are and being very transparent about what they are. We're not trying to replace humans. We are trying to enhance their experience and automate and have an AI-assisted process, not a, you know, human replacement process, if you will. So that's great. And it's complicated.

[00:06:14] There's so many steps in implementing new technology from stakeholder buy-in to change management to demonstrating value. There's so much going on in this area. What best practices or resources would you recommend to leaders who are planning to adopt new technology, whether it's AI or machine learning, to their payment integrity efforts? Yeah. So I think initially it's to get your business strategy and your technology initiatives aligned, right? So what are the business needs? What are the requirements?

[00:06:43] And on the technology side, what can be done? What resources are there? There are so many tools and technology and partners out there. I mean, you just look around this conference here, there are technology vendors everywhere. So many. So who do you partner with? How do you vet those opportunities? Again, back to security and compliance, who lives up to the standard that you need to be at as an organization to build a partner with some of those folks? I mean, so I think that's initially getting those boxes checked as far as, okay, we have a business plan.

[00:07:13] We have a strategy from a technology standpoint. Are we going to build it? Are we going to buy it? Are we going to partner? You know, and then who are those partners going to be, right? And then again, identifying a use case. What is the use case? Let's build a proof of concept. Let's prove this out. Let's get buy-in, get some momentum. You know, then you can build upon that and then move forward. And that's kind of how we've done it. You know, start with a small use case. We have a concept.

[00:07:38] Okay, let's build something around that and then improve it, train it, enhance it over time, and then continue to build those. Again, data is key to this. I mean, AI and machine learning are all built on data. Data, data models, good data, the old garbage in, garbage out. You know, if you don't have good data, then you're not going to have good results. I'll give you an amen on that one. The data needs to be cleaned. For sure. So look, we're here at this conference. The theme is bold.

[00:08:07] Can you give us an example of how you and Saris are taking bold moves to make payment integrity better? Good question. Bold, huh? I had not heard that, but okay. Yeah. So, I mean, it kind of fits in that space, right? We like to be on the cutting edge of technology on the top of that wave and not behind that wave. So getting ahead of some of these technologies, implementing these things, being bold, not being able to take some risks. You know, come to the table with some of our partners and customers and say, hey, you know, we've got this concept. We've got this.

[00:08:37] We want to try this. Are you willing to work with this? And try some things and see what works. That's great. Yeah, that's a phenomenal example. And I love what you guys are doing in this space. For anybody that wants to learn more, Steve, about you, about the company and ways to engage, what's the best place for them to get in touch? And what closing thought would you leave them with? Sure. Well, you can find us at saris.com. You can find us on LinkedIn. I think we have a pretty good presence there on LinkedIn.

[00:09:06] We're here at the conference. We have a booth and we're sponsoring. So if you're in-house and you want to come by and see us, then find our booth. And we've got some folks who can connect you. And yeah, I mean, just excited to be here. It is a great time to be in this space and to be in IT and to be in technology. I've been doing it for a long time, but I don't know that I've ever seen as much excitement around data and technology and AI and the things that are going on right now. So it's really pretty cool. That's awesome. Well, folks, there you have it.

[00:09:33] Steve Sutherland, Senior Vice President of Information Systems at Saris. Make sure you check out the show notes for ways to get in touch with him and the team at Saris. Now's the time. Now's the time to make sure your payment integrity is in the best shape that it could be. Steve, thanks for joining us. Thank you. Appreciate it.

[00:10:13] This podcast is produced by Outcomes Rocket, your healthcare exclusive digital marketing agency. Outcomes Rocket exists to help healthcare organizations like yours to maximize their impact and accelerate growth. Visit OutcomesRocket.com or text us at 312-224-9945.