HIStalk Interviews Stephen Gorman, CEO, RCxRules

Stephen Gorman is CEO of RCxRules of Burlington, VT.

Tell me about yourself and the company.

Like many people in this industry, I’ve spent my entire career in the healthcare IT space. I started out working at IDX in the early ‘90s when I was 24, which now seems like a long time ago. I held various leadership positions at IDX and GE Healthcare before joining forces with revenue cycle experts from a longtime IDX customer to start RCxRules back in 2010.

RCxRules helps medical groups improve their billing and coding, which is admittedly a pretty crowded market. There are a couple of things that make RCxRules unique. The first is that our technology focuses on harnessing our customers’ deep understanding of their unique billing and coding challenges. We then take that expertise and help them automate as much of their billing and coding process as possible.

We also have a deep appreciation for just how challenging the healthcare industry is. We appreciate that successful IT projects require a real partnership with our customers to be successful. We pride ourselves on rolling up our sleeves and working closely with our customers to deliver a solution that really meets their needs.

To what extent are provider organizations using customizable rules for billing?

The short answer is customized rules are used all the time. When we started RCxRules, we incorrectly believed our customers would find our “standard” billing rules and guidelines to be most valuable. We quickly learned it was our ability to easily create custom rules that customers appreciated the most.

As we dug into this, it made sense. With the adoption of EMRs, doctors are now entering the billing information directly into these systems, and we all know doctors are not billers or coders. In the old days, doctors scribbled markings on paper charge slips to indicate billing information. Billers then performed the very valuable but underappreciated work of translating that charge slip into a set of billing codes that insurance companies would accept. The billers eventually learned the idiosyncrasies of the doctors they supported and intuitively corrected their specific issues. They provided a great deal more value than simple data entry.

To make this process work well in the current electronic and EMR-centric world, our technology had to harness the knowledge of these billers. We learned that our technology had to be flexible enough to deal with physicians’ idiosyncrasies, and that a one-size-fits-all approach doesn’t meet the customers’ needs.

What billing challenges have resulted from expanded telehealth volume?

While expanding telehealth was a great move for both patients and providers, it really wreaked havoc on the billing process, especially back in April and May of 2020 when CMS and other payers were scrambling to liberalize the use of telehealth. Pre-pandemic, medical groups needed to use certain codes and modifiers to designate a telehealth visit, and these codes were designed to downgrade the reimbursement rate. A critical aspect of the telehealth expansion was normalizing the reimbursement with traditional face-to-face visits. So literally overnight, the payers then wanted different codes and modifiers to reflect that the care was being provided via telehealth, but that the visit qualified for normal reimbursement levels.

Telehealth billing is still complicated, especially with different payers having different policies, and our product helps manage this complexity. But at least now the guidelines aren’t changing every week as they were back in the spring of last year. The next big challenge is going to come when the public health emergency ends and the payers establish their long-term policies for telehealth.

What technologies and processes, especially those involving physicians, are needed to successfully move to value-based reimbursement?

In some respects, moving to value-based care models is extraordinarily challenging. But the concept is pretty simple. Value-based care models focus on compensating physicians for spending the right amount of time with their patients to deliver the necessary care. Sicker patients need more care and attention, and therefore money more to treat. At its core, this is an intuitive concept that allows physicians to get off the fee-for-service treadmill and allocate time based on clinical need.

This simple concept becomes very challenging in a few ways. The first being that physicians have to live in two worlds, fee-for-service and value-based models, which have different incentives and drive different behavior. The second is the actuarial-like accounting and reporting that is necessary to allocate the right amount of money to groups based on the health of their patients. This is where HCC coding comes in. Older and sicker patients cost more to care for than younger and healthier patients. Again, it is an easy concept to grasp, but the devil is definitely in the details.

The bottom line is that the physicians need help succeeding in this new model. The staffing profile and technology that are optimized for fee-for-service don’t work in value-based models. The physicians need help clinically and administratively. Clinically, they need to staff care teams that can support both physicians and patients, and they need data on which patients need the most care. They can get this data either from their own population health solution or from their payers. Administratively, the priority is utilizing HCC coders and HCC technology to ensure the physicians’ good work with patients is correctly reported to the payers so the right amount of money is allocated for care.

What are the company’s priorities over the next 3-5 years?

Our customers are large medical groups. We fully appreciate the challenge they are living through balancing the fee-for-service world with the value-based care world. It’s the proverbial “foot in two canoes” challenge. Most medical groups have more priorities they want to accomplish in any given year than resources to get them done. They sometimes talk of feeling like they’re on a treadmill that keeps speeding up every year.

Our focus over the next three to five years will be the same as our focus over the last 10: helping customers get off that treadmill. We will continue to build and deliver solutions that remove as much manual effort from this complex billing and coding process as possible. We want to free up our customers’ time so they can accomplish more of their priorities.