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Provider Data Accuracy: Why Relationships Matter More Than Addresses

Posted on by Arun Sharma

By Barb Kijanka

You’ve probably heard the taglines:

“Accuracy is your competitive edge.”

“50% of provider data is inaccurate.”

“Every inaccurate record is a missed appointment.”

These statements grab our attention — but most solutions offered fall short. Why? Because provider data isn’t like a phone book. It’s far more complex. To understand how provider data really works requires moving beyond surface-level fixes to a model that reflects real-world practice patterns.

The Myth of One-to-One Accuracy

In a phone directory, most listings have a single address and phone number. Only about 4% of Americans own a second home, meaning 96% of entries are straightforward. Providers, however, are different. Over 60% are associated with a group, with more than 1.4 million of the 2.7 million providers in the U.S. practice in multiple settings. Many have affiliations with several groups. Couple this with a host of acquisitions and mergers, and a single line address point gets blurred even more.

So when a consumer asks, “What’s the provider’s address and phone number?” — it’s not a simple question. The real question is:

  • How does this provider practice in the community?
  • What groups are they affiliated with?
  • Where do they actually see patients?

 

Why Flat Data Models Fail

Most data-cleansing vendors treat providers as single entities, chasing individual addresses. This approach creates illogical results because it ignores relationships. Providers inherit addresses from their affiliated groups. If you don’t know the group’s address, you can’t make a logical connection. When a provider leaves a group, their inherited address should terminate — reducing inaccuracies and explaining why the provider is no longer there. Managing data from the bottom up leads to chaos. Managing from the top down — starting with group accuracy — creates consistency.

The Relationship Model: A Better Way

The first step to provider data accuracy requires aligning data to a relationship model. Consider these key themes:

  • Groups have brick-and-mortar addresses and phone numbers.
  • Providers inherit these details through affiliations.
  • When affiliations change, addresses update logically.

This approach mirrors real-world practice patterns and prevents the endless chase for individual addresses.

Beyond Demographics: The Contract and Network Layer

Accuracy isn’t just about demographics. Providers are tied to group contracts and multiple network structures. Simply flagging an address as “wrong” without answering key questions creates risk for payers, networks, and patients. If a provider leaves a group, what happens?

  • Are they still under the group’s contract?
  • Do they have an individual contract?
  • Did they exit a narrow network?
  • What about patient continuity of care?
  • Is network adequacy impacted?

Identifying and managing the connections to contracts and defining and analyzing the network criteria prevents out of network consequences.

The Real Work

True accuracy means understanding why a change in provider data occurred and what implications might result. Vendors that only say, “This address is wrong,” miss the bigger picture. The future of provider data management lies in relationship-driven models that connect demographics, affiliations, contracts, and networks.

The Technical Advantage

The right technical solution is essential for sustaining a strong relationship model. It should provide a clear structure that organizes groups and participants in a hierarchy, while enabling data inheritance where appropriate. Combined with structure, the technology must enforce criteria and rules that preserve the integrity of contracts and networks. The solution must have a complex sourcing model, not just web crawling capabilities. There are proven and authoritative sites all with weighted confidence complexity. Modern solutions go beyond reactive data management; they enable the continuous monitoring of changes within the practicing community. With the right AI and advanced sourcing capabilities, detecting data updates is no longer a challenge; the real focus should be managing the impact of those changes. By embedding complex algorithms and rules, the right technology can isolate the implications of any change, empowering informed decisions. Platforms like Sagility’ s Provider Forward™ are designed to deliver holistic data management, ensuring accuracy, integrity, and adaptability in the ever-changing data environment.

Bottom Line

Provider data accuracy is hard — but it is not impossible. Start with relationships, not addresses. Build a data model that reflects how providers practice in the community. Define and align contracts and network criteria. Invest in the right technology. Only then can you deliver the accuracy that truly matters.

Advancing Care with Intelligent Next-Gen Technology

Posted on by Arun Sharma

This article is the second of a four-part series describing how the four business process management (BPM) pillars can optimize operations.

By Madan Moudgal, Executive Vice President, Chief Digital Officer

As healthcare organizations face mounting pressure to improve outcomes, reduce costs, and enhance experiences, the intelligent application of next-generation technologies has become a strategic necessity. From AI-powered contact centers to predictive analytics and GenAI voice agents, these innovations are transforming how organizations deliver and manage care. But technology alone isn’t enough; moving the needle comes from pairing these tools with deep operational expertise. Embedding human intelligence into every layer of the healthcare value chain ensures that automation not only streamlines tasks but also drives smarter human decisions, faster resolutions, and better care coordination.

Advanced data analytics plays a critical role in enhancing the transfer of AI to human intelligence. By surfacing actionable insights — like identifying common points of failure in claims or predicting high-risk patient behaviors — organizations can reduce redundant transactions and support more informed decision-making. The result is less friction across the system and greater operational agility.

Operational, Business Benefits for Payer-to-Payer Interactions

A GenAI voice agent supports payer-to-member communication; it can do the same for payer-to-payer communication in several important ways. Confirming member coverage is a time-consuming, arduous task. With the assistance of a GenAI voice agent, however, health plans can shift much of this work to this emerging, powerful technology. Because the GenAI agent can make outbound calls to other payer organizations to verify a member’s coverage, the technology coordinates benefits between payers.

In addition, a GenAI voice agent supports efficient claims processing through the automation of routine tasks like claims verification, eligibility checks, and prior authorization requests. This automation reduces processing time, mitigates errors, and improves operational efficiency, which reduces expenses and leads to significant cost savings.

Enhancing Stakeholder Relationships

GenAI voice agents actually build and maintain relationships among payers, providers, and members. The reason? This technology ensures that member information is captured correctly and acted upon by health plan experts: care coordinators, caregivers, and providers. In addition, GenAI voice agents free up staff for more strategic activities within the business.

Healthcare operations also demand intelligence that can learn, adapt, and actively enhance how work is done. Agentic AI does not just offload repetitive tasks, but augments process design, elevates productivity, and enables proactive decision-making across the patient care lifecycle. Agentic AI agents act with autonomy and purpose, guiding interactions, surfacing recommendations, and refining processes in real time, reducing variability and delivering superior and consistent outcomes in cost, quality, and member experiences.

How Hybrid Intelligence Empowers Care

Imagine that a physician submits a request for a non-standard treatment. Agentic AI can verify whether the procedure is approved or denied. If denied and the patient challenges the denial, the agent can automatically follow up to gather documentation and identify potential solutions. If the challenge requires more complex medical expertise, the agent can escalate the case to a human reviewer. This process blends intelligence, reduces delays, and gets patients the care they need faster.

When organizations integrate technology intelligently with human expertise, their ability to strengthen their operations increases, their ability to be more cost competitive improves, and their likelihood that they will overcome the range of challenges facing this industry advances dramatically.

The Future is Intelligent Care

The future of healthcare lies in intelligent, adaptive systems that do more than automate —  they learn, evolve, and optimize. The approach to GenAI and Agentic AI can empower healthcare organizations to reduce friction, enhance collaboration, and deliver measurable improvements in cost, quality, and satisfaction. By aligning the right technology with the right processes at the right time, organizations can move beyond efficiency toward excellence. In a rapidly changing industry, hybrid intelligence is not just a competitive advantage — it’s a catalyst for transformation.

Read more in our white paper, Fixing the Friction: How Strategic Operations Management Unlocks Healthcare Efficiency at Scale, to explore how the four BPM pillars can reduce operational burden, improve patient outcomes, and drive resilience across the care continuum.

Medicare Advantage Health Plans: Is OBBBA an Opportunity? 

Posted on by Meghan Dunham

By Michael LeVangie, Senior Vice President, U.S. Consulting Practice

 

A New Era for Medicare Advantage 

The One Big Beautiful Bill Act (OBBBA) is reshaping the healthcare landscape and, with it, Medicare Advantage (MA). While the legislation introduces considerable financial and operational pressures, it also opens a window for healthcare entities to transform. 

For health plans willing to adapt, OBBBA can serve as a catalyst to modernize infrastructure, strengthen partnerships, and improve member outcomes. The key is viewing compliance not as a burden, but as a springboard for innovation. 

Understanding the OBBBA Impact 

OBBBA is a sweeping budget and tax measure with far-reaching implications for Medicare and Medicaid. According to PwC, the law will “dramatically reshape the health industry,” with the Congressional Budget Office projecting $1 trillion in reduced federal healthcare spending between 2025 and 2034. 

The changes will reverberate across the payer and provider ecosystem: 

  • Medicare funding pressure: Cuts triggered by the Statutory Pay-As-You-Go Act could reduce Medicare spending by $490 billion from 2027 through 2034 — forcing MA plans to rethink benefit design, provider negotiations, and pricing models. 
  • Provider network instability: A CFO of a large physician practice recently told KLAS, “If state and federal people do things that are going to hurt us and make us lose a lot of money, we will cancel our Medicare Advantage contracts.” Shrinking reimbursement could cause some providers to exit networks altogether, threatening access and member satisfaction. 
  • Eligibility shifts: New restrictions on certain non-citizens, refugees, and asylees who have paid into the program will narrow the potential MA enrollee base — altering risk pools and revenue projections. 
  • Operational risk management: MA plans will need tighter collaboration with providers to ensure accurate documentation and risk adjustment. Incomplete or inaccurate coding could result in underfunded populations and missed opportunities to reflect true member health status. 
  • Impact on low-income populations: The repeal of two rules designed to ease access to Medicare Savings Programs (MSPs) will likely limit assistance for vulnerable members, increasing disparities in care and cost burden. 

While these shifts introduce new challenges, they also underscore the need for data-driven, technology-enabled agility — the kind that enables health plans to respond in real-time to evolving regulations, reimbursement, and member expectations. 

Turning Compliance into Capability 

Forward-thinking MA organizations are already reframing OBBBA from a compliance exercise into a transformation roadmap. Those who invest now in scalable, intelligent systems will be best positioned to balance cost, compliance, and care delivery. 

Key enablers include: 

  • Modern Data Infrastructure: Breaking down silos and integrating clinical, financial, and operational data to enable real-time risk scoring, regulatory reporting, and strategic forecasting. 
  • AI-Driven Automation: Leveraging predictive analytics and workflow automation to streamline claims, improve documentation accuracy, and strengthen audit readiness. 
  • Agentic AI and Digital Engagement: Combining advanced digital engagement tools — member portals, chatbots, texting, and app-based communication — with empathetic human agents to enhance member experience and retention. 

The combination of technology and human expertise allows MA plans to operate with greater precision, transparency, and efficiency. It’s not only about satisfying OBBBA requirements, but outperforming peers who treat the bill purely as an administrative challenge. 

The Opportunity Ahead 

Change is inevitable, but how organizations respond defines their success. OBBBA is not just a legislative hurdle; it’s a moment for payers to evolve into more resilient, data-driven enterprises. 

By accelerating investment in intelligent automation, actionable analytics, and AI-powered workflows, MA plans can achieve: 

  • Operational efficiency through faster, more accurate processes 
  • Regulatory agility to stay compliant amid ongoing change 
  • Improved member care through better insights and engagement 

In the end, OBBBA may compress margins, but it can also expand capabilities. The health plans that act now will not only survive the disruption but set the standard for how innovation and compliance coexist in the Medicare Advantage era. 

In healthcare’s next chapter, compliance isn’t the finish line — it’s the starting point for innovation. 

