Guest: Thomasina Wilkins, Chief Revenue Officer, Sinai Chicago Host: Praveen Chandran
Introduction and Revenue Cycle Leadership Journey at Sinai Chicago
Praveen Chandran: Hi everyone and welcome to another episode of Season 2 of the RC Executive Lounge podcast series. I'm your host Praveen, and I'm really glad you're all joining us today. I'm going to be introducing a guest I've been very excited to speak with today, Thomasina Wilkins.
Thomasina has over 25 years of experience as a cross-functional healthcare business operations subject matter expert. She has extensive experience leading day-to-day engagements in a variety of healthcare settings including academic medical centers, safety net hospitals, and multi-specialty physician groups. Thomasina Wilkins has served as senior leadership managing up to $400 million in net patient revenue monthly, serving domestically in the United States as well as internationally. Her experience includes managing healthcare financial and clinical engagements across the nation. She is most known for her approachable coach personality and ability to strengthen and bring together diverse teams to create a successful, positive, and productive team environment. Key project initiatives include revenue cycle enhancement, artificial intelligence implementations, and workflow optimization. Specific areas of focus include patient access, HIM and coding, patient financial services, CDI, physician and RN clinical documentation improvement, charge capture, denials management, revenue integrity system conversions, and compliance training.
Thomasina has led multiple performance improvement and financial transformation engagements, partnering with leadership in public and community hospitals to implement process changes and drive sustainable financial results and an enhanced clinical patient experience as a team. Thomasina recently authored a comprehensive cross-functional clinical best practices and financial denials prevention handbook for the Abu Dhabi public health system in the Middle East. She also assisted in the implementation of the first physician and nurse clinical documentation improvement revenue integrity compliance program in the region. Thomasina currently serves as Chief Revenue Officer at Sinai Chicago. She holds clinical credentials, is a Certified Billing and Coding Specialist, a Certified Electronic Health Records Specialist, and is formally trained on over 30 healthcare information intelligence systems. Thomasina is a known subject matter expert in the industry and was recently named one of Becker's Top Women to Know in IT. A featured speaker at Becker's Healthcare Health IT and RCM Annual Meeting, Thomasina has shared a philosophy that captures how she approaches revenue protection: when I think about what brings cash in the door, it is proactive loss mitigation, utilize your system to proactively mitigate through.
We'll talk today about her journey to the CRO seat at a mission-driven safety net system, how she thinks about AI and automation in the revenue cycle, her international perspective on revenue integrity, and what health systems need to do right now to protect and recover revenue. Now let's welcome Thomasina Wilkins.
Thomasina, welcome to the show and thank you so much for joining us today.
Thomasina Wilkins: Thank you.
Claims Denial Management Framework: Mission Alignment, ROI Prioritization, and Cross-Functional Partnership
Praveen Chandran: Let's jump right in. Most organizations have claims denial management as a multi-year ongoing initiative. Now you have very extensive experience in this field. How does it work in your organization? How do you determine priorities for this program? And in general, what is your framework for approaching a program of this scale?
Thomasina Wilkins: Well, I will share with you that each approach is different based on your organization. First and foremost, you have to keep your mission in your line of sight. So although you may have a full toolkit of things you can utilize, you have to make sure that it is in alignment with your mission, it is in alignment with revenue integrity, and it is a strategic approach that you are rolling out in terms of partnership across the organization.
When I think about what we choose as a priority, you first start with what are the barriers to cash collections. If we're talking about claims management and denials, that's a good place to start. What are you losing at the end of the day? What are your margins like? And when you start to look at that and peel back the layers, you start to realize, looking at it from a domino perspective, what are the highest to lowest priorities based on return on investment. Meaning if your denials at the end of the day are always medical necessity or authorization-based, you want to look at your volumes as well as your actual dollar amounts, and based on that you can strategically align yourself with what are the root causes. And start bringing in your partners a little bit earlier, showing that framework that revenue cycle is all of us. It does not start at the back end. It starts at partnership. It starts at mission. And that's how you start to get your strategy together in order to see that full picture of what you need to do in order to obtain success.
Top Denial Drivers, Initial versus Final Denial Rates, and Setting Realistic Targets
Praveen Chandran: Makes sense. And again, given your extensive experience in this area, what have been some of the top reasons driving denials? What patterns have you seen or observed in data across multiple organizations?
