Get ready for an enlightening conversation with Alison Gibson, a seasoned health information executive with an impressive 15-year journey. From her humble beginnings in accounts receivable to a medical billing maestro, Alison's story is one of self-education, determination, and a passion for the healthcare industry. We'll follow her career trajectory, highlighting her coding journey, her notable achievements in value-based care, and her experience working with AI in the healthcare industry.
We dig into Alison’s fascinating work in value-based care and medical billing operations, her time developing products for Optum, and her invaluable experience in concept research and development. Listen as we explore her work with medical cost savings, her interactions with medical directors to better understand coding rules and regulations, and her seamless transition to in-person work and continued growth in the field.
Alison talks about her exciting future plans — including her upcoming presidency of the AAPC chapter in her local community — and offers her views on the dynamic field of health information management. Join us for an intriguing conversation and gain insights from an expert who's seen the healthcare industry evolve in real-time.
Get ready for an enlightening conversation with Alison Gibson, a seasoned health information executive with an impressive 15-year journey. From her humble beginnings in accounts receivable to a medical billing maestro, Alison's story is one of self-education, determination, and a passion for the healthcare industry. We'll follow her career trajectory, highlighting her coding journey, her notable achievements in value-based care, and her experience working with AI in the healthcare industry.
We dig into Alison’s fascinating work in value-based care and medical billing operations, her time developing products for Optum, and her invaluable experience in concept research and development. Listen as we explore her work with medical cost savings, her interactions with medical directors to better understand coding rules and regulations, and her seamless transition to in-person work and continued growth in the field.
Alison talks about her exciting future plans — including her upcoming presidency of the AAPC chapter in her local community — and offers her views on the dynamic field of health information management. Join us for an intriguing conversation and gain insights from an expert who's seen the healthcare industry evolve in real-time.
Hey everyone, welcome back to the channel. Today we are here with Allison Gibson. Allison has a pretty vast health information career over 15 years executive leadership, value-based care and she's very passionate about advancing healthcare systems that align with incentives, improve efficiency and optimize care delivery. So thank you so much, allison, for coming down to the studio today to record this podcast. So first I wanna know a little bit about your journey and health information, because you are more overall health information based than you are just like medical billing and coding based. So can you walk us through like your health information management journey and how you got to where you are today?
Speaker 2:Sure, 15 years or so, so I feel like it kind of ends up being a bit of a long story. But I actually started by getting a temporary placement when I was 20 years old with a third party company that did accounts receivable for various medical groups. So I started doing that, always was good at math and analytical type stuff, so quickly got really interested in the medical billing portion, looking at those EOBs, understanding how the contract rates are applied, how the write-offs are happening, who's responsible for what, understanding those deductibles and coinsurance. So I did that for a little while and I really liked it. But it was a temporary position, so it was just a contract for a couple of months. Whenever I was let go from that they didn't ask for us to come in permanently. So I was like, well, you know, I really like that, maybe I'll go back to school, yeah, right. So I got a part-time job at a hospital, part-time with benefits, because that was very important. I was a grown-up, right, right.
Speaker 1:I had a 20 year.
Speaker 2:I have to come off my parents' insurance exactly, and we didn't get to be there till 26 back then. Yes, yeah, I had to make sure I had benefits and then I got pregnant with my daughter, so that kind of changed my trajectory a little bit. I didn't continue going back to school at that time, but I really enjoyed that medical billing and coding. So I thought, you know, I hope I can find something similar, found something similar, but not quite the same. I was working for a company that actually did Medicare Advantage billing, working with CMS. So they actually were billing the beneficiaries for their monthly premiums for the Medicare Advantage plan and so they were subsidized by CMS. So think you have Medicaid, you're eligible for that, but you also have Medicare. Now you're in a dual plan, so you were billing or processing subsidies for these Medicare recipients.
Speaker 2:I wasn't really a fan of that job. It wasn't what I thought it was when I heard it was a billing job. But I did stay there for a year, worked with quite a few people that I had worked with in that temp space, so we were kind of, you know, all together there. But after that I got a job. I lived in Northeast Pennsylvania, so now we live in Southeast, or I live in Southeast Pennsylvania and I was working at a private practice group there. I started in the counts receivable and it was back to the same. I loved it, I learned it, it was great. We did not have a coding department, we only had an accounts receivable department. So as our group got bigger and we gained more specialties, particularly electrophysiology, we started getting lots of denials that no one really understood. Doctors coded for themselves again no coding department whatsoever. So we had complicated surgeries going on and doctors just giving us codes and we'd wait till the denials came because we didn't know what was happening. They were just going up into the ether and then coming back tonight.
Speaker 1:Which was very telling of the time. That's just how things ran back and I've had practice days we, the understanding of the coding knowledge 15 plus years ago was not what it was today.