Looking for deeper insights? Download our companion white papers to explore actionable strategies for both payers and providers:

The One Big Beautiful Bill Act: A Strategic Guide for Payers
The One Big Beautiful Bill Act: A Strategic Guide for Providers

What Happened to Enhanced Direct Enrollment? The New Reality Under OBBBA

Posted on by Charlotte Robidoux

By Sri Lakshminarayanan

The One Big Beautiful Bill Act (OBBBA) has ushered in sweeping changes that are fundamentally reshaping how consumers enroll in and maintain health coverage. These regulatory shifts introduce new complexities and pressures for both individuals and the systems designed to support them:

  • Medicaid Work Requirements and Stricter Eligibility Checks: OBBBA now mandates more rigorous eligibility verification and work requirements, increasing administrative complexity and raising the risk of disenrollment. 

  • Marketplace Tax Credit Restrictions and Expiring Subsidies: With enhanced subsidies set to expire and new restrictions in place, affordability is reduced, potentially leading to coverage losses for many. 

  • Elimination of Automatic Reenrollment and New Verification Mandates: The removal of automatic reenrollment and the introduction of additional verification steps make it harder for members to retain coverage, increasing the likelihood of gaps.

While the Enhanced Direct Enrollment (EDE) program remains available, these regulatory changes will have a significant impact on EDE operations. Mandatory pre-enrollment verification and stricter subsidy eligibility — especially for low-income immigrants and those with fluctuating incomes — have made the enrollment process more challenging. The expiration of enhanced premium tax credits at the end of 2025 will further erode affordability. Although these changes do not directly target EDE, they effectively limit the number of people who can benefit from it, resulting in fewer successful enrollments.

These developments have transformed the enrollment landscape, demanding greater adaptability from both consumers and health plans. EDE, once celebrated for its simplicity and efficiency, now faces a more complex environment shaped by OBBBA’s mandates. As eligibility checks become more stringent and affordability concerns grow, re-examining EDE’s role is critical; can it still deliver on its promise of a seamless, user-friendly experience? Answering this question requires understanding (1) EDE’s evolving significance in the OBBBA era, (2) its impact on customer experience, and (3) the operational strategies that health plans must adopt to succeed in this new reality.

  1. Is EDE a Critical Solution in the OBBBA Era?

Despite these challenges, EDE remains a valid and vital enrollment pathway. The technology and partnerships that power it are still in place, but EDE platforms must now adapt to new compliance rules, which could slow down the enrollment experience. Consumers may face delays or denials if they can’t meet the new documentation standards, and the simplicity that made EDE attractive is now at risk of being overshadowed by policy-driven complexity.

EDE was designed to simplify the enrollment experience, allowing consumers to sign up for coverage directly through payer websites without being redirected to HealthCare.gov. It was fast, user-friendly, and a major step forward in modernizing healthcare access. Now, EDE must evolve to meet the demands of the post-OBBBA world, requiring clear guidance from CMS; collaboration between states, insurers, and tech vendors; and continued advocacy to preserve consumer-friendly enrollment pathways.

  1. Can EDE Still Deliver a Seamless Customer Experience Under OBBBA?

For first-time buyers, the insurance shopping experience is often confusing and stressful. OBBBA’s new requirements add further complexity, making seamless, integrated enrollment more important than ever. EDE eliminates disruptive handoffs and keeps customers engaged within the health plan’s digital ecosystem, minimizing leakage to federal platforms and competing products.

However, under OBBBA, members who previously found EDE simple may now encounter additional documentation requests, more frequent income verification, or even loss of eligibility for subsidies. In response, payers must help to:

  • Educate members about the new requirements and help them navigate the changes.

  • Update EDE platforms to comply with evolving federal and state rules, while maintaining a user-friendly experience.

  1. How Can Health Plans Achieve Operational Excellence Amid OBBBA’s Demands?

Health plans must go beyond basic integration. EDE is not just a technical add-on; it can function as a strategic asset for navigating OBBBA’s layered requirements. Automated workflows, real-time eligibility verification, and proactive member support are essential to manage increased administrative burdens and improve accuracy. AI-powered outreach and multilingual communication strategies can help educate members about new eligibility rules, work mandates, and subsidy changes, reducing confusion and disenrollment risk. The administrative burden is growing, but EDE’s flexible framework means it can adapt — provided that technology investments and policy alignments are in place. Success will depend on staying informed, proactive, and adaptable in the face of ongoing regulatory change.

Bottom Line:
EDE isn’t gone — but it’s no longer operating in the same environment. The One Big Beautiful Bill Act has reshaped the rules of engagement, and those who rely on EDE must now navigate a more complex, restrictive system. Payers can remain proactive and promote success by considering the following actions:

  • Focus on ways to improve retention given the stricter eligibility checks and reduced subsidies.

  • Offset administrative complexity by modernizing platforms and optimizing costs with AI and automation.

  • Identify the right partners to minimize risk and implement technology, infrastructure, analytics, and KPIs.

  • Invest in data sharing to enable better payer/provider collaboration and care coordination.

  • Consider the social determinants of health to address rising risks before they become -costly.

By implementing these strategies, healthcare payers can position themselves to navigate the challenges posed by OBBBA and continue to deliver high-quality care amidst a transforming healthcare landscape.

Precision Utilization Management: Prioritizing Patient Care

Posted on by Charlotte Robidoux

By Krithika Srivats

Providers view prior authorization (PA) as a manual, burdensome, and laborious process, mostly because of process missteps such as lack of clinical data integration, inconsistency in data exchange standards, and differing policies among payers. According to a recent American Medical Association survey, a majority (89%) of physicians report that PA interferes with continuity of care. Moreover, a majority (72) of physicians describe the burden associated with PA handling as “high.” or “extremely high.” Finally, 89% of physicians report that PA somewhat or significantly increases physician burnout.  An important front-line negative impact of this time-consuming and often ineffective process is that patients feel the brunt of the delays and are disgruntled due to the endless appeals before receiving the needed care.

Evolving Traditional UM Processes

The ongoing maturity of cognitive automation and predictive analytics supported by robust data sources presents an opportunity for payers to evolve traditional utilization management (UM) processes into an intelligent authorization process. The process could be less abrasive if it were more precise. Indeed, what if we took a surgeon’s scalpel to create a more targeted, precision UM process?  This more precise UM is a proactive data-driven program that uses the power of predictive analytics to provide a prospective view into the downstream needs of the patient, thereby reducing unnecessary repetition of authorization — every step of the way.

The precision UM method not only reduces burden on providers but leads to reduced provider abrasion, enhanced member satisfaction, and decreased administrative resources and costs in managing the authorization process.

Four critical elements of precision UM prioritizes patient care in the journey:

  • Precision analytics: Member analytics looks at member behavior, historical data on compliance with preventive/recommended treatment, comorbidities, and lifestyle factors to accurately predict duration and level-of-care needs. These analytics help provide a prospective approval for the entire course of treatment. For example, a request for varicose vein ablation can be automated through predictive analytics if the historical claims and clinical data show a patient’s lack of improvement with conservative compression therapy and abnormal lab-based venous varicosity. Other lifestyle factors — such as comorbidities or a ground-floor versus an upstairs bedroom — also factor into what additional services (physical therapy or home health) need to be authorized.
  • Provider scorecard: The provider scorecard comprises analytics based on compliance to process fraud, waste, and abuse, as well as outcome measures such as accurate and timely information submission. This provides the ability to audit on the back end for continued gold-card status across UM needs and can help drive dynamic changes to the automated authorizations for stringent cost and quality outcomes.
  • Intelligent automation of authorizations against clinical guidelines: Using machine learning tools enabled by natural language processing functionality, this innovation can reduce review time by 30-40% and optimize the approval to denial ratio by 20%.
  • Care management and care coaching to holistically address the member for better lifecycle outcomes: Upon identification of key parameters driving utilization needs, a holistic care transition and care management program can help members seek only necessary and targeted care needs that will maximize outcomes. Addressing social determinants such as two-story housing when the member has a walker or lack of transport to attend outpatient therapy can reduce unnecessary utilization, optimize recovery timelines, and reduce readmission to hospitalization.

Precision UM Requires End-to-End Expertise

To provide the precision focus above, healthcare organizations are looking for BPM partners with end-to-end-expertise and clinical resources to scale support with intelligent tools and workflows to reduce costs and improve the effectiveness of UM programs. These BPMs have the analytics to deliver superior insights with client data, including deep dives to determine root causes of inaccuracies and process inefficiencies. Adoption of precision UM, electronic requests, and interoperable data exchange can significantly improve the payer provider collaboration. Additionally, providers should also consider clinical data audit using NLP solutions, which would increase the accuracy of documentation required for the UM processes.

Rather than expending time and resources to hire or train internal personnel, a skilled BPM organization can bring knowledge and skills in these areas to an organization immediately, with limited lead time. Ultimately, the goal is to develop a partnership that brings precision-UM-focused talent, best practices, and resources to the table.

Prior Authorization and Payment Integrity: Bridging the Gap

Posted on by Arun Sharma

By Mitesh Kumar

The healthcare claims process is one of the most complex administrative workflows in the industry. Both payers and providers experience this complexity daily, and it often leads to inefficiencies, delays, and strained relationships. Two critical components — Prior Authorization (PA) and Payment Integrity (PI) — are at the heart of this challenge. Traditionally, these processes operate in silos, creating friction and unnecessary administrative burden. But what if we could bridge the gap between PA and PI to create a seamless, transparent, and efficient system?

The Problem: A Reactive Model

Today’s claims workflow is reactive. Providers seek PA for services, proceed with treatment, and then submit claims. However, PI rules often apply after the fact, resulting in denials and payment disputes. For example, a provider may receive PA for laparoscopic surgery but later face denial for separate anesthesia charges because PI rules bundle those costs. This back-and-forth creates administrative burden, delays payments, and erodes trust. Both sides feel frustrated — providers believe payers intervene unnecessarily, while payers worry about inappropriate treatments. The root cause? Lack of upfront transparency.

A New Approach: First Time Right

The future lies in connecting PA and PI at the start of the process. Imagine a system where PI rules are applied during PA submission. This “First Time Right” approach ensures providers know the expected payment and documentation requirements before delivering care.
Key benefits include:

  • Denial Prevention: Identify potential issues before claims submission.
  • Payment Precision: Provide accurate, predictable payments.
  • Smarter Collaboration: Build trust through transparency.

For instance, if anesthesia charges are typically bundled, the system alerts the provider during PA, allowing adjustments or additional documentation upfront. This proactive model reduces appeals and accelerates payment cycles.

Technology as the Enabler

Achieving this vision requires advanced technology. While claims systems already apply payment rules, integrating these into provider-facing portals is the next frontier. Modern portals allow document uploads, but embedding PI rules will enable real-time validation and feedback. Providers could enter line items for surgery, recovery, and physiotherapy, and immediately see if physiotherapy exceeds coverage limits—along with guidance on required documentation. This evolution shifts payers from a “deny and defend” stance to an “enable and ensure” approach.

Building Trust Through Transparency

Trust is the cornerstone of payer-provider relationships. Today, uncertainty about final payments breeds skepticism. Even when correct payments arrive, prolonged disputes damage confidence. By merging PA and PI, payment expectations become clear from the outset, reducing friction and fostering collaboration.

The Road Ahead

Implementing this integrated model is no small feat. It demands IT investment, workflow redesign, and cultural change. But the payoff is significant: streamlined operations, reduced administrative burden, and a healthcare ecosystem built on trust and efficiency. The opportunity is clear—move from reactive corrections to proactive precision. By bridging PA and PI, we can create a claims process that works right the first time, benefiting providers, payers, and, ultimately, patients.

Healthcare organizations must start exploring technology partnerships and process redesign initiatives today. The sooner we align PA and PI, the sooner we can deliver better outcomes for all stakeholders. It’s time to transform the claims experience from a source of friction into a foundation of trust and collaboration.