Thomasina Wilkins: Absolutely. One of the highest is definitely medical necessity. There is a gap between what our payers define as medically necessary and what our clinicians -- the person we have entrusted with our patients' medical care on a day-to-day basis -- sees as the appropriate approach to make sure patients are cared for safely and with integrity. I think this will be one of the top denial reasons seen around the country. Not only at my organization, which is a safety net hospital where we see the sickest and most vulnerable patients every single day, but this is one of the top denials you will continue to see. This will never be at the bottom of the list. And why? Because it's a wide interpretation of what's medically necessary.
The payer may say this is what the data shows, this is what the benchmark shows. But your clinician, the person that the patient sees, the educator, the person entrusted with care every single day, will be the one who makes that choice. And at the end of the day it may result in a denial because it's not the usual and customary approach. As a person leading the charge in medicine, they may say in this instance there was a different, more advanced, holistic approach to treat this patient -- and they agree with it. That does not mean that the payer concurs with that conclusion. And that is why medical necessity will forever be one of the top denials you will see. And you may have to advocate on behalf of the patient or your organization in order to make that case.
Praveen Chandran: Makes sense. And we have talked to a lot of organizations, and when you look at the typical denial rates we have heard from them, it ranges from something as low as 4% to as high as 27%. Now when you look at up-and-coming technologies like agentic AI, and assuming that organizations are implementing agentic AI and operational changes, what do you think is a realistic target most organizations can aspire to when they think about denial rates?
Thomasina Wilkins: Well, when we think about denial rates, we have to be clear: are we talking about initial denial rates or are we talking about final denial rates? Making that determination makes a difference. Your initial denial rate is what you should be looking at because that helps you prepare for what your goal is. You have to look at what your current performance is now and gauge what is the benchmark you want to get to later. And when you start looking at the metrics behind that, you have to look at what like facilities are achieving, what are their metrics around the country, and having that data in hand lets you know where you stand.
Now, from a conservative perspective, 4% is ideal for final denials, but it is not a reasonable denial rate to expect on your first time out of the gate. Organizations are not perfect, they cannot predict payer behavior, and of course there's that gap in terms of medical necessity -- and because of that, your first time out of the gate will not be 4%, but that should be your goal. Always have that marker of what like facilities are achieving. If you're an academic facility or a specialty clinic, look at metrics from facilities in your geographical area or similar organizations. From a conservative perspective, 4% is a good marker for your final denials, with the intent that you look at your initial denial rate and sort out preventable from non-preventable. Those things that are preventable -- those are the high priority ones that you advance strategically on a day-to-day basis to prevent at the time of service.
Operational and Technology Team Tension, Multi-Year Program Design, and Recalibration Cadence
Praveen Chandran: Makes sense. And normally when you look at organizations, there is always an interesting tension between your technology team -- which is in a way considered the innovation team -- and your operations team. Operations wants to knock off immediate short-term priorities, and the technology team wants to focus on long-term, bigger bets. Some of them may be riskier bets, but nonetheless bigger bets. How do you manage this tension between the two organizations?
Thomasina Wilkins: Absolutely. And this is the space that I live in every single day. I'm a cross-functional executive, so my skill set serves at the intersection of IT, clinical, and financial. Bridging that gap is definitely one of the things I've been able to engage staff about on a day-to-day basis. Your IT team will tell you about your tools, the things you can do strategically long term. Your operational team will tell you what are realistic things you can implement day to day. The goal is to make sure that from a clinical perspective you are not impacting clinical care as well as patient experience.
Praveen Chandran: And what does a success target look like for a multi-year program like this? Because every year you're going to set a different target. How do you determine the right target for any given year, and when do you know that in a program like this you're closer to achieving the final vision?
Thomasina Wilkins: How do you know? Because the numbers are going in the right direction -- and that direction is decreasing. How do you determine a multi-year project? You have to do it in phases. You also have to gauge whether there have been governmental changes or payer changes. If either of those occur, you have to recalibrate. I would say every 60 to 90 days the recalibration needs to occur. You have to ensure that you are in alignment with those things that ensure cash collections at the end of the day. If you are not, you are not gauging success.
And if you're not monitoring and calibrating every couple of months to ensure improvement, then you would be going in the wrong direction. So I think that recalibration at certain timelines is appropriate and that's how you get to success. How do you know that you're there? Because you obtain that success. And if you have to go with a different approach, then that means you haven't obtained the ultimate place that you want to be and that further quality and performance work needs to be done. So recalibration at certain pinpoints of the project is definitely needed.
Praveen Chandran: Makes sense. That's a great transition point to the next segment. Please stay tuned.
Proactive Loss Mitigation: The Initiative Philosophy and Warm Handoff Framework
Praveen Chandran: Welcome back everyone. Thomasina, please walk us through a recent claims denial initiative that you and your team led. Let's start with what challenges you were solving for.