Speaker 2:Little to nothing is what I would say. You know, we were lucky that we knew a CAT scan was a 7,000 code, you know so. But I kind of started learning the coding because I'd have to pull the records to submit to insurance companies and we'd get the denials and I'd read the record and I'd look at the description of the code and I'd think, wait a minute, this doesn't sound right, maybe there's something better. So I kind of started figuring out coding on my own. They finally hired one coder to be our compliance department and she was wonderful and I told her how I was interested in learning how to code and she taught me how to code E&Ms, because that was the majority of what our private practice did, yeah, so the first thing I even learned coding was E&M. Yeah, and you still stuck with it. After that I did yep, I sure did. You know, it was very interesting to me. It actually felt like a whole different side of what I'd been looking at, because I was thinking these complicated surgeries that are always getting denied not how do I know what level of visit it. So that was really good. And then I kind of approached our management team and said, you know, really interested in coding. I'd really like to do a job coding. Is there any way that that is gonna expand? We literally have one person. So they kind of gave me a deal right, like well, you can start coding, and if you start coding and you get a certification, give you a raise and we'll let you work in the coding department. Oh well, I thought so. It was actually really good.
Speaker 2:I had a very supportive boss at the time and that's exactly what I did. I started training with the coder that was there. She taught me how to do E&M. I remember printing out a CPC practice test and doing it by hand. So I did that and I took the CPC test and passed it on my first try and got my raise and officially became a coder. Luckily, I had already been working there for more than a year, so I got my A removed immediately, which was really cool. So I worked there for a while and then when I left there, it's because I moved. So I moved about an hour and a half away, made the commute for about two months, which was terrible, if you know anything about In Pennsylvania in our weather. It was dead of winter that I made that commute from Southeast to Northeast PA.
Speaker 1:Yeah, and it doesn't take much for it to make an hour commute like a two hour commute in the winter. No, like a little bit of snowfall and all of a sudden it's double the time and mine was a complete turnpike commute.
Speaker 2:So if anything shut down on the turnpike I'm stuck. But I did that for about two months before I got a job with a very large local health system as a physician auditor. Then when I say very large local health system, it's huge, huge, huge. Now. It was still huge then. But we had one auditor which was ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ah. One auditor for an entire physician practice which probably at the time had 500 plus physicians and I don't know how many advanced practitioners. Probably tripled that at this point, but still that one auditor.
Speaker 1:I totally feel you. I think my last auditing role working for a large organization we had probably a couple of thousand physicians and four auditors.
Speaker 2:So I mean that's a similar ratio. Yep, so I did that. But when I started there I worked for her to a manager who reported to our director and I quickly kind of gained I don't know side of the director. She saw what I was doing and how I was doing it, got to know her a little bit more. She was ready to retire. So she decided she wanted to retire and they said please don't retire. What we really need from you is somebody to help work on our EHR. And we'd really love them to be certified in coding because we need to make templates for doctors. We need to especially make templates for specialty doctors because we've gotten EHR and we've got out the box templates. One, they're not really what they need for what they do in practice and two, how do we know their compliance? So she plucked me and about four other people from the coding department and made us into the EHR build team. Okay, was this kind?
Speaker 1:of like Obama era, where everyone was kind of pushing like it's now time.
Speaker 2:We have to get them Definitely Obama area. Yeah, I mean we were already on an EHR, but it was very much out of the box and everything we did with that EHR. We called the vendor and we had consultants come in and do so. We didn't have anyone on site that was actually actively working on that EHR build type stuff and we did more than just templates. We did a lot of things that have expanded my knowledge and got me where I am today.
Speaker 2:In an EHR, people have to place orders, they have to receive results, and that's when the quality payment program was first starting with Medicare. It was PQRS, then the position for the reporting system and I became the owner of that, partially because a lot of our data came from the EHR, but also because I was building the EHR so I could look at quality specifications and make sure all of our orderables and resultables that matched anything quality measure related had the correct coding, not necessarily CPT or ICD coding, but the correct coding on the back end so that it would become structured data and be able to be reported for the quality payment program. So while I was in that EHR team, that became my job, part of my job, and three months of every year is when we would report for PQRS. So I had an entire team of people helping me take away from their side job, abstracting data from charts, pulling things that came in free text that were structured data, a three-month project every year. So we kept doing that, getting a bit more involved in quality, starting contracting with our local payers and enrolling in quality programs that weren't quite the same as Medicare but were kind of that little book, the kind of like the glide path to where Medicare was. So same kind of measures but not exactly getting shared savings, just kind of incentivizing. We started doing things differently.
Speaker 2:At the physician group we decided well, we're doing all this and getting all this money from CMS lead to incentivize our providers to kind of change the way they practice. So in doing that they actually created a brand new team, the value-based care team, and I became the value-based project supervisor because I was already supervising the one very large project that we had that was value-based. So I did that. I loved that job. When I was doing that job I not only worked with the physician groups and their staff on how to meet these quality measures, I helped create dashboards in the EHR. So that point of care. When a physician is seeing a patient, it will pop up and say Victoria needs her colonoscopy, victoria hasn't had a depression screening Victoria's diabetic and needs her A1C checked so that right at the point of care they could see what quality metrics this patient matches and what they might be due for, so that they could be a bit more proactive in getting these things done for these patients. So a lot of my work was working with the staff, teaching them how to utilize these dashboards, but also I had a team that worked at the business office and continued to do that abstraction and work with those insurance companies to submit that data and also coordinate with the physician practices and get policies and procedures going. Everything was brand new.