Learn more about Claims Services and Payment Integrity Solutions

Payment Integrity: Why Automation and Hybrid Strategies Matter

Posted on by Arun Sharma

By Bob Starman

In today’s complex healthcare ecosystem, payment integrity (PI) is more than a back-office function—it’s a strategic imperative. Despite advanced claims systems, errors persist, often ranging from 3% to 5%, costing payers hundreds of millions annually. For large organizations, these inaccuracies can determine whether they report profits or losses. In fact, recovering half a billion dollars in overpayments can be the difference between financial stability and negative earnings.

Prepay vs. Post-Pay: Finding the Right Balance

The industry debate continues: Should payers prioritize prepay methodologies, which validate claims before payment, or post-pay audits, which identify errors after payment? Prepay solutions reduce downstream corrections, but relying solely on them is risky. Post-pay audits remain essential for catching undetected discrepancies and recovering overpayments.

The winning formula? A hybrid approach that combines prepay diligence with robust post-pay recovery. This strategy ensures comprehensive oversight and maximizes accuracy.

Technology: Driving Payment Integrity Forward

Automation has transformed payment integrity practices. Advanced platforms now dominate claims processing, reducing manual intervention and improving accuracy. These systems excel at data mining and repricing, identifying errors faster and more effectively than traditional methods.

Organizations that embrace automation gain a competitive edge. Their systems continuously refine algorithms, improving detection rates and minimizing human error. For example, one firm’s pioneering payment integrity software—developed over 25 years ago—has evolved into a sophisticated platform for repricing and payment accuracy. Today, automation is the backbone of successful post-pay integrity checks.

However, technology adoption requires significant investment. Some firms still rely on manual reviews due to budget constraints or a belief in human oversight. Yet, as financial pressures mount, automation is no longer optional—it’s a necessity.

The Financial Stakes

Even a 95% accuracy rate leaves room for billions in overpayments. For large-scale payers, payment integrity directly impacts profitability. Recovery efforts can transform financial outcomes, preventing losses that would otherwise trigger negative disclosures to investors and stakeholders.

Why Payment Integrity Matters More Than Ever

Healthcare payers face mounting financial pressures, making payment integrity a critical discipline. Organizations that prioritize automation, data-driven analysis, and rigorous post-pay audits position themselves to:

  • Recover lost revenue
  • Strengthen operational efficiency
  • Maintain financial stability

The future of payment integrity lies in innovation and balance. Firms that combine prepay diligence with advanced post-pay recovery — and invest in technology — will lead the way in reducing errors and safeguarding financial health.

Bottom Line: Payment integrity is not just about compliance—it’s about survival. In an era of tightening margins, payers that embrace automation and hybrid audit strategies will thrive in the evolving healthcare ecosystem.

Force Multiplier: OBBBA x Medicare Advantage Member Communications

Posted on by Arun Sharma

By Chris Shiffert

The impending policy shifts from the “One Big Beautiful Bill Act” (OBBBA or H.R.1) put Medicare Advantage (MA) plans in a unique and enviable position when it comes to member communications.

Not what you expected, right? But don’t stop reading.

By implementing a multifaceted communication strategy, MA plans, particularly those serving dual-eligible and low-income populations, have the opportunity to move beyond standard, one-way messaging and communication to adopt a high-touch, member-centric approach.

The new rules in OBBBA present a great chance to connect with MA members where they are—whether online through a member portal, on their phones via text, voice calls, or apps, or through Agentic AI supported by human agents on a plan website.

OBBBA provides an opportunity to improve member communications that can be implemented with MA members now and extended to commercial members in the future.

New Policies Need New Communications

With OVER 34 million Americans enrolled in Medicare Advantage, OBBBA changes affect many health plan members. And the ongoing modifications could influence long-term member health and payer financial results. (H.R.1 mainly targets Medicare and Medicaid, with substantial attrition of Medicaid beneficiaries. Medicaid and Children’s Health Insurance Program benefits will be cut by $1.02 trillion, mostly by eliminating at least 10.5 million people from the programs. Of the more than 10 million people losing Medicaid coverage, 1.3 million would remain eligible for Medicare while losing Medicaid coverage.)

For the new eligibility restrictions, communications must focus on providing clear, accessible information.

New communication methodologies can impact these challenges:

  • Elevated out-of-pocket costs for members are a threat to care utilization. When members face higher out-of-pocket costs, they are less likely to seek care. This leads to a rise in avoidable hospitalizations and ED visits, which affect member health and Star Ratings scores.
  • Churn from frequent redeterminations destabilizes the MA member base. The increased frequency of eligibility checks for dual-eligible members creates a significant administrative burden. This can cause breaks in coverage, disrupting care plans and undermining the ability to meet quality and health metrics.
  • AI-powered audits introduce new operational and compliance risks. As sophisticated AI audits come into play, MA plan administrative teams face a new level of scrutiny. This can lead to increased audit volume and require significant investment in internal compliance systems.

 

Scaling Personalized MA Engagement

As humans, we are masters at personalized engagement. But high-touch human support is not easily scalable for MA plans. To create a sound strategy, MA plans must understand not only an individual’s personal needs but also ways to counteract OBBBA changes at scale.

Despite vast repositories of data, payer databases have been traditionally siloed. Companies often rely on standard reporting and ad hoc analytical processes that fail to fully leverage member-level data across departments and functions, resulting in missed opportunities to better understand and support members.

By contrast, AI-enabled predictive capabilities can create a comprehensive whole-person view of each member’s healthcare goals and objectives, consumer behaviors, communication likes and dislikes, as well as other factors. With these insights at an MA plan’s figurative “fingertips,” it becomes much easier and more efficient to communicate with members not as ID numbers but as real people with complex, often contradictory, expectations.

An MA plan using these concepts will become the trusted source of truth on how OBBBA impacts individuals. Use H.R.1 as a foothold to strengthen a health plan’s MA brand as a compassionate and reliable partner in navigating a complex and changing system.

The Force Multiplier

The force multiplier is uniting OBBBA changes, technology like AI, MA plans, and MA members in such a way that the combination creates an experience greater than any single event or entity could on its own.

Here are a few ideas to help MA plans get the most out of the new environment by leveling up member relationships:

Get to Know Each Member

To provide a high-touch experience, you need to understand each member’s unique story. A digitally supported strategy, powered by data, allows the creation of a personalized experience. By using data on who members are, why they joined, and what their expectations are, you can drive more meaningful interactions that reinforce your brand as a trusted partner. Use multi-lingual agents or live translation services to ensure every member feels welcome.

Cultivate Trust

Trust is essential for retention. Using advanced analytics, MA plans can identify and mitigate negative experiences that could undermine trust, such as unanswered questions or poor service, before they lead to disenrollment or social media confrontations.

Prioritize Star Ratings

Star Ratings can be a driver of enrollment and financial success, with strong ratings potentially boosting enrollment. Because retention directly impacts an MA plan’s score, a data-driven, personalized communications strategy can improve ratings by tracking and addressing a member’s experience throughout their journey.

Hopefully, I’ve convinced you that OBBBA is an opportunity rather than an obstacle to overcome. Not only is H.R.1 the new normal, it’s a new way to look at interacting with MA plan members using innovative technologies to create operational advancements that can reinvigorate MA plans, making them more efficient and effective today and in the future.

Looking for deeper insights?
Download our companion white papers to explore actionable strategies for both payers and providers:

[Download] The One Big Beautiful Bill Act: A Strategic Guide for Payers

[Download] The One Big Beautiful Bill Act: A Strategic Guide for Providers

The Risk of Shadow AI in Healthcare and Why it Matters

Posted on by Arun Sharma

By Sumant Kawale

Shadow AI appears to be the latest issue associated with this technology. A “shadow” is an apt description for what’s happening across many industries and businesses, healthcare included. As the unauthorized deployment and use of AI tools by teams or individuals who don’t get a green light go-ahead from IT or security departments, shadow AI lives in the murky place between receiving approval for its use or not.

Shadow AI can cause a crisis in any business, but for those of us in healthcare, there are many ways its use can lead to extremely bad outcomes for every stakeholder: providers, payers, patients, and members.

Impacting Medical Diagnosis, Treatment, Patient Safety

Shadow AI is the latest technology risk facing healthcare. We’ve seen similar risks when Internet searches became easier to perform, and reliable information became accessible.

If you were dealing with a diagnosis as a provider that you were unfamiliar with, you could quickly look for information on any search engine. With a full page (or pages) of results, this was a simple way to locate information because you could readily identify the source and ignore those that were less reliable.

With AI, this gets harder, as it is not always easy to explicitly link sources to answers. And that’s a big problem when organizations, departments, and people rely on Shadow AI to inform decisions. With Shadow AI, IT and clinical departments haven’t had an opportunity to vet the data sources on which the AI is trained. Indeed, these departments likely aren’t aware of the use of Shadow AI within the organization.

Compliance and Data Privacy

Privacy is critical for payers, providers, and operating partners. Data exfiltration is a huge risk and is associated with significant penalties. Stakeholders work each day to confirm that healthcare data is safe and secure and remains within the organization. Nevertheless, data breaches are an ongoing problem for healthcare, with more than 274 million people having their data exposed in 2024.

Sending patient or member medical data to Shadow AI is akin to handing a burglar the keys to your house. You can do it, but don’t be surprised if you get home and all the valuables are gone. Using Shadow AI to process healthcare data can expose an organization to mishandled data or, much worse, a full-on breach.

Unmonitored AI Usage

While lockdowns and approved website lists are table stakes, AI tools have become too ubiquitous to completely lockdown. Data exfiltration is possible even when texting by using a smartphone and taking pictures. As a result, guiding the use of AI increasingly becomes a task that needs consistent reinforcement and ongoing openness and transparency when communicating about the topic, while reiterating the serious consequences of data breaches.

The optimal middle ground is to grade data sensitivity. Protected health information should never make its way out of secure IT system environments, especially not in email. Further, tools should be available in development environments to use the latest and greatest hosted AI models, again keeping the data in-house.

The latest APIs may sometimes be out of reach because of customer security concerns, but secure experimentation with mock data can be encouraged to understand how AI produces results.

How Organizations Can Respond

As with many decisions in life, there is no easy answer to the use of Shadow AI. Even with safeguards in place and explicit instructions on the use of AI in a healthcare organization, the use of Shadow AI will continue to occur.

Three ways to lessen the use of Shadow AI:

  • We feel the right way to tackle this is to restrict critical answers to clinical questions, for example, to known sources only. This approach can be embedded in the organization’s knowledge management system, allowing the user to receive answers without knowing their exact source, while the AI team establishes the necessary safeguards to ensure the information is reliable and accurate.
  • As with most business workflows, the right way to mitigate risk is via a distributed model. Monitoring is key to ensure that users do not copy and paste data or even open unauthorized websites that host AI solutions.
  • Use HIPAA-certified AI services that have zero retention policies to mitigate the exfiltration risk associated with using external APIs. Many responsible organizations simply don’t use external APIs to ensure that no data is sent externally.

These recommendations only represent partial measures of an overall AI strategy that healthcare organizations should consider before employing AI solutions. In addition, organizations must balance internal pressures to work faster, drive down costs, and work smarter with the need to do all we can to protect patient and member data.

Healthcare data is sacrosanct. Because it contains highly personal and sensitive information that directly influences a person’s well-being, privacy, and security, safeguarding this data is essential to maintain trust with patients and members.

No matter how valuable AI seems to — increasing efficiency, cutting costs, or improving care — we can’t lose sight of those we serve.

Sumant Kawale is Senior Vice President of Technology Solutions at BirchAI, a Sagility company.

