The healthcare revenue cycle is undergoing an unprecedented digital transformation, driven primarily by the rapid adoption of artificial intelligence (AI), machine learning (ML), and robotic process automation (RPA). From patient scheduling to final payment collection, technology is being implemented nationwide to automate processes, improve productivity, and reduce the margin for human error.
The shift is dramatic and fast-paced. Top areas for the use of AI in the revenue cycle include prior authorization, ambient clinical documentation, autonomous coding, denials prevention, claims submissions, and denial management. The technology is already showing measurable results. According to Experian Health’s State of Claims 2025 report, 69 percent of providers who use AI say it has reduced denials and/or increased the success of resubmissions.
As healthcare organizations rapidly embrace these tools, the core mission of health information management (HIM)—to ensure the integrity, security and accuracy of patient data—becomes even more critical. HI workers are essential stakeholders in the revenue cycle, and the absence of their expertise during AI planning and implementation discussions poses significant compliance and financial risks.
Financial stability drives healthcare sustainability. As such, health information (HI) professionals must be actively involved in these digital initiatives. Here are three high-stakes areas in revenue cycle automation where the voice and expertise of HI professionals are not just helpful, but essential.
Area 1: Ensure Information Protections During Provider-Payor Data Exchange
The automation of release of information (ROI) to payors is a prime example of where technological efficiency must be carefully balanced with professional diligence. Advances in automated information retrieval and direct payor access to electronic health records (EHRs) are pushing health systems’ capabilities in this area.
However, a people-plus-technology approach is essential to ensure only the proper amount of information is shared with payors and HIPAA’s minimum-necessary standard is met. Whether the solution is automated retrieval or direct payor access to the EHR, the technology is only as good as the instructions it follows. HI guidance is essential.
Here are three areas for HI involvement in provider-payor data exchange:
- Building and development: HI professionals possess a deep understanding of current regulatory compliance, documentation standards, and the payor landscape, making them uniquely qualified to participate in the building and development of automated documentation analyses and templates. For example, a template must be comprehensive enough to include necessary details–beyond document type–such as the anesthesia record in a surgical packet, ensuring the overall documentation is complete.
- Specificity: HI professionals must also lead the development of specific documentation templates for unique requests. This includes templates categorized by payor, denial type, or managed care contract. These templates help ensure that the documentation pulled is appropriate, correct, and sufficient to support the billed services and meet the clinical requirements of the request.
- Ongoing management: Once templates are in place, they should be evaluated quarterly or, at minimum, annually. Without consistent review or updating, outdated templates could inadvertently cause more denials.
The industry’s push for faster payor connectivity, including payors’ direct access to the EHR, is often presented as a solution to reduce administrative burdens for both providers and payors. However, there are risks to this approach.
A panel session at the AHIMA25 Conference reiterated that HI leaders aren’t often involved in these decisions and concerns of over-disclosure run rampant. Payors may potentially access unnecessary encounters or documentation not related to the initial request, thereby increasing the risk of additional claims denials and patient privacy concerns.
HI leaders must demand a seat at the table to establish strict, compliant guardrails to limit access, ensure transparency, and protect the organization’s data integrity and financial interests during provider-payor data exchange.
Area 2: Integrate Expertise into Prebill Audits for Revenue Integrity
The goal of revenue cycle automation is not just speed, but also integrity. HI professionals play a crucial role before a claim is submitted to catch errors that automation alone can miss.
For example, prebill audits conducted by coding professionals ensure completeness of clinical documentation and maximize coding accuracy before claim submission to prevent downstream claims denials.
We frequently see HI professionals involved in these two areas of prebill workflows.
- Targeted prebill audits: Technology can review all claims, flag those with the highest probability of error, determine where a prebill audit is needed, and flag these cases for review. Specific audit areas can be determined by leveraging denial data specified by payors or selected risk areas.
- Coding mismatches: Automation tools alone are not currently equipped to consistently catch subtle but costly coding mismatches. Examples include:
- A significant surgical code (e.g., revenue code 360) missing the corresponding ICD-10-PCS code.
- Procedure codes missing the device code or a skin substitute missing the product code.
The presence of certified coders in a proactive, denial prevention program ensures that documentation and coding is not only financially accurate but also compliant with all official coding and reporting guidelines. This compliance support is essential for mitigating payor denials, future payor audits, and government investigations.
Area 3: Take an Active Role in AI Technology Evaluations and Implementations
HI staff are enterprise experts on clinical data and revenue cycle workflow. They understand how data is captured, abstracted, curated, exchanged, and managed long-term. They have also served as integral partners in the healthcare revenue cycle over decades. And they understand all the various legacy workflows, from prior authorization to denial management.
This expertise is indispensable when evaluating and implementing new AI systems in the healthcare revenue cycle. Before a single AI bot is deployed, the task to be automated should be assessed, re-engineered with new technological capabilities in mind, and fully vetted by HI experts. Steps include:
- Stakeholder engagement: AI implementation decisions are often made solely by upper management and IT. Best practices require engaging all relevant revenue cycle stakeholders, including HI leaders, to ensure the technology integrates seamlessly and appropriately within existing clinical and billing workflows.
- Audit the bots: AI algorithms are not infallible. Just as human coders and billing staff are subject to audits, so should the AI bots. HI’s role extends to setting up the governance framework to audit the automated outputs for accuracy, compliance, and clinical validity during the testing phase and beyond. This is particularly vital given the current environment where payors are increasingly presumed to be using AI to automatically issue denials or down-code claims, requiring providers to have equally robust mechanisms in place to review appeals.
- Set goals: HI professionals need to help define the key performance indicators (KPIs) for the technology. Teams should focus on practical and measurable outcomes.
Urgency to implement new AI, ML, or RPA solutions should not override proven technology evaluation best practices. Do your homework, research each solution for specific use cases, and meet with the vendor’s existing clients. Rapid implementations without proper vetting and testing processes lead to fail-fast results and missed executive team expectations.
The digital transformation of the revenue cycle is not a threat to the HI profession; it is an immense opportunity to elevate the position from data gatekeeper to strategic partner. By stepping up to protect patient information, participating in pre-bill reviews, and taking part in technology evaluations, HI professionals help ensure new, automated revenue cycles are accurate, compliant, and ultimately, successful.
Dawn Crump, MA, CHC, LSSBB, is Vice President, Revenue Integrity Solutions, at MRO and oversees revenue integrity technology and service lines. Malissa Powers, BS, RHIT, CDIP, CCS, CICA, is Program Manager, Revenue Integrity, at MRO and has over 25 years of HIM experience.
By Dawn Crump, MA, CHC, LSSBB, and Malissa Powers, BS, RHIT, CDIP, CCS, CICA