Speaker 2:So that was a really wonderful job for me. I loved it, I was very happy, but out of the blue, my colleague from back at that physician group in northeast Pennsylvania called me and said hey, I'm working at Optum and there's a job that we have opening and I think you'd be great for it. And I said nope, I love the job I have Now. I'm a value based project supervisor and it's wonderful and I love it. And she said give it a chance. I thought about it and I said tell me more about the job. And the job was working for Optum 360 on their natural language processing innovation team on their computer assisted coding product. And I said tell me more.
Speaker 2:So, a long story short, I spoke with her boss. We got on great obviously to various kind of niche field and you can talk the talk with somebody you get Right. So I was talking about all my value based work and all of that. And it turned out that they wanted to start doing some proof of concept work. They've had a computer assisted coding product with Optum years and years and years. It's still being developed day to day, consistently refining. But it's that product, it's going to code your record and that's what it's going to do.
Speaker 2:We started doing proof of concept work and, based on my background, with value based, I did a lot of that. It was at the time we had all kinds of names for it. Now it's clinical language intelligence and it's a true product from Optum. But what we did is took unstructured data and, like I was kind of saying I was doing with the other EHRs, we had the natural language processing engine from the computer assisted coding module, read all of that text and then, instead of applying an ICD or a PCS or CPT code, it would pull out SNOMED codes like codes and RXNORM codes, so that we would be able to see how those match in specifications but more so clinical indication.
Speaker 2:So, for an example, the big project I worked on that is now called Optum Case Advisor, but in POC it was from a large executive health resources group actually in Pennsylvania that Optum had acquired they I think their main business was overturning appeals for inpatient claims that were denied and said, no, they should have been observation. So they're fighting them and saying, no, they really should have been inpatient. And here's why they literally had a binder this large of all the appeals they had ever won. So if they said, oh, I've got a patient that was in for a GI bleed and it denied, they'll turn to GI bleed and they'll find whatever appeal they want and how they want it. And what levels of whatever was there, what clinical indicators they found that made that in the chart and then they would pour through manually a chart trying to find the same clinical indicators so that they could win their appeal basing it on a form or appeal. That's the gist of it.
Speaker 2:Well, we turned that electronic for them. We took that giant appeal binder that they had. We OCRed them, so we scanned all of them and turned them into text that would be searchable. Search that text, apply all those codes and now you have structured data where, instead of looking for certain blood pressures, certain lab levels, certain test results, pulling all of those out, telling you what they are and applying structured coding to them, should you need that for anything? Wow, really enhance their workflow.
Speaker 2:But it became a new product as well that they could now offer to anybody who wants it for the same reason. And obviously, continuous refinement right, the more appeals you get, or the feedback you get from a client and that is saying, hey, we got this, this is a new indicator that we know, we can find it, or just add all the indicators and then you'll know Low lab, high lab, pick out what you need. So that was really cool and I really really enjoyed that job. But I did that for about two years and I'm the type of person I tend to work at the same place but I move around.
Speaker 1:Right or get bored. Or someone finds out how talented you are.
Speaker 2:Well, I'm not going to say that, but I will touch on that as well because, as you can see, you'll hear, I have maintained relationships with all of these people and my friend that called me. Most of my career has been through my networking and the relationships I've built. But when I left there I thought you know, what do I want to do now? Like Optum United Health Group, huge multinational company, I could go anywhere I want. What do I want to do, right? So I just started poking around to see and a job came up for concept research and development. And what that team was is we developed what we ideated. It was called so I thought of it. I got paid to think, we ideated and we developed concepts to save money for the insurance company. So essentially, you find up medical cost savings, but utilizing my medical coding and billing knowledge. So I know the coding rule for this. I know oftentimes it's miscoded as this. Well, now I'm going to look at some data of all the times of that miscode and see if I can find some patterns that might just look a little wrong or a diagnosis code that maybe doesn't match altogether. If we have coding for bill, this code, sometimes for non-occlusive disease or for occlusive disease and that diagnosis code is for a non-occlusive disease. On the occlusive code, I have reason to think. Either you've built the wrong diagosis code or you've built the wrong CPT code, something's wrong. So that was what a lot of my stuff was Finding claims where something was wrong and we should request the medical record to determine what the correct coding was. So this was on the insurance and the guidelines yes, yes, so I was working for Optum, but the client was UnitedHealthcare, so we were looking at UnitedHealthcare claims.
Speaker 2:That job encompassed a lot. It's obviously not just medical coding, medical billing. When I tell you I had to talk to everyone and their mother at UnitedHealth group to get funds approved, I'm not lying. That is where I learned to adjust to my audience. I'm so used to talking to other people who are medical coders, who are doctors. Now I'm talking to lawyers. I'm talking to people from network who are writing contracts. I'm talking to people who don't even know what a CPT code is sometimes Right, but I'm having to translate my maybe complex concept even complex to us Right Into layman's terms so that I can get it approved by people within the company who don't know what I'm saying If I say the complicated words or if I start talking CPTs. So I really learned my presentation skills and also being able to adjust to my audience, which was infinitely helpful as I kind of progress.