The One Big Beautiful Bill Act: What It Means for Payers and Providers

Posted on by Arun Sharma

By Michael LeVangie, Senior Vice President of Consulting at Sagility

Healthcare payers and providers face unprecedented financial pressures every day due to a combination of systemic, economic, and regulatory factors. With the passage of the One Big Beautiful Bill Act (OBBBA), economic stress will continue to grow, albeit at a more rapid pace.

Healthcare stakeholders already face declining reimbursements and rising costs. Traditional operational models and the continuing use of outdated data systems were unsustainable even before OBBBA entered the picture. Now, many health plans and providers are grappling with a critical question: how can we maintain quality of care and financial viability when the goal posts continue to move?

The answer lies in a strategic reevaluation and optimization of core operations — from eliminating data silos to enhancing operations and adding cost-effective healthcare resources. And while the changes won’t be quick or easy, payers and providers should consider OBBBA as an opportunity to jumpstart necessary tech and operational improvements.

Reimbursement Cuts and Rising Costs

Healthcare organizations are currently navigating a turbulent financial environment, intensified by OBBBA. This legislation is projected to reduce federal healthcare spending by approximately $1 trillion through 2034, primarily through major cuts to Medicaid and other programs.

Let’s explore the influence of OBBBA on providers and payers:

    • Decreased Reimbursement Rates: Providers are experiencing a reduction in the money they receive for services, affecting their ability to cover operational expenses.
      • OBBBA Impact: The Act will cut Medicaid and CHIP spending by more than $864 billion over the next 10 years. These cuts directly impact reimbursement rates for providers, particularly those heavily reliant on government programs. States, especially Medicaid expansion states, will face new restrictions on provider taxes and state-directed payments, further limiting their ability to supplement funding. Some hospitals, for example, will weather this storm better than others. “About 4 in 10 hospitals had negative operating margins, and 12% had margins below -10%, but 24% had margins at or above 10%, suggesting some will have greater capacity than others to absorb any losses,” according to KFF.
    • Escalating Medical Costs: The cost of medical care in the U.S. continues to climb. Like most things in life, a health plan’s Medical Loss Ratio (MLR) is a balancing act on the thin edge of a knife. If the MLR is too low, it can signal that a health plan is spending too much on administration or driving profit; if it’s too high, this can mean that more premium dollars are going to healthcare, sometimes to the detriment of decreasing fraud, waste, and abuse or bringing new operational systems online. Striking a balance will be more difficult under OBBBA.
  • Operational Strain: With fewer dollars available, payers and providers are struggling to maintain adequate staffing and resources for day-to-day operations. This often leads to a reactive, tactical approach supported by short-term fixes, leaving little time or resources for strategic planning or organizational transformation.
    • OBBBA Impact: The Act imposes new administrative burdens, such as more frequent eligibility redeterminations for Medicaid enrollees, as mentioned earlier, and work requirements. This increases operational complexity for Medicare Managed Care, demanding more resources — human and technological — at a time when funding is being cut.

Operational Optimization Amid OBBBA Realities

The moment to act is now. In this unique environment, operational optimization is essential for survival. The era of “doing more with less” is long gone; it is now time to fundamentally rethink how to provide services.

That means payers and providers must identify the core challenges caused by OBBBA. And address them quickly. The top operational improvement areas to consider amid OBBBA changes include:

  • Call Center Efficiencies: Overcome long wait times, high call volumes, and inefficient member and patient processes with automation and AI enhancements
  • Communications: Improved inbound and outbound experiences to enhance member loyalty
  • Claims Operations: Our claims Claims Center of Excellence (CoE) speeds up processing of payments, benefiting both providers and members
  • Staffing Shortages: Hybrid staffing models combine onshore, nearshore offshore teams. Augmenting clinical staffing includes licensed nurses and care coordinators to support payer and provider operations.
  • Medical Cost Management: Optimizing utilization management and ensuring appropriate care delivery
  • Strategic Outsourcing: Partnerships are a viable and attractive option to receive specialized expertise and realize efficiency gains
  • Automation and AI: Using technology in administrative and some clinical processes can significantly reduce manual effort, improve accuracy, and lower costs
  • Human-Plus-Technology Models: A hybrid approach that combines human expertise with technology is the most effective solution

Today Is the “New Normal”

Healthcare entities are so immersed in daily operations that implementing a broader, transformative vision can be overwhelming, especially with OBBBA changes in the queue. Nevertheless, building and implementing a strategic plan will help payers and providers find a path forward.

The “New Normal” demands a bold approach. By optimizing operations, utilizing technology, leveraging a skilled workforce, and forging strategic partnerships, payers and providers can make significant strides in these challenging times. It’s time to bring novel solutions and new perspectives to healthcare to uncover hidden inefficiencies and opportunities.

Whether you’re a payer or provider organization, this is the new reality. It’s time to make changes that have been put off for years.

These changes are no longer a matter of “if.” It’s “when.”

And “when” is now.

Looking for deeper insights?
Download our companion white papers to explore actionable strategies for both payers and providers:

[Download] The One Big Beautiful Bill Act: A Strategic Guide for Payers

[Download] The One Big Beautiful Bill Act: A Strategic Guide for Providers

Transforming Healthcare Operations with End-to-End Expertise

Posted on by Charlotte Robidoux

This article is the first of a four-part series describing how the four business process management (BPM) pillars can optimize operations.

By Sohail Djariri

In the complex and interconnected world of healthcare, operational excellence requires more than discrete expertise; it demands an integrated, end-to-end understanding of both payer and provider domains. From member services and claims processing to clinical reviews and revenue cycle management, organizations that possess this holistic view are uniquely positioned to identify inefficiencies, streamline workflows, and deliver seamless, patient- and member-centric experiences.

Driving Synergistic Savings Across Customer Touchpoints

Analyzing workflow issues end-to-end ― across the healthcare journey from call centers to claims ― can yield valuable insights. Members typically call to ask about their benefits, prior authorizations, and claim status. Next-gen technology, including predictive analytics and process mining, can visualize all the steps, end-to-end, that occur across the member journey. The result: a visual representation of issues that affect all customer touchpoints. Addressing these issues results in measurable outcomes:

  • Reduced operational costs: 20%-25% for contact centers and as much as 35-40% for claims.
  • Lessened number of touches per claim from ~7 to 1.5 to 2.
  • Accelerated issue resolution.
  • Improved member and provider satisfaction.

Identifying bottlenecks across all customer touchpoints provides information about how to resolve bottlenecks, prevent them from happening in the future, and elevate the customer experience. Reduced internal handoff, rework, appeals, and calls by 15% ultimately enhances NPS, which leads to better Star Ratings.

End-to-End Utilization Management

Utilization management (UM) also illustrates the importance of end-to-end domain expertise. Sagility’s precision UM method addresses issues such as process missteps due to lack of clinical data integration, inconsistency in data exchange standards, and differing policies among payers. End-to-end domain expertise enables clients to overcome any imprecision, lessening provider burden, which reduces abrasion, enhances member satisfaction, and decreases administrative costs in managing the authorization process.

Four critical elements of precision UM meet the patients where they are in their care journey:

  • Precision analytics: Member analytics looks at member behavior, historical data on compliance with preventive/recommended treatment, comorbidities, and lifestyle factors to predict duration and level-of-care needs accurately. These analytics help provide prospective approval for the entire course of treatment.
  • Provider scorecard: The provider scorecard yields insights about compliance with process fraud, waste, and abuse requirements, as well as accurate and timely information submission. This process provides an opportunity for a back-end audit, helping to automate authorizations for stringent cost and quality outcomes.
  • Intelligent automation of authorizations against clinical guidelines: Using machine learning tools enabled by natural language processing functionality, this innovation can reduce review time by 30-40% and optimize the approval to denial ratio by 20%.
  • Care management and care coaching: Upon identification of key parameters driving utilization needs, a holistic care management program can help members seek only necessary care needs that will maximize outcomes. Addressing social determinants can reduce unnecessary utilization, optimize recovery, and reduce hospital readmission.

To provide this kind of precision focus, healthcare organizations are looking for BPM partners with end-to-end expertise and clinical resources to scale support with intelligent tools and workflows to reduce cost and improve the effectiveness of UM programs.

Integrating Healthcare End-to-End

Healthcare organizations that integrate end-to-end domain experience are positioned to pull the right levers. End-to-end domain expertise is more than a strategic advantage; it’s a necessity for healthcare organizations aiming to thrive in a value-driven environment. End-to-end visibility streamlines handoffs between departments, reduces rework, and closes gaps across all stages of care and administration. Deep domain expertise can help healthcare organizations bridge functional silos, lessen administrative burdens, and improve outcomes across the entire care continuum.

Read more in our white paper, Fixing the Friction: How Strategic Operations Management Unlocks Healthcare Efficiency at Scale, to explore how the four BPM pillars can reduce operational burden, improve patient outcomes, and drive resilience across the care continuum.

Aging in Place: Why Consulting Is the Backbone of an Exceptional Stakeholder Experience

Posted on by rajath neodesynz

By Michael LeVangie

Healthcare has many stakeholders. Not the least of which are older adults. There are more than 59 million people 65 years and older in the US today, according to the US Census Bureau. And that number continues to grow.

These older adults find their way to traditional Medicare or Medicare Advantage, while others may be dual-eligible because of their financial circumstances.

They have a common desire to live in their homes and communities as they age. For some, this is easy, thanks to good health. For others with declining health, including chronic conditions, comorbidities, and dementia, it’s much harder to accomplish.

That’s where aging-in-place programs come into play. 

Getting it right is complex. Consultants can help to examine organizational data, claims, existing programs, and additional data points to increase the likelihood of your program’s success.

Payer, Member Opportunities for Aging in Place

Aging in place opens the door to lower costs while helping members accomplish what may be one of their most important lifelong goals: maintaining independence.

With the help of a consultant, payers can identify operational savings, while concurrently improving the member and provider experience. It’s not an either-or decision. It’s the ability to create the best experience for all stakeholders.

Consultants offer a new assessment of the aging-in-place solution while gathering a holistic view of data and prospective aging-in-place members.

That abundance of data can help drive an exceptional aging-in-place program. When a consultant works hand-in-hand with a payer to parse that data, the findings help payers understand what services and benefits are needed to build an effective program that can drive lower costs.

Using data analytics, the consultant helps the payer understand the chronic conditions found in the older adult population. This helps determine what preventive care services should be administered in a lower-cost setting, such as the participant’s home or an outpatient clinic, compared to services administered in a hospital. Data analytics also uncovers the need for non-emergency medical transportation, meals, and community services.

For health plans, the opportunity derives from cost takeout generated by healthier members, fewer ED and urgent care visits, and better relationships with primary care providers and community organizations.

Get There Before the Puck

Expanding access to preventive healthcare, primary care, and aging-in-place services not only drives down costs but also benefits Medicare and dual-eligible populations. 

Aging-in-place programs, like Sagility Smart StepTM, help health plans move from reactive medicine to initiative-based medicine. Rather than waiting to identify members through a series of claims indicating diabetes or heart failure diagnosis, payers can get ahead of the puck. 

As hockey great Wayne Gretzky famously said: “I skate to where the puck is going to be, not where it has been.” 

Healthcare-focused consultants have the knowledge, expertise, and insight to help payers get ahead of the puck by recommending actions to shape an aging-in-place program that benefits multiple stakeholders, including payers, providers, members, and patients.

3 Common Reasons for Claims Denials and How To Address Them

Posted on by rajath neodesynz

By Krithika Srivats

In the often-changing world of payer rules, regulations, and code changes, claims denials hit providers fast and hard.