Thomasina Wilkins: What challenges are we solving for? Around the country, I think as a Chief Revenue Officer and all CFOs and executives, the main thing is to increase margins as well as return on investment, and to increase cash collections while not impacting your formal mission.
What was the project? I will share with you that around the country, most denials programs put all resources toward the back end and fixing things in AR recovery. So what was my approach to this initiative? And it's very unique to my leadership style. I've talked about this around the country and at seminars and masterclasses. The initiative: proactive loss mitigation.
What does that mean? It means that we are working as partners. Revenue cycle is all of us. That means the first time that the patient picks up that phone, we are all partners in that patient's care. We are all caregivers. So in terms of increasing revenue at the end of the day, it requires all of us to be partners and have that warm handoff at every single place in the revenue cycle -- whether that being scheduling the patient, making sure they have their referrals in place, obtaining the authorizations, ensuring clinical care so you have the justification to bill, or even advocating on behalf of the patient at the time of denial to ensure that the facility receives the reimbursement expected because they performed that service in good faith for the patient.
So that was the initiative. Sometimes when you do the work, at the end you may encounter disappointment -- but for me, the initiative equates to partnering with all of your key leaders and stakeholders, ensuring that they understand the importance of their part in the process and how they can impact the pre-bill stage to ensure success. The goal is minimal rework, being on track for your final denial rate, and recalibrating when an initiative does not align with the mission.
In my current position, I serve as Chief Revenue Officer for one of the largest safety net hospitals in the state of Illinois. One of our biggest challenges is resources -- resources, having enough grants, tools, AI, those things. But in terms of initiative, we all work together as a team under partnership to ensure that the initiative is not only worked by revenue cycle, but also has clinical, AI, and operational partners as well.
Vendor Selection, Build versus Buy, Implementation Lessons, and Tracking Success
Praveen Chandran: Makes sense. And in this case, once you identified the challenge, did you work with a partner or was everything implemented in-house? How did you make this decision of build versus buy?
Thomasina Wilkins: Yes. When choosing partners, you have to choose them very strategically and also early. You have to identify where your challenges are and what your needs are. You should identify what you can do in-house, and then when you don't have those resources in-house, make sure you partner with a vendor that understands your mission and your challenges, and that has the resources to deliver a good return on investment. If you're paying them on a monthly basis, then you should receive a formal return on investment. And choose those partners that are in alignment with your ultimate goal.
Praveen Chandran: Makes sense. And when you went through the implementation, were there any unforeseen pitfalls, surprises, or lessons you'd like to share with our audience?
Thomasina Wilkins: Yes, I'll definitely tell you about some of the pitfalls we've experienced. Around the country there is a misconception that denials management and denials recovery starts post-bill. It does not. And I think sharing that understanding with your clinical leaders and your IT leaders, doing a look-back at lessons learned, and recalibrating your partnerships by sharing that information with them -- it not only educates them about the work that has to happen on the back end, but it also shows them the things they may be able to partner with you on at the time of service.
I do think that lessons learned are determined by doing a data look-back to see what the root causes were and sharing that information with every partner every step of the way. And they may be able to share with you: you're looking at that from a back-end or revenue cycle perspective, but on the front end I know where that started. So lessons learned: bring your partners in, allow them to support you in your initiative, and with that partnership you'll move the needle to get to your final denial rate.
Praveen Chandran: That's a very powerful insight. Thank you so much for that, Thomasina. For this kind of a program, during implementation or post-implementation, how are you tracking success and what has been the measurable impact so far?
Thomasina Wilkins: Yes. We track success by benchmark KPIs. If the initiative is to increase your point-of-service collections, you are tracking that benchmark maybe by department, facility, or location. Stating what the current performance is from a trending KPI perspective, but also gauging how close you are to success. And make sure you socialize that as well.
When you start from bare bones, as with the implementation of a new system from a legacy system, you're going to have some challenges. As those root causes decrease, cash collections increase -- and that's how you gauge success at the end of the day. Are you collecting more? Are your benchmark KPIs moving in the right direction? Are you recalibrating when they don't? Are you sharing with your partners and working across those service lines in order to get the help you need to prevent things that lead to cash collections loss?
Praveen Chandran: Makes sense. And I think that's a good segue into our next segment. When we come back, we're going to be talking to Thomasina about up-and-coming technologies like agentic AI and the impact of these technologies on claims denial management. Please stay tuned.