Speaker 2:I worked very closely with medical directors there. One is, if he's watching, hi, dr Falk, I'm going to tell him. But I lean on him a lot. He was my clinical guy at Optum. So not a clinical person, I like to think I know what I'm talking about, but I oftentimes don't. But I know the coding portion and I can understand the rules and regulations. So with me or someone like me and a medical director by my side presenting these concepts to people, it's weird to kind of go from the physician side where I kind of feel like I'm sort of the bad guy because I'm trying to tell you here's what I need you to do and where's how I need you to do it To. You're on my team and we're fighting for the same point. So that was a great relationship that I formed immediately and carried me through almost four years in that position.
Speaker 2:I worked very closely with lots of people. My team there was wonderful. I mean, I can't say enough about them. Most of them are still there. But again about four years on I thought what am I ready for now? And I thought maybe I'll get back to value-based care and see what's going on over there. I'm a little couple years out, victoria. I were talking before. You get a couple years out of something and you feel like you know nothing about it anymore. So I applied for and got a job as an associate director of national value-based care operations, which I'm not an operations person, had never done operations before. So kind of in that journey of just being in health information management, I'm trying to kind of tick off those boxes. What skill do I not have yet Right, and operations was one that I didn't have. So in operations.
Speaker 1:In that role, were you just overseeing general operations, or did you have a team under you as well?
Speaker 2:So they weren't directly reporting to us, but we were responsible for the value-based care team and it was for UnitedHealthcare. So that particular team at UnitedHealthcare was probably 500 plus clinical transformation consultant, mostly nurses, some coders, some people that had just been in the field or in health information management and made their way to this. Maybe whatever trajectory they got there no specific, you have to be this or you have to be that but they worked directly with practices who had contracted with UnitedHealthcare in value-based care arrangement to help them meet their value-based care metrics. Oh, okay, you know, trying to achieve their goal of achieving their shared savings or whatever incentives, whatever their contract is for, but at the same time obviously saving that same money for UnitedHealthcare or achieving shared savings for them. So it was a mutual partnership going for the same goal but on both sides. But we were responsible for that operation. So the operation part I was responsible for was two-fold strategic operations. So we've got all these value-based care initiatives. But what else can we do? We have certain ways that UnitedHealthcare would contract with practices in a value-based care arrangement. But what else can we do? We have lots of fee-for-service. How can we maybe convert some of this fee-for-service revenue to value-based revenue.
Speaker 2:So it was strategizing on that. So again, looking at lots of data, looking at claims, looking at diagnoses, finding those patterns, could this be a bundled payment situation? Is this a surgical procedure? What can we maybe do with pregnancy and maternity? It's already paid as a bundle, but what else could we do to kind of make that an episode of care instead of just claim-by-claim-by-claim type things?
Speaker 2:So that was one part of it, and then the other part was the true operations part, which was defining ratios for these clinical transformation consultants. Because you could have five practices and I could have five practices but three of my practices might have been on EHR for years and years and years and have their own quality department and they don't even really need our help. And we might have two practices that are brand new and don't know what's going on and don't even understand how to submit anything for quality. So I had to figure out workloads and ratios and how can we assign these practices certain levels and what level? What does that actually mean?
Speaker 2:What is a level one? What is a level two? What characteristics do they need to have? What are the exceptions to those characteristics, to make sure that no one was being overworked, no one was being underworked, but that every practice was receiving exactly what they needed, which was honestly a totally new thing for me. I had never done anything like that. So very big learning experience, very big learning curve, but still kind of under the umbrella because as I move up and help information management and more and more leadership roles, you know those are kind of things you have to deal with. So that was really good for me.
Speaker 1:If you don't mind me interjecting right here. So one of the things I wanted to talk to you about was the value-based care, and you mentioned about how kind of moving away from the fee-for-service and the value-based care and how we can enhance that a little bit more. I feel like we've been hearing so much for how many years now. Oh yeah, value-based care, this is the future. We're going to no more fee-for-service, we're not going to have this fee-for-service. It's going to be gone. And it's been so long that I've been hearing this now and I'm just like, okay, when in the future? Because it's been how many years now and we're still so concentrated on fee-for-service and the value-based care. I don't feel like is progressing the way everyone's been saying it's going to.
Speaker 2:It's a slow walk, right. What you'll notice is, year by year, fee-for-service reimbursement is going down. Value-based reimbursement is going up but, like you said, that's been going on for at least the last decade, if not longer. That's five years or so. More and more prominent, as you see, more and more value-based arrangements come in, but fee-for-service is still the predominant revenue.
Speaker 2:I don't think in my lifetime we're going to see value-based care takeover. I mean, we're always going to have acute illnesses and acute injuries, right? Things that you can't be helped. I got the flu last week. I don't want my doctor to not get paid for taking care of me because they couldn't prevent me getting the flu. I fell down the stairs and broke my ankle. Same thing.