Payers deny nearly 15% of all claims they receive—including many that were pre-approved—only to have 54% of them overturned after lengthy and costly provider appeals. To make matters worse, the cost to providers nationwide to appeal decisions is approximately $262 billion every year.

Providers already face shortages of qualified healthcare professionals and shrinking margins. That makes denials more than an operational inconvenience—they’re a persistent threat to financial viability and the delivery of quality care.

Every provider I’ve met—from providers with single-person practices to hospital systems with thousands of healthcare professionals—wants one thing: to eradicate, or at least limit, clinical denials.

3 Reasons for Denials

Three major reasons underly why clinical denials occur:

  1. Insufficient Documentation of Medical Necessity: It’s not enough to document the medical services a patient requires following an examination, testing, or diagnosis. Payers increasingly require detailed clinical evidence to justify services. Or they would rather have the patient treated in a less intensive care setting. Providers must ensure that all documentation—letters of medical necessity, progress notes or documentation for specific care services—clearly supports the diagnosis, treatment, or level of care provided to the patient. When this detailed information is lacking, payers often deny the claim even when the care was appropriate.

  2. Prior Authorization Failures: Missing or incorrect prior authorizations are a leading cause of denials. As payers continually adjust rules and automate adjudication, scenarios emerge in which some prior authorizations are rejected when they should be approved. For these reasons, it becomes increasingly important to get claims right the first time.

  3. Coding and Billing Errors: Simple clerical errors like mistakes in CPT/ICD codes, mismatched modifiers, or outdated codes will trigger denials. Often, these errors are due to office staff turnover, training gaps, or system limitations. No matter how they happen, mistakes set off an expensive cycle of rework and appeals.

Unfortunately, the Experian Health 2024 State of Claims provider survey suggests that these provider-related challenges will continue for some time:

  • 75% indicate that claim denials are increasing

  • 77% indicate that payer policy changes occur more frequently

  • 67% indicate that the time it takes to be reimbursed is increasing

Providers, large and small, expect these issues to get worse before they get better.

2 Ways to Limit Denial Exposure

Fortunately, providers that employ the following strategies will go a long way toward preventing many denials and mitigating the impact of most.

No matter how often providers employ AI and analytics, train staff, or keep abreast of changing payer rules, policies, and reimbursement rates, claims denials won’t go away. At least not in the near term.

Since providers know that 15% of claims will be flagged by payers, it’s critical to have a plan in place to deal with this certainty. By adding the ideas below into this plan, providers can limit exposure by including in their plans the following steps, designed to address denials before and after they occur.

  1. Before

Preventing a denial beforehand is the gold standard―when all providers can intercept any omissions or errors present in a claim.

The gold standard results from bringing together human expertise and technology:

  • Predictive analytics to identify denial patterns to ensure the claim doesn’t have any of the previously denied information

  • Automated workflows to flag denials for missing prior authorizations

  • Predictive models to show the propensity to overturn denials based on the payer, the claim, and the potential denial type

  1. After

After the denial has occurred, it is important to use the most streamlined and effective processes to limit financial exposure, whether that’s staff time or simply getting paid for the work that’s been completed.

As payers concentrate on post-service denials by implementing payment integrity analytics, as well as auditing and validating clinical rules, the follow-up aspect of denials becomes more important and complex.

After-the-fact denials management actions to facilitate appeals:

  • Ensure clinicians use clinical denial root-cause analysis or data from past payer denial letters

  • Use payer-specific policies and line-of-business-specific medical guidelines and apply them to denied claims to ensure payer medical necessity levels have been met

  • Tailor the appeal request by aligning it with payer criteria

  • Request that clinicians analyze disparate, often siloed, medical records to identify record gaps required for appeals

  • Use automation to follow-up on technical denials and locate opportunities to resubmit the claim with required information

  • Conduct outreach to obtain any missing medical records using administrative resources

It Takes Change to Make a Change

Ultimately, finding a solution to the daily influx of clinical denials won’t be easy and will take a considerable amount of time to resolve. With the constant changes in the healthcare industry, although clinical denials won’t vanish, they can be dramatically reduced with the right technology and cross-functional teamwork. Many providers are navigating complex reimbursement scenarios and growing numbers of denials every year.

Providers can only effect change within their businesses, operations, and staff. To do so requires both cultural change within operations and internal workflow, as well as technological innovations. Improving the claims process is about shifting from a reactive cycle of denial/appeal to a model centered on people, AI, and actionable data to break the cycle.

Prevention isn’t just a financial strategy for managing claims denials, it’s necessary for long-term sustainability.

Visit sagilityhealth.com to learn more about Sagility’s Clinical Denials solution for providers.

Transform Healthcare Operations with Nurse Assist

Posted on by rajath neodesynz

By Abhishek Danturti Sharma

Healthcare payers and providers face delays in prior authorization (PA), heavy administrative burdens, compliance risks, and inconsistent decision-making, all while facing increasing amounts of clinical data. Many healthcare organizations looking for digital AI-led solutions to overcome these impediments lack the expertise and infrastructure to make changes. 

The Sagility Nurse AssistTM addresses these challenges systemically by reimagining utilization management (UM) and PA workflows with a GenAI-powered, Agentic AI platform built for healthcare. 

Nurse Assist brings together the best in technology, data analytics, and domain-specific expertise to impact healthcare operations. Nurse Assist can help you:

Accelerate Workloads and Overcome Data Variability

Nurse Assist reduces manual workloads by over 80%, accelerates clinical decisions to under three minutes, and improves care coordination by combining GenAI, Agentic AI, and advanced Clinical Language Processing (CLP). It uses optical character recognition (OCR) and CLP to extract structured data—such as diagnoses, medications, and demographics—from unstructured formats like handwritten notes, scanned faxes, and electronic health records (EHR) records. The system then triages cases by complexity, standardizes inputs to ensure semantic alignment with medical guidelines and payer rules, which enables automated approvals for routine requests, flagging exceptions for human review.

Use Deep Clinical Intelligence for Confident Decisions

What sets Nurse Assist apart is its deep clinical intelligence. Embedded clinical decisioning algorithms, informed by evidence-based guidelines and payer-specific rules, generate decision recommendations—much more valuable than typical search results—along with transparent rationales and audit trails. A confidence scoring system and color-coded annotations support nurse reviewers in making rapid, confident decisions. Developed in response to market gaps and validated through real-world pilots, Nurse Assist proves that automation can be both accurate and trusted by clinicians.

Leverage Decades of Clinical Learning

Unlike many AI solutions that offer generic automation or standalone analytics, Nurse Assist is purpose-built for healthcare and deeply rooted in the realities of clinical operations. It builds on existing UM and PA practices by embedding AI directly into the clinical workflow—bridging the gap between administrative efficiency and clinical accuracy.

Trained on decades of industry data, the platform’s AI component includes evidence-based guidelines, payer-specific rules, and clinician-focused judgement. But instead of simply digitizing these processes, Nurse Assist innovates by coordinating an Agentic AI architecture that combines advanced document recognition, CLP, and large language model-powered reasoning. 

Nurse Assist uses a continuous learning loop, powered by our subject matter experts’ feedback, to ensure that the platform aligns with evolving payer policies and clinical standards. The solution’s continuous learning abilities instill confidence among users.

Drive Interoperability, Scalability

Given the diversity of payer systems and workflows, we designed Nurse Assist to address interoperability issues by designing flexible, standards-based integration options via APIs, Fast Healthcare Interoperability Resources (FHIR), and browser extensions, allowing rapid, secure deployment without overhauling existing infrastructure.

Accelerate Care Through Innovation

The innovation lies not just in the technology, but in how it transforms labor-intensive, error-prone tasks into streamlined, accurate, and clinically sound processes. Nurse Assist ’s human-in-the-loop oversight and transparent rationales for recommendations not only ensure compliance and safety but also help to increase adoption among clinical reviewers. By complementing—not replacing—clinical expertise, Nurse Assist accelerates care delivery, reduces denials, and cuts administrative waste, setting a new standard for AI in healthcare.

Nurse Assist Drives Healthcare Excellence

With a priority on clinical, ethical, and operational concerns, Nurse Assist has emerged as a trusted, scalable AI solution, transforming traditionally laborious UM and PA processes into a streamlined, high-accuracy, and clinically sound workflow. Nurse Assist helps clinicians work smarter, allowing them to spend more time treating patients.

Nurse Assist recently made The Cloud Awards 2025 A.I. Awards Shortlist for the Best Use for AI Healthcare. The “Best Use of AI for Healthcare” award recognizes innovative applications of artificial intelligence that significantly impact the healthcare industry, improving patient outcomes, enhancing clinical decision-making, and driving operational efficiencies.

Ready to transform your utilization management and prior authorization workflows?
 Discover how Nurse Assist can accelerate clinical decision-making, reduce administrative waste, and improve patient access to care.
[Contact us to learn more ➜]

Sagility Recognized for Excellence in Healthcare BPO

Posted on by rajath neodesynz

By Sohail Djariri, Chief Growth Officer, Sagility

At Sagility, we often talk about smarter healthcare business solutions—and recently, the industry has taken note.

I’m proud to share that Sagility has been recognized by three independent analyst and research firms, each highlighting the measurable impact we’re delivering across payer services and the healthcare business process optimization space. These honors aren’t just about what we do; they’re proof that our clients see the difference.

  • Dual Leader in Avasant’s 2025 RadarView™ Market Assessment
    Avasant named Sagility a Leader in both its 2025 Clinical and Care Management Services Business Process Transformation RadarView™ and its 2025 Healthcare Payer Business Process Transformation RadarView™ market assessments, recognizing our innovation and the value we deliver across care management, population health, and quality improvement initiatives. The report cited our work in generative AI, avatar-based clinical knowledge systems, and our frailty resilience program, Sagility Smart Step™, all driven by our 40,000+ team members who are dedicated to improving outcomes for the organizations we serve.

    Learn more about Avasant’s Care Management Assessment and their Payer Process Transformation Assessment

  • Black Book Ranks Sagility #1 for Claims and Payer Customer Service
    Black Book Research named Sagility the top-ranking vendor for managed services in outsourced claims adjudication and integrated customer service operations for health plans and payers at the AHIP conference in Las Vegas. This recognition is especially meaningful because it’s based entirely on feedback from more than 200 U.S. health plans, comparing 30 vendors across 18 performance indicators. Knowing that our clients recognize the impact of our integrated claims and member service solutions is a powerful reminder that drives everything we do.

    Learn more about Black Book’s recognition

  • Everest Group’s 2025 PEAK Matrix® for Payment Integrity 
    Everest Group named Sagility a Major Contender in its 2025 PEAK Matrix® for Payment Integrity Solutions, recognizing our strength in pre-pay and post-pay operations, fraud, waste, and abuse detection, and clinical and coding reviews. This recognition highlights how our technology-enabled services, enhanced by the integration of Devlin Consulting and BirchAI, support scalable cost containment through AI-powered claims repricing, diagnosis-related group (DRG) audits, and predictive analytics.

    Learn more about Everest Group’s recognition

What This Means for Our Clients

Each of these awards underscores a shared truth: business process optimization in healthcare isn’t just possible—it’s necessary. Sagility is leading that transformation through deep healthcare domain expertise, clinician-led services powered by AI innovation, scalable delivery across global markets, and results that speak for themselves.

To our clients and partners: thank you for trusting us to do the work. And to the entire Sagility team, this is your win. Let’s keep raising the bar.

Here’s to what’s next.

– Sohail

Reading Between the Lines: Intelligent Solutions for Unstructured Healthcare Data

Posted on by rajath neodesynz

By Alan Vitale and Don Searing

Healthcare payers struggle with unstructured data (clinical notes, faxes, handwritten forms), which makes up over 80% of healthcare information. This data, unlike organized claims data, slows operations, hides crucial insights, and leads to poor experiences for both providers and members.

