Dr. Eric Bricker is an internal medicine physician and Chief Medical Officer at ‪AHealthcareZ, a popular healthcare finance YouTube channel.

In this episode, Eric and Zack break down revenue cycle management (RCM), the flow of money in U.S. healthcare.

They cover how healthcare plans are funded, how Medicare Advantage differs from traditional Medicare, how eligibility checks work, medical coding, and why what doctors bill insurers isn't what they're paid.

• (00:00) - Intro
• (00:31) - Starting the AHealthcareZ YouTube channel
• (02:03) - The clinical vs. administrative sides of healthcare
• (04:05) - When does clinical care transfer to administration?
• (06:00) - The four buckets of funding
• (09:10) - The shift to Medicare Advantage
• (11:20) - How real-time eligibility checks are used
• (14:13) - The history of real-time eligibility checks
• (15:54) - Why insurance verification still relies on phone calls
• (17:24) - Traditional Medicare and MACs
• (18:45) - Medicare Advantage
• (19:17) - What is capitation in healthcare billing?
• (21:22) - Why traditional Medicare claims are easier to process
• (22:28) - How medical coding and billing work
• (26:22) - Why medical coding is so complex
• (27:05) - Upcoding in medical billing
• (28:17) - What is charge capture?
• (29:13) - Billed vs. allowed amounts in healthcare billing
• (30:41) - Why billed and allowed amounts differ
• (32:52) - What is repricing?
• (34:14) - Why small practices sell to hospital systems
• (35:04) - How AI and RCM tools are changing small practices
• (37:26) - How much of revenue cycle management (RCM) can be automated?
• (41:07) - Insurance float and why it matters
• (41:56) - The economic impact of more efficient RCM
• (43:28) - Patient responsibility and out-of-pocket costs
• (45:26) - What Stedi customers are building
• (46:05) - What Dr. Bricker would change about RCM

AHealthcareZ videos related to this episode:

• Revenue Cycle Management in Healthcare Explained: https://www.youtube.com/watch?v=rqdWr9ynZ_o
• Do Insurance Carriers Want Healthcare Costs Up or Down? https://www.youtube.com/watch?v=ELyvOLkxADU
• Traditional Medicare vs Medicare Advantage vs Medicare Part D vs Medicare Supplement Explained: https://www.youtube.com/watch?v=KRzBxPj-eQk
• Healthcare Uncovered Ep 2: Denied Requests: Medicare Advantage and the Rise of Prior Authorizations: https://www.youtube.com/watch?v=5hwCF1HPjOI
• Medical Coding Overview: https://www.youtube.com/watch?v=fqNBNE_YSro
• Health Insurance Claims Adjudication: https://www.youtube.com/watch?v=bM9e2EPUg0g
• Health Insurance Claim Repricing: https://www.youtube.com/watch?v=u8upoDe0nwI
• Hospital Chargemaster Explained: https://www.youtube.com/watch?v=2PUwLXW2-sw
• Insurance Float Explained: https://www.youtube.com/watch?v=WBOYDnPfkUU
• Patient Out-of-Pocket Healthcare Costs Explained: https://www.youtube.com/watch?v=ilfgZiJNwyM
• Hospital Finance Explained: https://www.youtube.com/watch?v=O1CGDi50Nys

Brendan Keeler is Interoperability Practice Lead at HTD Health and author of the Health API Guy Substack.

In this episode, Brendan explains why healthcare standards are actually a good thing, how HIPAA and X12 enable interoperability, the history of FHIR (Fast Healthcare Interoperability Resources), how information blocking and related laws are changing health tech, and how AI may reshape the healthcare standards and regulation.

• (00:00) - Intro
• (00:31) - Healthcare standards are actually a good thing
• (03:11) - How HIPAA helps with interoperability
• (07:52) - Interoperability lessons from X12 in other industries
• (10:15) - FHIR and the evolution of clinical interoperability
• (14:37) - The tradeoffs of healthcare standards
• (16:59) - How AI could impact healthcare standards
• (23:05) - What is information blocking?
• (26:08) - What is RPA?
• (28:33) - The downstream effects of information blocking laws
• (42:21) - The gravitational pull of systems of record
• (47:50) - How much is left to unlock in interoperability?
• (49:56) - What would Brendan change about FHIR?

Caroline Loy is Principal Product Strategist at Turquoise Health.

In this episode, she explains what health plan design is, the decisions employers make when designing or buying plans, and how plan design affects care.

• (00:00) - Intro
• (00:15) - What is health plan design?
• (01:35) - Who decides plan design?
• (02:32) - What are self-funded vs fully insured plans?
• (04:32) - How do employers choose between self-funded and fully insured plans?
• (06:44) - What are the levers employers can pull during plan design?
• (09:43) - How many employer plans are self-funded vs. fully insured?
• (10:27) - Employer access to claims data with self-funded plans
• (12:36) - How would an employer build a self-funded plan?
• (13:52) - Broker, TPA, and carrier: What does each do?
• (16:57) - The questions employers ask during plan design
• (19:33) - What does the plan design process look like?
• (21:02) - Can employers incentivize behavior through plan design?
• (23:50) - How does plan design impact providers?
• (25:12) - How does plan design affect collections?
• (27:35) - What are accumulators? How do they affect predicting patient responsibility?
• (31:53) - Revenue cycle management (RCM) for providers
• (35:01) - What does Stedi do?
• (36:25) - How does Turquoise Health help providers predict patient responsibility?
• (38:38) - What is the difference between CPT codes and Service Type Codes?
• (43:20) - What are contracted rates?
• (45:42) - Who are Turquoise Health's customers?
• (46:36) - How would Caroline change revenue cycle management?
• (48:31) - Outro