Accelerate Cash Flow & Cut Denials with Ensemble’s Neuro-Symbolic AI

Business Impact at a Glance: In a Q1 2024 pilot across five acute-care hospitals, Ensemble’s EIQ Neuro-Sym agent delivered a 15.2% lift in denial appeals overturn rates and a 35.4% reduction in average patient call times—translating into $1.2 million in additional cash collected and a 20% drop in call-center operating expense over 12 weeks.

1. Executive Summary: Turning AI into P&L

• Cash Acceleration: 15.2% higher overturn rate on clinical denial appeals, recovering an incremental $250K+ per hospital in just three months.
• Cost Reduction: 35.4% shorter average patient call duration (from 6.3 min to 4.1 min), lowering per-call costs by $1.75.
• Scalable Automation: Agentic workflows integrated into Epic (FHIR R4) and Cerner via API, covering 600+ RCM steps from eligibility checks to appeals submission.

2. Real-World Deployment: Who, Where & When

Ensemble worked directly with the revenue cycle leadership at Meridian Health System (5 hospitals, 2,500 beds), starting a controlled A/B pilot on January 15, 2024. Two peer hospital groups (1,000 accounts each) followed existing workflows while the other two used the EIQ Neuro-Sym agent. Production integration leveraged:

• Epic’s Claims API (HL7 FHIR R4) and Cerner Millennium SOAP endpoints for real-time data exchange.
• Twilio-based telephony handoff: AI handles initial patient verification and basic inquiries; high-risk or emotional calls escalate to live agents via SIP trunking.
• A Git-backed symbolic rule repository maintained by Ensemble’s clinical informatics team, updated monthly with payer guideline changes.

3. Measured Results & Methodology

Denial Overturn Improvement: Baseline overturn rate was 21.8% over a 12-week period. The AI group saw 25.1% overturns, a +15.2% relative lift. Cohort sizes: 3,200 appeals total (1,600 control vs. 1,600 AI). Metrics included first-appeal success and downstream cash realization tracked through the hospitals’ A/R ledger and verified by an independent audit firm.

Call Time Reduction: Across 10,452 patient calls, average handle time dropped from 6.3 minutes (control) to 4.1 minutes (AI). This 35.4% reduction was accompanied by a +15% Net Promoter Score lift, measured via post-call surveys. AI managed 48% of calls end-to-end; 52% required human handoff when rules flagged complex issues.

4. Governance, Compliance & Risk Management

• PHI Controls: End-to-end encryption, tokenization, and role-based access. Ensemble operates under a Business Associate Agreement (BAA) and maintains SOC 2 Type II certification.
• Explainability: Symbolic trace logs show rule applications for each decision, supporting internal audit and payer negotiation.
• Escalation Framework: Customizable thresholds (e.g., appeal complexity >3 codes, call sentiment negative) trigger human review through an internal ticketing system integrated with ServiceNow.
• Limitations: Current pilots excluded self-pay and Medicare Advantage cases due to guideline complexity; broader rolls will follow in H2 2024.

5. Integration & Scalability

Ensemble’s modular architecture allows rapid deployment:

• API-First: Standard REST endpoints connect to Epic, Cerner, and telephony platforms in under 4 weeks.
• Rule Management: Clinical teams update payor guidelines via a low-code console; changes propagate to agents with automated regression tests.
• Monitoring & Analytics: Real-time dashboards in Tableau track throughput, success rates, and compliance metrics; alerts fire when performance falls below SLA thresholds.

6. Next Steps for Business Leaders

Ready to move beyond proof of concept? Here’s your playbook:

1. Benchmark Your Baseline: Capture current denial mix, overturn rates, days in A/R, and call-center KPIs over an 8–12 week window.
2. Define Pilot Scope: Start with clinical denial appeals and patient call automation. Target a 5–10% relative improvement for executive approval.
3. Governance Alignment: Establish PHI safeguards, human-in-loop policies, and audit processes before go-live.
4. Scale & Expand: After a successful pilot, integrate across all RCM steps, leverage additional rule libraries, and roll out to supporting BPO partners.

Contact Ensemble for an Executive Briefing

Accelerate your revenue cycle with proven neuro-symbolic AI. Book a 30-minute strategy session with our Chief Innovation Officer, Dr. Aria Thompson, to review pilot design, ROI projections, and compliance safeguards. Email us today or schedule a live demo.