Legacy systems can’t efficiently process this unstructured content. Manual review of documents like medical records, handwritten notes, and faxed claims is slow and often misses vital information, hindering critical processes like grievance handling and clinical reviews.

The answer lies in combining intelligent automation with human expertise. Technologies like Intelligent Content Processing (ICP)—which reads, identifies, extracts, and routes documents—and Natural Language Processing (NLP)—which interprets text context and meaning, including sentiment and clinical terminology—are key. These tools streamline data intake and unlock insights. However, they’re most effective when paired with human teams to manage exceptions, validate data, and provide essential context.

This human-tech partnership significantly improves efficiency. For example, automating grievance intake means documents are scanned, analyzed by NLP for urgency and type, and then automatically routed with key information extracted. This leads to:

  • Reduced manual handling
  • Faster turnaround times for grievances and appeals
  • Improved audit readiness
  • Enhanced member and provider satisfaction
  • Access to previously hidden data for better analytics and planning.

Ultimately, by leveraging AI with human oversight, unstructured data transforms from a burden into a strategic asset, leading to more efficient, precise, and empathetic healthcare operations.

Read the full article on Health IT Answers.

How Senior Care Communities Can Leverage Data To Reduce Rehospitalizations

Posted on by rajath neodesynz

Preventable rehospitalizations remain a critical concern for senior care organizations, impacting both operational efficiency and resident outcomes. 

Readmissions drive up healthcare costs, disrupt continuity of care, and often signal deeper systemic issues. While traditional interventions like care coordination and discharge planning are still essential, progressive healthcare leaders are increasingly turning to advanced analytics to shift from reactive to proactive care. 

By harnessing predictive insights and real-time data, executives can identify at-risk residents earlier, allocate resources more effectively, and ultimately, reduce avoidable readmissions, improving both clinical and financial performance.

The full article originally appeared in i Advance Senior Care.

Denial Recovery Starts with Smart Teams and Smarter Tools

Posted on by rajath neodesynz

By Krithika Srivats, Senior Vice President of Clinical Practice at Sagility

In today’s rapidly evolving healthcare landscape, hospitals and physician groups face mounting challenges from clinical and coding denials. While technology has improved efficiency, it has also enabled payers to adopt more complex, technology-driven denial tactics.

Post-acute care denial rates more than doubled—from roughly 11% in 2020 to 23% in 2022—likely due in part to the addition of automated review processes in those years. Coding-related denials surged by 126% in 2024, and clinical documentation audits increased by 100%, according to a recent benchmark study.

The broader denial trend shows no sign of slowing. Pharmacy claims denials jumped 16% between 2018 and 2024, and marketplace insurers denied an average of 20% of all claims in 2023, with some rejecting up to 33%. These rising denial rates leave providers facing heavier administrative burdens and increased revenue loss.

The Cost of Denials: A Multi-Billion Dollar Crisis

Clinical denials aren’t just an operational headache; they can create a financial catastrophe. U.S. hospitals lose an estimated $262 billion each year to initially denied claims, averaging nearly $5 million per provider. Denials tied to authorization issues, medical necessity, and documentation errors continue to rise. Clinical denial rates doubled from 13% in 2021 to 28% in 2023.

Some of the top reasons for denials include:

  • Inadequate documentation supporting medical necessity
  • Missing or incorrect prior authorizations
  • Level of care disputes (e.g., inpatient vs. observation)
  • Coding inconsistencies (e.g., National Correct Coding Initiative edits, including Medically Unlikely Edits, or missing modifiers)

Why Are Overturn Rates So Low?

A KFF analysis finds that consumers appealed only about 1% of denied in-network claims in 2023; of those appeals, insurers upheld 56% of the original denials, and consumers rarely pursued external appeals. Common barriers include:

  • Poorly written appeal letters that lack clinical rationale
  • Lack of documentation on medical necessity pertaining to the level of coding and billing
  • Incomplete or missing medical records
  • Delayed response timelines

With the right partner and strategy, providers can turn this gap into a valuable revenue recovery opportunity.

Sagility’s Two-Pronged Approach: Technology + Clinical Insight

Sagility changes the narrative with a proven methodology that blends deep clinical expertise with advanced automation. The results speak for themselves:

  • Fast-tracked 75% of cases for appeals based on propensity models.
  • Achieved over 3x improvement in overturning prior auth denials and medical necessity denials.
  • Scaled our services from three hospitals to 16 hospitals
  • Added all specialties, including facility denials for behavioral health, diagnosis-related group (DRG) denials, extended length of stay, and long-term acute care hospital (LTACH) denials. 
  • Achieved a high-complexity denials overturn rate that is 2x higher than peers.

What Makes Sagility Different?

Sagility brings together smart technology, clinical expertise, and payer-savvy processes to deliver real results. But what truly sets us apart is our deep-domain experience across the healthcare ecosystem. We don’t just apply best practices; we help to define them.

Our team has spent decades navigating the complex dynamics of payers, providers, and regulatory frameworks. That experience shapes every intervention we deploy. Instead of a one-size-fits-all approach, we customize denial management strategies based on each client’s unique needs, denial types, compliance related to lines of business, and payer mix. Our strategies are rooted in firsthand knowledge of what works and why.

We focus on precision, efficiency, and full transparency, backed by tools that drive smarter decisions and better outcomes. Some of our industry-informed tactics include:

  • Custom Appeal Letters: Tailored to payer criteria and denial type; each letter includes precise clinical justifications supported in disparate medical records, that is needed to improve overturn rates.
  • Analytics-Powered Prioritization: AI-driven models help identify which denials are most likely to succeed, so teams can focus their efforts on what matters most.
  • End-to-End Denial Management: From DRG reviews to medical necessity validations, Sagility supports the full denial lifecycle to maximize recovery.
  • LLM-Based GenAI Tools: Large language model (LLM)-powered tools boost nurse productivity and accuracy during medical record reviews.
  • Real-Time Dashboards and Reporting: Clients gain full visibility into denial trends, audit trails, and financial recovery, all in one place.

Our tailored approach delivers measurable value, whether starting small or scaling systemwide. One engagement that illustrates this evolution began as a limited pilot and grew into a transformational solution.

Case in Point: Scaling Success Across a 20-Hospital System

After struggling with rising clinical denials in the wake of COVID-19, a major faith-based health system turned to Sagility for support. The engagement began as a focused pilot at two hospitals with just five nurses. As the pilot delivered strong early results, the health system expanded the partnership to 19 hospitals and more than 40 clinical experts. We helped the organization build internal confidence, optimize processes, and recover lost revenue throughout the engagement.

Key outcomes include:

  • 68% of clinical denials qualified for appeal, up from 40%.
  • 60–62% success rate on overturned denials, up from 20-22% with the client’s in-house teams.
  • More than $12 million in annual collections, up from $1.5-$2 million.

High-Cost Drug & DRG Denials: No Case Too Complex

Sagility’s clinical team brings the expertise needed to address complex denials, from advanced biologics to nuanced DRG coding disputes. We use guidelines from MCG Health, the Centers for Medicare & Medicaid Services, and payer-specific sources to deliver clinical validations that meet payer expectations.

For example, we overturned a DRG denial for sepsis by identifying documentation gaps and applying Sequential Organ Failure Assessment criteria to support the diagnosis codes and level of care.

The Path Forward: Proactive Prevention and Continuous Learning

Sagility’s work doesn’t end with appeals. Our platform delivers actionable insights that improve documentation, reduce future denials, and help providers strengthen compliance and accuracy. Through regular audits, real-time feedback, and personalized guidance, we help clinicians and coding teams build a culture of accuracy and accountability.

The healthcare industry can’t afford to treat clinical denials as inevitable. With the right mix of expert clinical insight, automation, and payer-specific strategies, organizations can recover millions of dollars to reinvest into patient care. Our work with clients proves that overturning clinical denials isn’t just possible—it’s scalable, sustainable, and smart business.

Visit sagilityhealth.com to learn more about Sagility’s Clinical Denials solution for providers.

How Agentic AI is Revolutionizing Healthcare Payer Contact Centers

Posted on by rajath neodesynz

By Abhishek Danturti

In the world of healthcare, payer contact centers are the nerve center of customer service. From answering billing questions to navigating the labyrinth of insurance benefits, these centers and staff handle it all. But the current system often falls short: long wait times, human errors, and frustrated customers. Enter Agentic AI—the future of customer service in healthcare. 

This innovative technology is poised to completely transform the way payer contact centers operate, improving efficiency, satisfaction, and accuracy across the board.

What Exactly is Agentic AI?

Think of Agentic AI as a supercharged assistant. Unlike traditional AI, which relies heavily on human oversight, Agentic AI can make autonomous decisions, dynamically interact with customers, and manage complex tasks on its own. In the fast-paced environment of healthcare payer contact centers, this means faster resolutions, fewer mistakes, and a smoother experience for both agents and customers.

The Big Problem: A Slow, Inefficient System

The healthcare industry is notoriously complex, and nowhere is this more apparent than in payer contact centers. Customers often call with questions about their claims, coverage, or prior authorizations—each of which involves layers of detailed information. This complexity leads to lengthy wait times, frustrated callers, and overburdened agents. As the demand for customer service grows, so too do operational costs. A Health Affairs article reported that wasteful administration spending could range from $285 billion to $570 billion. 

The Game-Changing Benefits of Agentic AI

  1. Smarter Virtual SMEs

Traditional chatbots are helpful, but they often fall short when dealing with nuanced, complex issues. This is where Agentic AI shines. These AI-powered assistants can handle everything from simple billing queries to more complex tasks like claims status updates or coverage explanations. Imagine calling in to inquire about a claim status and having the AI instantly retrieve up-to-date information, even taking action if needed—like issuing a claim adjustment. No more waiting on hold or explaining your issue to multiple agents.

Example: A customer calls about a billing discrepancy. Instead of waiting for an agent to search through files, Agentic AI instantly pulls up the relevant codes, identifies the issue, and even issues a resolution in real-time. The customer walks away with a solution—and a much happier experience.

  1. Predictive Analytics for Proactive Service

What if your insurance company knew your questions before you even asked them? With Agentic AI’s predictive analytics, this can be a reality. By analyzing historical data, AI can anticipate common queries and address them proactively, reducing the need for customers to reach out in the first place.

Example: A customer frequently calls to inquire about their deductible. Agentic AI can recognize this pattern and send automated reminders, offering updates on their remaining balance or changes in coverage, preventing future calls and improving customer satisfaction.

  1. Simplifying Prior Authorization and Claims

Prior authorizations are a major pain point in healthcare. The process is slow, confusing, and often requires multiple touchpoints. Agentic AI is changing that by automating the entire approval process. By accessing medical records, reviewing treatment plans, and cross-referencing approval guidelines, AI can make decisions in real-time, speeding up the process and reducing the waiting period for critical treatments.

Example: Imagine a physician submits a request for a non-standard treatment. Rather than the usual back-and-forth between the payer and provider, Agentic AI can instantly verify if the procedure is covered and approve it on the spot, or request additional documentation if needed. This reduces delays and gets patients the care they need faster.

  1. Streamlining Scheduling and Appointments

Scheduling can be a nightmare, especially when coordinating tests, consultations, or treatments. With Agentic AI, payer contact centers can automate appointment scheduling, integrating with health records and available provider slots. This minimizes scheduling conflicts, reduces human error, and ensures patients are seen at the right time, without the usual back-and-forth.

Example: A patient calls to schedule an MRI. The Agentic AI can access their records, identify the nearest available appointment, and book it on the spot. No need for an agent to step in—everything is handled in real-time. The AI also sends reminders and follow-ups, ensuring the patient never misses their appointment.

