First, mark your calendar for the morning of November 6th when the SFHHA will be hosting a program looking at optimizing the insurance claim process. This program will open with a presentation by Andy Brailo, Chief Commercial Officer, Premier, Inc., who will share the results of Premier’s survey of their members looking at the impacts of health insurance denials, authorizations, and wrong payment amounts.

Why can’t we find solutions that everyone can live with? I just received an informational brochure from the American Hospital Association (AHA) entitled, “Skyrocketing Hospital Administrative Costs, Burdensome Commercial Insurer Policies are Impacting Patient Care”.

Understandably, representing the interests of hospitals, the brochure shares some concerning information. What I find most distressing is that while we talk about these issues, seemingly forever, I see little to no improvement. In fact, it is worse. “Between 2022 and 2023, care denials increased an average of 20.2% and 55.7% for commercial and Medicare Advantage (MA) claims, respectively.” We know that in our area between 2019 and 2022 the absolute dollar amount of Medicare denials has increased significantly.

Something that we will talk about in our upcoming program is the growing use of Artificial Intelligence (AI). The AHA identified AI as one of the causes of this growth in denials. Citing the poor use of this technology leading to a growing number of automatic denials, the AHA contends that insufficient care was taken in setting up these programs. In fact, citing a report by the Department of Health and Human Services (HHS) Office of Inspector General, “it is estimated that 75% of care denials are eventually overturned.” More work for what reason?

So, in this struggle between providers and insurers, “where does this leave us?” In a recent study by McKinsey they “found that hospitals and health systems are conservatively spending an estimated $40 billion annually on costs associated with billing and collections.” The truth is that it is not only these two players who are impacted by this struggle.

This process affects patients in several ways. First, care is both delayed and denied thus leading to compromised patient care. Second, administrative costs associated with the claims denial process have to be recovered. So, when providers are negotiating contracts with insurers, the rates they seek will include these administrative costs. So, negotiated rates will be higher to reflect these costs and insurers will pass these new costs/rates on to their customers. Us.

So, why can’t all the parties get together and agree to processes that increase efficiency for all parties and thus make healthcare less expensive? I am not sure. But couldn’t the main parties get together and jointly build AI to make the processes more efficient, thus saving unneeded expense and compromises to care? I think, “Yes”.

What it might take is our bringing together a larger group of stakeholders to have these discussions and then moving those discussions on to action.

Come and hear more on November 6th at the Memorial Regional Convention Center. More information to follow. Registration will be available on our website October 1.