Speaker 2:I mean, there's some sort of bundles you can do with surgical and post-care, but what about me, who didn't need surgery, right? So you're always going to have acute illnesses that you can still give quality fee-for-service care for and that you need to give quality fee-for-service care for. I just don't see how. I mean, I'm not going to say it can't happen, but I've seen a lot of data and I've seen a lot of claims, and to make a value-based care arrangement that works all the time for everyone isn't going to work. Even in bundle payment episodes. You see things like that because things happen that are unrelated and people need $1,000, $10,000 injection, or a patient has cancer and after their knee replacement and that still gets bundled in their bundle payment.
Speaker 1:Right, right and even, I think, to some degree. You know the AMA has a very strong hold on their CPT code set and it's been even interesting. There's a lady, sherry Poe Bernard, who recently was asked if she was going to be making the third edition of her risk adjustment coding book, which was published by the AMA, and the AMA had said, oh, we're not really interested in continuing producing this risk adjustment book because they get paid for CPT.
Speaker 1:So I thought it was very telling that they're not really wanting to push the value-based care, their risk adjustment, coding care models, as much as they want to push their fee for service, which they have the licensing fees for for CPT, which makes sense from a business view right. Right, it's like I get it, but.
Speaker 2:Yeah, the one thing I actually and I always forget to mention that is I did finally go back to school while I worked through United Health Group. So, oh wow, when I was in the NLP team, I started going back to school for my bachelor's in health information management. I attended Western Governors University, which is completely online and it's an at-your-own-pace university. Oh wow, and having been in the field for about 15 years, I got a bachelor's degree in eight months.
Speaker 1:Okay, you have your master's though now, don't you? I do.
Speaker 2:So after I got my bachelor's degree in eight months, I thought maybe I should try for that master's. And the good thing is, you know, tuition reimbursement through work is what I use for that and the university that I went to being a kind of at-your-own-pace, competency-based university, I was able to kind of have my employer pay for almost all of my schooling because I finished it so quickly. Oh, wow, so it was great. You know, hi, no student loans. I would have never had that thought. I went back to school when I was 20, right, right, exactly. So you know, sometimes you don't get there right away, but then you get there. But yeah, I went back again to WGU for my master's in health leadership has since become a master's in health administration, which everyone obviously knows what that is.
Speaker 2:I'm trying to get my diploma reissued just via MHJ so that no one asks me when an MHL is. We want an MHL is anymore, but for now it's a master's in health leadership. But that's also been something that helped me almost kind of check that box for those other associate director jobs, because while I had been in the coding field and the health information management field for that long I didn't have that associates or bachelors degree, I had a box sometimes. Right, I had all the certifications, but not those check boxes. So as soon as I was able to check the box, it was easy for me to make those transitions. Wow. So that was really good too. And again, I was able to get my employer to pay for those things. So I will always say take advantage of those two if you want to, because it will definitely help you in your career. Yeah.
Speaker 1:So last week you were saying that you were working in the value-based care with UHC. So then what happened after that?
Speaker 2:I was laid off from UHG. So there was a bit of a mass layoff at UHG back in August of this year and I was part of that layoff. So we were a brand new department and then they were looking to cut costs and, you know, pretty easy to get the brand new people out of there, right. So we got laid off and I went on vacation the week after and I thought you know, okay, what am I going to do? We were already scheduled to go on vacation. So I said I'm not going to do anything, I'll go on vacation. When I get back I'll start doing things. So I updated my resume and I started looking around at what sites to upload it on, what jobs to apply for, and kind of just got started. And I immediately got a call but it wasn't from a job that I applied for. It was from a job that had found my resume on one of the sites I had uploaded it to.
Speaker 2:Okay Happened to actually be a local company who reached out to me and asked me if I would be willing to interview for a position. So I did some pre-negotiating before I agreed to do the interview and then I interviewed and I got the job within a week. I went in and met everyone on my 40th birthday. They told everyone that I came in on my birthday just in case they didn't hire me. I wanted them to feel a little bad about it. Make it good if they're doing something else, that's right, but I do have a funny thing about that too. So on my birthday I met everyone and then about three days later they called and offered me the position. So I've just recently started, as of October 16th, as the coding compliance manager at Medical Imaging of the Lehigh Valley. I know, and now you're- working.
Speaker 1:You've gone from working remotely, right? Yes, working in person.
Speaker 2:How's that been going for you? Interesting, it's going to be hybrid. It is hybrid. I am actually lucky enough that I'm replacing someone that's retiring and she will be there through the end of the year. So I'm in person with her for the next two months or so, hoping to download her brain into mine, and then I will be hybrid from then. I actually already worked from home in my two and a half weeks, so it'll probably be, you know, not so much in the office, but it is a big change. I haven't commuted in almost seven years. Again, beyond lucky that this is only 10 minutes from where I live, so I can't complain. I don't even have to get on the highway. And I said, you know, if I had to take another job in an office, I couldn't have asked for a better commute. Honestly, right, right.
Speaker 1:So pretty happy about that I'm a little surprised that you or maybe you have been, and we just haven't discussed it been tapped by a lot of these AI companies, because a lot of your skill sets seem to be something that I feel would be of interest to a lot of these companies developing the AI coding modules and programs.