The Tangible Benefits of Agentic AI for Healthcare Payers

  1. Cost Savings and Efficiency

Automating routine tasks means fewer agents are needed to handle basic inquiries, which significantly reduces operational costs. With fewer errors and faster resolutions, Agentic AI frees up human agents to focus on more complex issues, creating a leaner, more efficient operation.

  1. Happier Customers and Increased Loyalty

With faster responses, fewer mistakes, and more personalized service, customers will feel more valued and less frustrated. As AI continues to learn and improve, it will drive even greater satisfaction, leading to higher customer retention and reduced churn.

  1. Continuous Learning and Improvement

Agentic AI constantly learns from each interaction, which means its performance improves over time. This ability to continuously adapt and enhance service makes it a long-term solution for evolving customer needs and industry challenges.

The Future is Now

Agentic AI is not just a buzzword—it’s a game changer for healthcare payer contact centers. By automating routine tasks, speeding up prior authorizations, improving scheduling, and proactively engaging with customers, AI is transforming customer service into something faster, smarter, and more efficient. As healthcare organizations continue to adopt these innovations, the results will be clear: reduced costs, improved satisfaction, and a brighter future for both payers and their customers.

It’s important to note that Agentic AI is not a standalone strategy. To be effective in healthcare, enterprises should adopt a hybrid approach that joins AI automation with human intelligence. This human/AI combination can dramatically improve the healthcare experience and drive better outcomes for organizations and customers.

The era of Agentic AI is just beginning, and it’s shaping up to be the healthcare innovation we’ve all been waiting for.


This article originally appeared in Call Center Times.

5 Big Ideas From AHIP 2025 That Will Change Healthcare for the Better

Posted on by rajath neodesynz

By Sohail Djariri

The AHIP 2025 conference brought forward groundbreaking insights that will reshape the future of healthcare for stakeholders. 

Whether you see yourself as a payer, provider, member, or patient, you will be affected by the programs, solutions, and ideas shared at this conference. Many of us fall into one or more of these groups, so understanding where the industry is heading is not only important to our work, but to our everyday lives.

From the rapid integration of AI-driven healthcare to the continuing emphasis on health equity and the importance of chronic disease prevention for people of all ages, healthcare leaders discussed and proposed innovative solutions to these long-standing challenges and many others. 

5 Big Ideas to Improve Healthcare

AHIP 2025 underscored the continuing, positive shift in the healthcare landscape, setting the stage for a more efficient, member-centered system driven by tech-enabled solutions guided by healthcare experts. 

If there was a single concept behind many of the ideas expressed at the event, this is it: Technology when you want it; people when you need them.

My top five takeaways from AHIP 2025 reflect this important concept:

  1. AI & Analytics Are Driving Transformation—But Execution Matters

AI was on everyone’s lips. It’s not just a buzzword; it’s an urgently needed operational enabler. 

But attendees acknowledged that AI alone won’t solve the industry’s challenges or improve the member experience. When we humanize AI, the technology serves health plans, providers, and members while reducing abrasion between each group. To reach this goal, health plans are actively evaluating how AI can automate repetitive tasks, augment decision-making in utilization management and care management, and enhance the member experience through more personalized interactions. 

Industry leaders stressed that AI initiatives must be governed by and aligned with the organization’s strategic initiatives. Many emphasized the need for practical, compliance-friendly AI use cases to demonstrate clear ROI. 

AI hype will no longer work.

  1. Payers Prioritizing Value-Based Care & Behavioral Health Integration

One clear theme was the industry’s efforts to strengthen value-based care (VBC) models, expand access to behavioral health, and integrate physical and mental health services to improve member outcomes and reduce costs. 

Attendees expressed a strong need for scalable behavioral health support, digital mental health solutions, and trusted partners who can bridge care gaps and offer practical solutions.

Success stories highlighted the need for intentional, collaborative payer-provider models to realize the promise of VBC. 

  1. Medicare Advantage Under Scrutiny

Discussions centered on policy shifts impacting health plan Star Ratings, risk adjustments, and access to services by beneficiaries.

Speakers emphasized the continuing need to balance fraud prevention—Medicare Advantage (MA) made improper payments of $19.07 billion in 2024—and preserving MA program value. 

Rising healthcare costs, intensifying enforcement of overpayments by CMS, slowing market growth, and health plans exiting the business altogether are muddling the MA market for those plans that remain.

  1. Holistic Health Approaches Expanding

Sessions on social determinants and “Food as Medicine” were well-attended and demonstrated how plans are addressing care beyond the clinical setting to improve equity and health outcomes. 

There’s a continuing need to help members address care beyond traditional clinical settings, including integrating non-medical “treatments,” such as housing, nutrition, and community support. Each can improve health equity and improve member outcomes when using a holistic approach.

  1. Heightened Focus on Member Experience & Flexible Operations

Payers continue to rank member experience at the top of their strategic priorities list—driven by the need to elevate Star Ratings, meet retention goals, and improve competitive differentiation. Member contact center inefficiencies remain top of mind, while the desire to increase the number of digital self-service options—member portals, chatbots, texting—continues to grow. At the same time, there’s broad interest in flexible outsourcing models that balance cost savings with high-touch services.

The Way Forward

Those of us who are part of the healthcare industry are also part of a defining moment in innovation that emphasizes the growing synergy between technology and human expertise. 

As healthcare continues its shift toward a more efficient system, I’m looking forward to seeing how we can better streamline processes, personalize care, and enhance accessibility. 

I believe the prevailing theme for healthcare—no matter where we end up in the future—must be one where technology serves as an enabler or support system, not a replacement for humans. We’ll find that the best technology innovations are those that empower healthcare professionals to help provide compassionate, informed care.

Sohail Djariri is Chief Growth Officer at Sagility.

How Member Engagement Can Bridge the Gap Between Medication Adherence, Non-Adherence

Posted on by rajath neodesynz

By Sohail Djariri

Creating an empathetic, holistic health plan member experience can drive improved engagement and help resolve the challenges often associated with healthcare. While resolving healthcare issues is critical to a long-term health plan/member relationship, simplifying the entire healthcare system experience, especially for those taking prescription medications should be at the top of the list.

Timely education and intervention can help health plan members understand prescription benefits, medication costs, and the importance of adhering to a medication regimen. This is especially true for older adults and those with chronic conditions.

A tech-enabled, omnichannel approach ensures that members receive information using the real-time method they prefer: chatbot, self-directed website experience, or a phone call with a live agent. These personalized interactions and real-time solutions cater to every member’s unique needs on their schedule.

Adherence challenges and SDOH

While many reasons exist for medication nonadherence—cost, side effects, communication barriers, complex regimens—many adults 65 years and older cite price as a factor. A nationwide survey of more than 2,000 adults 65 years and older found that slightly more than 20% said high cost often prevented them from taking prescribed medications, according to the JAMA Network Open article. (Cost is among the top reasons that people don’t take medicines, according to the American Medical Association.)

Timely education and intervention can help health plan members understand prescription benefits, medication costs, and the importance of adhering to a medication regimen.

Medication nonadherence in older adults is an important challenge that must be addressed by the healthcare industry. Approximately 89% of those 65 years and older take some type of prescription medicine, according to the Kaiser Family Foundation. Depending on age, explains the Foundation, older adults utilize prescription medication at more than ten times the rate of their younger counterparts.

“Notably, among those who report not taking their medicines as prescribed, slightly more than half (53%) say they didn’t tell their doctor or health care provider (11% of the total) and one-fifth (22%) of this group say their condition got worse as a result of not taking their prescription as recommended (5% of total),” according to the Kaiser Family Foundation.

The responsibility to tackle health equity lies with all of us who work in the healthcare industry, as well as local, state, and federal agencies.

Healthcare access and economics can both impact medication adherence and fall under the domain of the social determinants of health (SDOH). Improving access to healthcare and prescription medication should be a high priority for health plans. Doing so can have positive impacts on health plans, including the ability to:

  • Improve member health
  • Increase member loyalty
  • Drive down costs for chronic conditions
  • Make fewer inpatient or emergency department visits

By addressing elements of SDOH, the healthcare industry can get closer to improving health equity for all who participate in the system. A majority of those working in the healthcare industry today say that addressing health equity is critical. “(M)ore than 82 percent of respondents—all of whom work in the health care industry—said that health equity is very or somewhat significant in our health care system today,” according to a Rise to Health Coalition study. “At the same time, less than half of respondents (43.08 percent) said they were either very or somewhat confident the current health care system can effectively address health equity.”

The responsibility to tackle health equity lies with all of us who work in the healthcare industry, as well as local, state, and federal agencies.

Improving member engagement

Older adults appear particularly susceptible to skipping important prescribed medications. Whether it’s cost or a poor understanding of the necessity of the prescription, the healthcare industry must implement programs to address these issues by:

  • Building a holistic, team-driven approach to help remedy the cost issue by guiding members toward pharmaceutical company discounts, offering less expensive options, or providing generic medications to reduce costs.
  • Utilizing omnichannel communications methods to inform members with easy-to-understand information about the importance of medication adherence.

Member experience programs such as these, as well as others designed to improve communication and understanding between the health plan and its customers, should be explored, and implemented. Much of the infrastructure and technology exists and continues to be improved, allowing health plans to impart knowledge using a variety of accessible and cost-effective tools. With a strategic approach, the healthcare industry can make progress quickly and continue to assist in improving the health of older adults.

Aging in Place Programs Drive Health Plan, Member Benefits

Posted on by rajath neodesynz

By Sohail Djariri

Identifying and mitigating frailty in older adult health plan populations through an aging-in-place-as-a-service solution can help health plans holistically approach this challenging issue in the member population.

A comprehensive solution combines all aspects of the program by creating an end-to-end, long-term view of the participant that relies on health data. The program uses participant information and integrates all operational and technological aspects of the aging-in-place program.

Frailty Definition, Health Plan Impact

Frailty is a condition in older adults characterized by an accumulation of deficits and a loss of physiological reserve which causes increased clinical vulnerability. Frail older adults suffer from multiple deficits across issues like weight loss, fatigue, and slow walking.

The physical and psychological effects on members are considerable; the impact on health plans is also substantial.

Cutline: Frailty increases with age. Source: Sagility data analysis.

There are several ways that frailty negatively manifests for health plans:

  • Frailty is an independent factor contributing to a decline in health and higher utilization of healthcare services.
  • The condition is highly prevalent, affecting 17% of those 50 years and older.
  • Early frailty identification and intervention are often overlooked in Medicare and special needs plan members.
  • Physicians rarely code for weakness, failure to thrive, gait issues, and functional deficits, causing a missed opportunity for health plans.
  • Frailty is underreported by 37%, according to Sagility data.
  • Electronic medical records don’t prioritize functional status as a priority field, and hierarchical condition category priorities aren’t directly related to frailty.

Frailty Is a Better Predictor of Long-Term Care Needs

Sagility analyzed Centers for Medicare and Medicaid Services data to understand how the use of certain healthcare modalities in older adults can be used to identify frailty. 

Cutline: Skilled nursing facility and home health cost as a percentage of the total cost of care by frailty indicator. Source: Sagility data analysis.

Cutline: Skilled nursing facility and home health cost as a percentage of the total cost of care by clinical indicator. Source: Sagility data analysis.

End-to-End Frailty Program Components

While frailty is a debilitating condition, modification is possible with early identification and targeted interventions. This is achieved through a whole-person program that includes clinical, community, and member communications. 

