By Jack Cumming
Recently, I attended a webinar titled, The Winning Edge for Defeating Denials, put on by HealthLeaders and sponsored by Aspirion, whose “mission is to get providers paid accurately, quickly, and transparently.” You likely don’t need to be told that denials are an increasing barrier to prescribed treatments.
Complexity
One takeaway from the webinar is that there is an enormous number of payers as well as a huge number of providers. The providers deliver care, but they depend on revenues in the form of reimbursements from payers. Payers may be government, commercial insurers, self-funded programs, or even individuals.
Obviously, payers benefit by finding a pretext to deny or reduce payment, while providers depend on payments for their financial survival. The complexity of the potentially adversarial system was the topic for the webinar. The conversation was eye-opening.
Is It Really This Bad?
That this is a hot mess, to speak colloquially, was brought home to me by a post on LinkedIn by Trevor Daer of Granite Peak Analytics, LLC, who posted his 80/20 rule for advisers in the benefit space. He wrote, “20% are REALLY good at what they do AND operate with integrity…. 80% are not great as an advisor but pretty good at making money.”
We’ve been reading and hearing anecdotally about denials, which can sometimes be tragic. What we haven’t heard as much is that many payers, though not all, are deploying sophisticated artificial intelligence (AI) “reviewers” to systematically deny claims that don’t meet stringent standards for medical necessity, eligibility, and more.
The Battle Joined
Not surprisingly, many providers — especially hospitals — are beginning to use AI “appealers” to respond to the bot-generated denials. Thus, there can be a “battle of the bots” lacking any human intervention. Lost in this revenue-enhancing emphasis is the patient whose treatment may be delayed or denied altogether.
Patients ought not be harmed by conflicting payer/provider wishes. The provider is the licensed expert determining what treatment is appropriate in any given circumstance. Like any expert determination, that decision can be appropriately challenged. But — and this is a very big BUT — the patient should not be the one who is disadvantaged.
Common Sense
If a physician or other medical expert orders a medical response to a patient’s condition, that expert directive should be carried out as ordered. There may be a medical review, but it shouldn’t be at the hands of the party with merely a financial stake. If then the payer successfully sustains the denial, it’s the errant provider who should bear the burden, never the patient.
Ideally, the interests of the payer and the provider would be closely aligned, but the proliferation of payers and providers makes that problematic. A different system from today’s piecemeal fee-for-service concept can help, but our system has become politicized in a way that prevents optimization.
AI offers the potential to make affordable healthcare available to almost all Americans, but no one, other than those who are mercenary, benefits from deploying AI bots to battle heartlessly with each other. We need to rethink the system.
The Bright Potential
The senior living industry has expertise in the care of the elderly. Older people constitute the highest-cost demographic for medical interventions. Still, even senior living is not exempt from the equivalent of those decried denials that we so often read of.
If a senior living care provider implies lifetime responsiveness but is not fully licensed, equipped, or staffed to meet all needs falling within that care scope, then that is tantamount to a denial.
What’s To Be Done
If the size of the facility impedes the financial feasibility, say, for mandated staffing licensure or ratios, then there is a need to rethink the business model or the offering itself. Type A contracts, if sensibly administered, may offer one solution. Type A contracts assume reserving actuarially during the years of independent living for the time of care dependence. Thus, reserve releases can help support care finances.
It may be, too, that shortsighted regulation is misguided with unintended negative social consequences. Correcting such political misperceptions is the justification for industry trade associations. Whether regulation is proactively sensible or merely negatively reactive is a measure of how effective such associations are in carrying out their mission.
In terms of pure financial feasibility, emerging technologies, including robotics, can help make feasible what now may seem counterindicated. Let’s at least put these issues on the industry’s discussion/decision agenda. That, too, is an area in which trade associations might lead. Trade associations are at their best when they lead their industries into the future instead of defending the status quo and opposing regulation.
This is part of a series considering how AI, robotics, and technology in general can take senior living from laggard to leader.