Speaker 2:I have been approached. A lot of them want a 1099 employee and I don't want to be a 1099 employee. I have a family that I'm supporting. Benefits, as we've said before, are very important, so I've kind of wished away at all the 1099 type stuff. But I have had some people reach out to me through LinkedIn, especially actually recently, as last week I've had some reach out to me for a part-time 1099 position developing AI logic for claims for CMS. So it is something. And again, linkedin, make sure that you're putting yourself out there, because even if you're working full-time, I mean some of that stuff. I'm thinking like now that I'm back in physician's side, like maybe I do want to know what claims AI logic is being developed.
Speaker 1:It's like the gold rush right now because everyone's trying to quick get in there and develop the ultimate program that's going to interface with Epic and Alina and everything, and it's fascinating to see them all kind of rushed together and trying to Everyone's converging upon it. Yes, People were telling me six months ago they're like your job's going to be gone in two months and I'm like never, the fax machines that we're still using, I don't know. I mean, I'm not saying there's going to be some changes, there's definitely going to be.
Speaker 2:I don't think it's ever going to take over for coders or health information management professionals, and now that I'm on the physician's side and I'm seeing the AI advancements on the physician's side, I'm totally blowing my mind. It's a whole different AI world that I'm used to and I love it. I think it's amazing because, again, like you said, I'm very passionate about the patient care aspect. I don't think I could be a doctor or a nurse. I can help the people who help people is how I kind of put it which is what I feel like I've been doing for the last 20 years in one way or another. But yeah, that's my career.
Speaker 1:So you have a lot of different certifications, in addition to your ones that you have for your degrees from Western Governors University. So you have your CPMA, your certified auditor, your accredited healthcare fraud investigator, which is very interesting. So which one of your certifications has been the most challenging one?
Speaker 2:Well, I would go twofold, right. So I have an RHIA, which is registered health information administrator, through AHIMA. That one is hard to attain because you need a bachelor's in health information management yes, it has to be through the right exaggeration or an accredited university, exactly. So that in itself I couldn't just say like I know all of this, let me go take the test, as I could for a lot of the AAPC certifications, where I'd just been in the field and I'd been reading medical records and I thought, yeah, I am pretty much your auditor, let me see about this test and that thing. So that in itself was kind of a big goal of mine to get my RHIA, but I had a big hump to get her in order to get that.
Speaker 2:And then the one that you just mentioned, accredited healthcare fraud investigator. So that's through the National Healthcare Antifraud Association, the NHCAA. That one was very hard to get because, unlike a lot of the certifications that we would hold in this industry, you need continuing education units before you can even apply. Oh, wow, and so many of them have to be direct from NHCAA. Oh, okay, yes, so it took me about two and a half years to get the relevant CEUs to even sit for that test because they also have to be directly towards fraud. Now, I've never worked directly in a fraud department. I didn't work in an SIU Special Investigation Unit which is really people who have that certification often work in an SIU. But when I was doing concept research and development, we found a letter. What?
Speaker 1:Yeah.
Speaker 2:And that was very interesting to me when I started finding the fraud and when I was doing all that data analysis. I wanted to learn how do I actually analyze this data and determine patterns that might indicate fraudulent activity? And that's a big part of that. Ahfi certification AFI.
Speaker 1:It's kind of what we would call it. So was that expensive then to have to get all of those CEUs? Like, how did they break that down? Do they think you pay for each CEU and then pay for the certificate that you was in and the exam and membership?
Speaker 2:and all that. Yes is the short answer, but in my case I was lucky enough that at the time I was employed by UHC. I was employed by UHG, who has a corporate membership with the NHCAA and offers monthly webinars that NHCAA offers. So I was able to get their direct CEUs in that way without having to purchase them myself. And then the other CEUs could have either been direct from NHCAA or at least pertinent to the fraud investigation. So when I took Excel classes or SAS classes or anything data related, I could kind of use that towards it, but not when I took, like, cardiology coding.
Speaker 1:Yeah right, so like the AAPC and the AHIMA ones will kind of cross the curve, because the AAPC will take a HIMA CEUs For the most part Right.
Speaker 2:Vice versa right, yeah, but not necessarily those, yeah. So it was pretty hard to accumulate them time-wise, but I was very lucky that the employer that I worked for at the time provided for that. I also had professional development opportunity in a year at Optinman UHG. So I was able to say at the beginning here here's what I would like to accomplish for my professional development this year and, if it was approved, Optin paid for that or UHG paid for that. So one year getting that certification was my professional development goal. Therefore, I got them to pay for it. So I kind of did that. I got my CPMA, my CRC no, not my CPMA, no.
Speaker 1:Cpma, CRC and AFI that way, oh, wow, it's always nice when they're clear with you about hey, we have a budget for you.
Speaker 2:And ask. Ask the question because sometimes they've never even thought about it, Right?