Agentic AI in Appeals, Denial Prevention, and the Case for Customizable Tools
Praveen Chandran: We are back. Now let's jump into what is one of the most exciting topics being talked about in the RCM community, which is agentic AI. Whichever event you go to today -- HFMA, HIMSS -- it's all about agentic AI. So as a leader at your level, what role do you see agentic AI playing in claims denial management when you look at the next 12 months versus the next 3 to 5 years?
Thomasina Wilkins: Yes. I do think that AI will play a very important role. Let's start with where we started: with paper billing. I was at the front desk, doing charting based on paper billing. Think about where we are right now -- we're at edits, but those edits still have to have manual intervention. Now as we move forward with artificial intelligence, we have a hand in that. That hand is our bots. Our bots will be able to move quicker and faster, support the root causes based on scripts, and strategically make decisions that would typically require one FTE. A bot will be able to do multiple things at one time in order to move you forward quicker. So I do see a significant space for artificial intelligence, just as we saw a significant change with paper billing. This will be a significant change.
Praveen Chandran: Makes sense. And when you look at the application of agentic AI in claims denial management, there are obviously areas where there will be small incremental improvements in the order of 2 to 5%, and there could be areas where agentic AI could truly bring step-function improvement. In your perspective, which areas can benefit the most from agentic AI to bring that kind of step-function improvement in claims management?
Thomasina Wilkins: I would say in the appeals process, most definitely. Here is why. One of the challenges I've seen is for organizations to determine payer policies and guidelines. And as artificial intelligence is implemented, you are looking at a specific payer that may be denying you -- and that payer may be using artificial intelligence at the forefront of their intake. So to be able to respond with the specific clause, bringing in the provider manuals as well, and providing facilities and clinics with the resources to identify where those clauses are -- I think that in the appeals process it will be very valuable.
Praveen Chandran: Makes sense. And when you're talking about appeals, do you also think that there is an aspect to denial prevention where AI is applicable? Just as a follow-up question.
Thomasina Wilkins: Yes. We talked about proactive loss mitigation. And how AI is typically really implemented on the back end for denials recovery -- AI should play a key part in the front-end recovery as well. If you know that 12% of your claims are being denied through authorizations, and in your final denial goal you want to get that down to 4%, then you need to ensure that you have those loss prevention mitigations starting at the process and not after you've already lost the accounts receivable. I do think that in the future state it will start playing a key part in defining those areas that require authorizations -- being able not only to define them but to strategically help you obtain referrals and monitor and manage those in a faster and more accurate way than we may be able to do as humans.
Praveen Chandran: Makes sense. And one last question for this segment: with respect to claims denial management outside of AI or agentic AI, are there other up-and-coming technologies that a leader at your level is watching very closely in terms of how they could impact your organization?
Thomasina Wilkins: Yes. What I am looking at is from a vendor perspective and what can be brought to market. I am looking at what's out there, but I am also looking forward to working with vendors who are open to receiving that information. Executives at the Chief Revenue Officer, CFO, or CEO level have years of insight into the root causes that lead to non-collections at the end of the day. And while there are developers getting that information right now and developing tools, I think a cross-functional subject matter expert like myself may be able to help in that design process -- more so as a think tank. Because as you start to design things that are best in class for the market, you need to have that strategic insight into what's happening. That pulse is very important.
In terms of things to come that I'm watching for, I'm looking for the autonomy within these programs to gauge things that aren't already on the table. You'll have your core model there. But I'm looking for the customization. Customization means: I am a safety net hospital, I am a rural hospital, I am an academic center. Our patients are being denied due to medical necessity. Those customizable tools based on your mission, your patient demographics, or the things that highly impact you from a trending perspective -- those are the things I'm watching for. Vendors in the market providing customizable tools to fit organizations' specific needs.
Praveen Chandran: Makes sense. That's a great segue into the final segment of our podcast episode. When we come back, we're going to be talking to Thomasina about the leadership challenges someone at her level faces. Given her depth of leadership experience, this is a segment you do not want to miss. Please stay tuned.
Leadership Metrics: Dashboard Anchors, Cash Collections, and Daily Watch Lists
Praveen Chandran: Welcome back everyone. Let's jump right in. Thomasina, there is always a specific metric that every RCM executive looks at every morning. For you, is there such a claims-related metric that you look at every day?
Thomasina Wilkins: Yes. I would say not individually, but I look at my dashboards every single day as soon as I log in. What am I looking at? I am looking at my cash collected versus my goal. That's something I look at. And then based on my work queues or my dashboard, I look at what's impacting that. We have our KPIs and metrics set up to tell us what that is. And that's your watch list. Your watch list is customizable to your organization and your mission.