Speaker 1:And yeah, because I've been in situations where we I was managing a team and they're like, oh, I want to go to this conference and I'm like, okay, well, our budget this year can't afford it, right, but when we're scheduling the budget for next year, remind me, because we can put that in for next year to have that additional information. We can't guarantee that we'll get it, but we can put in the request to get an additional budget for continuing ed or for a conference you need, because maybe we're bringing on a practice that has a certain specialty and we don't know anyone that has the training in that specialty.
Speaker 2:So we have to send you to a conference, yes, and I asked the question because with the job that I have now, I would be managing people and I haven't managed people directly actually ever in my career I've managed without the authority of them directly reporting to me, but I've never had people who are my direct report. So again, kind of each thing I do, I'm kind of gaining one thing, even if I'm going back to something I've done before. And that was one of the questions I asked in my initial interview was what's my education budget? What's my education budget for my employees? What type of training do they already have? What type of certifications do they already have? What are you willing to support for them to get?
Speaker 2:Yeah, as again, if we're talking about my career, all of the leaders in my life have helped me move on to the next thing and I want to be the same type of leader that I've had in my life, because I want these people to be able to do whatever they wanna do Right and you wanna be the right leader for them, and if you don't have the situations by the rest supporting you that they're saying, hey, we are also invested in their continuing education, then you don't get to be the good leader, absolutely.
Speaker 1:It's so frustrating when you're like, yes, I know this is important and if it was up to me I would absolutely give it to you, but I can't.
Speaker 2:And I honestly feel genuinely very excited about my new position because they seem to be very, very willing to let me do what I think needs to be done, and I really just wanna grow my team and whatever they need to do for professional development at work and outside of work. I wanna be able to give them that opportunity and I really think that, based on the chats that I had before and while being employed at my new job, I think I'm gonna be able to do that. And again, I wanna follow in the footsteps of these great leaders who have gotten me where I am.
Speaker 1:That's so amazing. So we have a lot of people on my channel that are like newbie coders and they ask me a lot about getting into health information management. Should I get my RHI T? Should I get my RHI based off of the broad knowledge you've had of the health information landscape? What advice would you give to someone who's just wanting to get into health information management?
Speaker 2:I would say put yourself out there. It's a vast, vast industry. It's not just medical coding, it's not just medical billing, it's not just EHR. If you think about a hospital, how many people have to work at a hospital and how many people have to do something to make one procedure go through right? What actually interests you in health information management? Are you an analytical person, like I am, and you wanna look at this math and figure out this billing and coding rules and all of that stuff? Because that's what really tied me in is learning. I've always been analytical, but now actually learning how to analyze and then from there kind of that data aspect as well. So you could do all kinds of things. You could be a production coder, you could be an auditor, but you can also be a data analyst, you can be a system administrator and there's still health information management.
Speaker 2:Like, health information management is such a huge thing, so just think about where you wanna be and then that probably fits in somewhere in health information management, have you?
Speaker 1:in your experience, done any kind of more programming, end of coding like SQL and stuff like that or Visual Basic? What of C++, all that?
Speaker 2:C++, I don't know, Like that's a plus plus when I was 15 years old. No, I have done a little bit with SAS. So when I was at Optum End doing the concept research, we would look at huge, huge data sets. We did have data analysts but a lot of times I wanted to run if I have a little idea. I didn't wanna ask a data analyst to run the data. I wanted to test my hypothesis before I started getting years and years worth of data.
Speaker 2:So I did learn some basic SAS so that I could run my own queries when I had a random thought or hypothesis, or so that I could whittle my hypothesis down so that I'm not being so broad and I can kind of see oh, now I see, looks like let me apply some more criteria to this because I'm a little too broad, I'm picking up a little too much of this universe. So a little bit self-taught on that. But got the opportunity to learn. I was given the opportunity, given the programming license, given the access through, again, my employer and again I can't say enough ask the questions. You can probably get more than you realize by explaining why you think you need something because, again, such a big, vast industry, so many things going on and so many different ways to get to your information.
Speaker 1:I wanna dial it back here for a second because I just remembered you said something about AI on the physician's side. So what have you seen so far with AI?
Speaker 2:So I'm working with a group of diagnostic and interventional radiologists and I've seen two forms of AI that's being used in practice right now, which are both amazing to me. One is, I believe it's called AI Doc and it's for actual images on radiology and what it does is it produces a heat map of the image. So, kind of think, if you're looking at the computer and you do a reversal of your colors, it produces a heat map of the image that points out an anomaly in the image. Now it might, it's gonna guess and it's gonna try to know this is a pulmonary embolism or this is whatever, but it's always an anomaly. And I spoke with a physician who showed this to me live and actually showed me a pulmonary embolism. So he pushed it, it did the heat map and you could see a very large anomaly space. Now it was a very large PE.
Speaker 2:He would not have missed it, clearly. But he was saying, you know, but it will also catch ones that are very small that I honestly might have missed. And if I can get this AI like it's not always right and I have to correct it, but if it can find one thing that I would have missed myself and it's more than paid for itself, and I 100% agree. It was amazing to see that and he showed me a few where it was right about what it found and a few where it was wrong about what it found. But also there's machine learning algorithms on the back and you provide feedback whenever you change it. So from having working on the other side developing these types of things, I know that that feedback's going back to whoever's producing that and they're gonna use that to refine that product and make it so that it's working better and identifying more properly.
Speaker 1:Yeah, and I think it definitely makes the work that we're doing in healthcare so much more meaningful, because we're able to concentrate on the more detailed information instead of being constantly overwhelmed. Now, of course, that doesn't come without some risks. Of course, we have a lot of issues that we're seeing right now with and kind of new versions, I guess, of some issues. We've already seen providers using the same macro or copy paste, and now it's just okay. Now we're automatically having some sort of AI tech fill in a note, but it's not necessarily correct or they all look the same, so it's the similar risk. But I think there's ways that we'll be able to utilize this more tactfully in the future so that we can produce things that are more concentrated on what we need to focus on in healthcare.
Speaker 2:Yes, I agree. I agree. The second thing that I've seen has to do with their dictation of their reports and also with quality metrics, which this is part of the reason I'm very excited about it, because the radiology side, I'm learning, doesn't have that many quality metrics that they can really utilize in their practice, because diagnostic radiologists are just reading diagnostic tests, interventional radiologists are performing complex interventional procedures, right. So both of those scales kind of don't really fit on what we talked about before, the existing quality paths. But there are some, and most of them are around incidental findings in radiology. So if I go for a scan my abdomen and pelvis but the field of view shows my lungs and there's a nodule on my lung Right, then they would find an incidental nodule. They weren't looking for any brain in my lungs. So we have a program that we are testing right now with some of our docs and I watched it in action.
Speaker 2:It takes their dictation. They're still dictating the entire body of that report themselves, but it takes their whole dictation and it formulates the impression from the findings that they have in the body of their note. Oh, and it does it in their own voice, so they teach it as they start it. They just dictate everything, including the impression, for however many studies, and then it's saying it in their voice. However, they tend to phrase things whatever they say and of course they could make those edits. But it's also alerting them that, hey, that incidental nodule you saw fits this Fleischer criteria. And if you place that Fleischer criteria in there, that's a quality measure that you identified that. So it can automatically know, based on the fact that you've dictated a certain size nodule that you saw, that that then meets the criteria for an incidental finding for the Fleischer criteria, and it'll put in your criteria automatically.
Speaker 2:So you're not trying to, you know, figure out the right way to say you use the Fleischer criteria for that incidental finding, right, which is really cool from my perspective, because now my doctors don't have to work so hard, right, they're already like same thing. We've seen it for years. I identified the nodule, you did. But I need just to know about the Fleischer criteria. I need to know about this and that. So it kind of prompts them and allows them to either choose that they want to use that criteria or no. There's an exception this patient's actually younger than 35 years old. I wouldn't apply that criteria. Well, then they can say younger than 35, and it'll give them the criteria for that. Yeah, so kind of like a decision support tool, but it's actually generating that from their findings, which was very cool to see and very powerful in the right hands because it's just so much great help to those physicians that know how to use it appropriately.
Speaker 1:But then of course you know we have those outliers. But for the intent that it should be utilized just amazing that sounds fantastic and, honestly, the productivity benefit for those physicians.
Speaker 2:Right, they're dictating their studies, they're not having to type out or dictate all this special criteria that they know in their brain and that they are using but that they have to verbalize or state in the exact right way for it to count for them, which I think is immensely helpful. Because you know, we've seen it for years with patients over paperwork and things like that, right, so it's the same kind of idea on that sense. But anything to me that makes life better for a doctor, that can enhance patient care, is great.
Speaker 1:Yeah, especially when we're seeing so much in physician shortages and just in burnout. Where you know nowadays you get sick or you need to talk to your doctor, it's like okay, well, you either can go to urgent care right now or, if you want to see your PCP, they can see you in three months. Or you know you go for a problem and you're supposed to follow up and, oops, that follow up is that never got scheduled. And then it's like what do you do in here? Well, like why do you need to see your physician?
Speaker 2:Yeah, and I can talk about that on a whole nother podcast and invite my husband, who comes from a place with universal health care. Yeah, yeah it's a common conversation in my house.
Speaker 1:So, alison, this has been great. I'm so excited that you came down to talk to me today about all these things with health information management, about with AI. What is next for you?
Speaker 2:What is next? Well, now that I am back working in my local community, I have applied to be the president of our APC chapter to follow in my friend Victoria's Footstep, and I'm pretty sure that I'm going to get it, considering I was the only nominee. But when the nominees came out, I also happened to know several of the other people who applied for positions that I used to work with at previous institutions, so I'm very happy to see who I think my team is going to be. So I think that's what's next for me is kind of getting myself more back into the local health information management community, since I've kind of stepped away from that for the last seven years. Meeting the people in my community that are doing these types of jobs and really just embracing my new position, building the team that I have, growing them professionally and being the best leader I can yeah Well.
Speaker 1:I think the Allentown chapter is so lucky to have you. Thank you, and it's going to be great to see what you're going to be developing. Feel free to tap into me because I like you and you came to talk to me today so I can certainly present for the Allentown chapter. You need a speaker for the 2024 year. Thank you so much again, allison, for meeting with me and my viewers today. Thank you,