If you are not collecting your cash or you're over, that watch list is telling you. Your watch list is customizable to you every single day. I think it's very important for a leader to establish what success looks like, customize your dashboard to look at that, and when you log in you can see where your focus is -- what I call your anchor. Are you moving in the right direction? Is your anchor in the right place, meaning your strategic focus on a day-to-day basis? Are you aligning your team, your people, processes, and technology to align with that success rate at the end of the day?
The only way to gauge that is to monitor and manage it very well. And that's going to be different for each organization depending on the root cause of non-collections. For me, that's what I look at every single day: the dashboard, my cash collected today versus my ultimate goal for the month, and then my watch list as to what are the barriers to that cash collections. Those barriers may be different from day to day. One metric today might not be the metric tomorrow. And if you have the right anchors in place, the right levers pulled, then as you see those go off, more than likely something else will come into focus too. But it keeps you on track, keeps you focused, and keeps you on the straight and narrow path to what you need to do.
Building Cross-Functional Momentum, Mission-Driven Leadership Advice, and Closing Reflections
Praveen Chandran: Makes sense. And as a leader at your level, what do you think are the biggest challenges faced by organizations in bringing step-function improvement to denial rates? You can always make incremental improvements, but what is stopping an organization from bringing step-function improvement?
Thomasina Wilkins: I would say it is medical necessity. You can improve things you can make a difference in. In terms of denials, you can get to the things that you can gauge and improve at the time of service. But when it comes to patient care, when it comes to maximizing that care, those are things you cannot forego.
As an organization that is mission-driven and a safety net in the city of Chicago, one of the highest-vulnerability areas, this is always going to be on the table for us. We're giving more in terms of mission and we're not bringing in as much because we still have to think about the denials at the end of the day. And one of the things I hope for other leaders around the country is to understand that our patients are still being seen, the access to care is still there. We still have to engage our payers to understand -- and through peer-to-peer reviews and denials management, at some point that voice will be heard and they may strategically change those policies. The way that happens is through appeals and denials management.
Praveen Chandran: Makes sense. And Thomasina, inherently claims denial management programs are complicated. Anytime you bring change, there is a lot of cross-functional coordination. Earlier in the episode you talked about your experience with cross-functional coordination. How do you build momentum for change with cross-functional teams when you're steering a complex claims denial management program?
Thomasina Wilkins: Absolutely. When you serve in a financial seat, most of the time finance and accounting will bring the numbers. But I think from an overall perspective, you have to talk about patient care, patient experience, and mission. Start off with your mission: this is the goal every single day, access to care, patient experience excellence with compassion. And then show from a denials management perspective what the volume is and what the cash impact is. Making sure that you break down those layers and share what your current tools are and what your barriers to success are.
And with that, you'll understand what you can change from an organizational perspective and what additional help you need -- whether that's outside support, vendor management, additional vendors, grants or funding, or bringing in more partners already in your organization to engage through that committee or subgroup. That denials management subgroup is a think tank of everybody. If revenue cycle is all of us, then you're going to need that feedback as well to ensure that you're gauging the pulse.
To keep that momentum up, you have to first stay anchored to the mission. This is a collaborative and shared goal. As we are financially stable and denials decrease, we are able to help more patients at the end of the day. As a safety net hospital, some of our patients have to choose between food, water, and prescriptions. As we work as a mission-driven team together at the end of the day and keep sharing that -- that's what keeps the momentum there. Shared goals, shared vision, one team, one approach. Even if you're working with vendors in a partnership, that's where the magic happens. That's where the teamwork happens. And that's what keeps momentum going.
Praveen Chandran: Makes sense. If there is a specific piece of advice that you would like to share with a fellow RCM leader or a CFO who is potentially tackling similar denial management challenges, what would it be?
Thomasina Wilkins: I would say that collaboration is key. While there are things you may feel that you can only change on the back end, you are definitely a key resource to be able to socialize that at the front end. Bring your partners from operational and clinical leadership as well. Share with them what your findings are, and I will definitely tell you that they will be a strong partner in helping you resolve it at the time of service.
Praveen Chandran: Makes sense. Thomasina, this episode has been fantastic in that you have shared so many wonderful leadership and claims denial management insights with our audience. Thank you so much for spending this time with our audience and sharing all these wonderful insights. Our audience are clearly walking away with a lot of wonderful suggestions and insights. Thank you so much.
Thomasina Wilkins: Thank you for having me.