A specialized, end-to-end program enables individuals to age on their own terms in their homes. The program should apply evidence-based assessments with specific clinical interventions designed to identify and address frailty. (Most aging-in-place programs are based on disease state and related comorbidities, rather than interventions that focus on frailty.) 

The program elements necessary to launch a holistic approach to aging in place include:

  • Frailty predictive analysis: Frailty is the key leading indicator of diminishing health and risk of falls. Using predictive analytics, health plans can identify and enroll members into a frailty program. Modeling also helps identify those members most likely to engage with the program and benefit from long-term participation.
  • Evidence-based interventions: Validated screening tools, such as the Tilburg Frailty Indicator assessment, should inform interventions, including care coordination services. These services include physical, behavioral, social, and life factors identification and treatment where appropriate.
  • Whole person care approach: This method identifies and addresses the root causes of non-compliance and unhealthy behaviors. It also helps members build resiliency and self-sufficiency.
  • Concierge member engagement: This member-focused approach helps build trust and relationships with members through omnichannel engagement. Member-centric clinicians and advocates bring empathy, listening skills, behavior change expertise, and openness to the program. The team also coordinates health plan benefits, including those provided by Medicare.
  • Technology platform: While much of an aging-in-place program is provided through a person-to-person approach, just as important is the technology. Health plans should use a highly secure platform with a flexible rules engine to allow seamless program updates and changes, as well as clinical content and workflows. Omnichannel member engagement can include email, a portal, text messages, chatbots, and calls.

Bring It All Together

A holistic approach to an aging-in-place program benefits health plans and members by driving financial, operational, business, and health value.

An aging-in-place program offers many important benefits for older adults, care teams, and health plans:

  • Identifies frailty through predictive analytics 
  • Prevents falls 
  • Builds resilience in older adults and supports their caregiving team 
  • Reduces skilled nursing facility admissions and hospital length of stay related to frailty 
  • Uses community partners to deliver home-based care
  • Optimizes coordination of supplementary benefits 
  • Provides clinically evidenced assessments and interventions using a multi-disciplinary team of clinicians
  • Improves Star Ratings

As the number of older adults continues to increase—with nearly 56 million as of the 2020 census—aging-in-place programs with a frailty focus become not only important to this population but mandatory for health plans to remain competitive in the future. 

Why Health Plans Should Take a Page From the Retailer Consumer Engagement Playbook

Posted on by rajath neodesynz

By Sohail Djariri

There are many communication systems and strategies available to healthcare organizations today, yet there remains a significant disconnect between those same organizations and their members. Ongoing distractions from social media, streaming, mobile phones, tablets, and more contribute to the noise and barrier between healthcare organizations and members. 

Breaking through this barrier is difficult for healthcare organizations attempting to share important, member-focused care information, including details about upcoming appointments, and preventive care.

While this quote approaches ways to improve “patient engagement,” health plan member engagement is virtually the same. After all, the patient and the member are the same person. “As individuals and governments invest in new models and initiatives, it’s essential to remember that patient engagement can come in many forms. Meeting patients where they are (virtual, home, clinic) and connecting through their preferred communication channel (patient portal, in-person, digital apps) are critical for facilitating productive and trusted patient–provider relationships.”

The goal of healthcare organizations is creating a long-term, satisfied member who’s on track to improve health and wellness.

Use multiple channels for engagement

With the technology available today, automating engagement is extremely important and easy to accomplish for healthcare organizations. Depending on the messaging—whether it’s information that should be broadcast or personalized—healthcare organizations should look toward:

  • social media platforms
  • AI-powered chatbots (online and phone-based)
  • contact centers 
  • direct-to-member email
  • healthcare-focused online communities
  • text messaging
  • websites and portals
  • e-newsletters

These technologies can automate prescription or vaccine reminders, provide educational content about chronic or acute conditions, and support communications before and after treatment. It’s critical to note that all of these tactics should be viewed as two-way communications; this means any comments posted to social media, text messages, and emails must receive a reply.

(Here’s my earlier article on improving member communication using an omni-channel approach to improve medication adherence.)

Learning from B2C brands

Some healthcare organizations are looking to retail organizations—Amazon, eBay, and others—for ideas to improve member communications. 

“To achieve their consumerism objectives, healthcare incumbents are looking at retail, tech, and other consumer sectors for inspiration to develop innovative solutions to well-known healthcare pain points across the end-to-end healthcare journey and to build trust-based and enduring consumer relationships,” according to a McKinsey article. “Unsurprisingly, consumers regularly point to consumer-focused companies in other sectors as setting an example for healthcare companies. Consumers want healthcare that includes personalized offerings and services, value-based pricing, and an elevated experience—all from distinctive, high-quality brands.”

Retail organizations utilize customer data to track a consumer’s every movement across the internet, allowing them to serve targeted advertising nestled into Instagram and Facebook feeds or employ retargeting advertising on third-party websites. This allows the companies to collect and analyze data relating to consumer activities and fine-tune communications to support conversions. “In every other industry, from social media to gaming to streaming, engagement is well understood and optimized. Companies like Netflix and Meta track daily active users, monthly active users, hours streamed, content clicked, and more to increase member engagement and deliver a personalized user experience that keeps people coming back for more,” according to an article in MedCity News.

The “conversion” health plans would like to enable is that of improved outcomes, member loyalty, and satisfaction with the plan and its offerings.

No matter which communication channel is appropriate for your members, and it will likely be more than one, messaging should be consistent across each to ensure that every participant who receives information—or could receive it—gets advice or recommendations that align with your organization’s mission and program goals. In addition, healthcare organizations must choose the channel that is most engaging for a specific member. If the health plan sends emails, for example, but the member would rather receive text messages, the communication will be ineffective.

“Consumer engagement is a core competency of B2C companies. These companies employ advanced analytics to deeply understand customer needs, develop products and services to meet those needs, and engage (market to) consumers through hyper-personalized messages and content across an array of traditional and digital channels,” according to Next-generation member engagement during the care journey, a McKinsey report.

Finally, IT security practices for all digital outreach must be top-of-the-line, include complementary graphics, and be implemented across all channels to support the healthcare organization and safeguard the trust of members, including the security of all HIPAA information. 

Segment member populations

Health plans must use member data to segment populations in the communication process. This can be done using demographic information, health conditions, claims, communication preferences, and more.

Just as retailers target consumers with messages using data collected from product interactions, healthcare organizations should tailor outbound messages to resonate with an individual member’s health and wellness goals. The communication strategy should focus on specific groups: those with chronic conditions, older adults, or people interested in healthy lifestyle choices, for example.

“Data science and advanced analytics are foundational to all aspects of next-generation member engagement, but this is especially true when it comes to supporting a member during his or her care journey,” according to a McKinsey report. “Advanced analytics enables the swift development of actionable personas (identifiable member segments with distinct known features and preferences).”

Continuous member engagement

The key to improving communication and long-term member engagement is consistency. This consistency is distributed across three areas:

  • messaging
  • channel
  • frequency

“Clearly, there is no monolithic engagement trajectory…. However, an important precursor to improving healthcare is to undertake an engagement-sensitive approach based on…desires and expectations. Failure to recognize and support the…engagement status might result in misalignment patient-provider expectations, dissatisfaction with care, and poor adherence to treatments, which undermine the real translation of the patient engagement goal into practice,” according to research published in Frontiers in Psychology.

When a payer actively manages member communications so that it becomes a reliable way for members to access essential information about their current and upcoming care, maintain health, and receive information about benefits, it will be possible to leap-frog competitors who have yet to implement 21st-century communications practices. 

Sagility Expert Insights: How As-a-Service Solutions Enhance Payer Performance

Posted on by rajath neodesynz

Healthcare organizations face tight budgets, a continued need to increase productivity, lower costs, enhance technology, and reinforce IT infrastructure all while continuing to improve the healthcare consumer experience.

While building and implementing a strategy to holistically address each of these challenges may seem counterintuitive at first, using an as-a-Service process makes it possible to achieve across-the-board advancements and improvements for health plans.

Implementing as-a-Service Solutions

Making modifications like these is a challenge no matter the approach. But using an as-a-Service approach, designed to mitigate the issues that come with organizational change, can help improve overall acceptance.

On February 14, Sagilty hosted a webinar, “Reducing Costs & Driving Innovation through as a Service Healthcare Solutions.” At this session, we explored exactly how payers can use the as-a-Service model to quickly react to business changes, improve consistency across business units and ensure compliance with regulations. This model fully addresses the challenges faced by healthcare organizations.

During the event, Sagility experts detailed how member engagement, claims and provider data management could be upgraded using the as-a-Service framework.

The Sagility experts who participated and shared their expertise:

  • Amitabh Singh, Chief Strategy and Practice Officer
  • Sivarama Rambhatla, SVP and Global Head, Solutions
  • Srikanth “Sri” Lakshminarayanan, SVP, Healthcare Practice

The group offered insights into as-a-Service programs in healthcare and how their use could drive cost reductions and help an organization innovate and build for the future.

Webinar Participant Questions

During the Q and A session, the presenters offered practical insights to help participants understand the model’s benefits and value.

Question: What is BPaaS? Answer: BPaaS is more than the sum of its parts when compared to traditional outsourcing services. BPaaS includes cloud-based technology, people and processes working together toward a common goal expressed by the health plan. BPaaS delivers holistic healthcare services using cloud-based platforms, creates end-to-end benefits to drive cost savings, enhances risk management, and provides access to innovative technology. Sagility’s programs are completely scalable and deliver substantial business outcomes, with up to 45% ROI compared to other Contact Center as a Service providers, for example.

Question: What are the benefits of implementing a BPaaS solution for provider data management?

Answer: Health plans can achieve multiple benefits when implementing Provider Data Management as a Service. The plan can consolidate processes, automate workflow and data comparison, and improve accuracy using analytics and business intelligence. Doing so reduces provider abrasion and helps build member satisfaction.

Question: What’s the best way to implement a BPaaS program?

Answer: Choose the journey that works best for your health plan. We’ve worked with organizations that wanted to experiment with Contact Center as a Service or Claims BPaaS before implementing additional services. They rolled out a pilot program that was expanded in the future. Many have found that adding more as-a-Service modules generates better operational and business results because of the holistic view the technology affords.

Question: What level of support do you expect from the health plan?

Answer: To implement a BPaaS solution, a high level of support is necessary. Typically, a health plan will assign a dedicated person or group to assist. This is important because we must build familiarity with the health plan’s existing technology and understand, at a granular level, all of the business needs and challenges. The health plan also must be highly active in rolling out a change management program for the project because BPaaS touches on areas throughout the health plan, and staff must be made aware of and become comfortable with the upcoming changes. Finally, engendering a trusting relationship between the partners is critical to long-term success.

Question: How long does it take to implement a BPaaS solution?

Answer: Implementations are not one size fits all. It depends on the complexity of the process, the type of health plan, member demographics, change management execution and other considerations. In general, however, an implementation takes six to 12 months.

Participants speak out on as-a-Service solutions

We asked webinar attendees questions about different as-a-Service topics to understand the current state of acceptance in the healthcare market and the challenges they see as most pressing.

What is a key driver for you to consider a Claims BPaaS solution?

  • 0%: Access to better technology
  • 33%: Reduction in per-claim cost
  • 8%: Increase member/provider NPS
  • 59%: All of the above

What are the most important components of an omnichannel CCaaS program?

  • 7%: Scalability
  • 7%: Seamless integration of digital assets
  • 6%: Increased customer engagement
  • 80%: All of the above

What is your organization’s BPaaS readiness?

  • 14%: I would like to learn more about Claims BPaaS
  • 0%: I would like to learn more about Provider Data Management as a Service
  • 72%: I would like to learn more about Contact Center as a Service
  • 14%: I am aware of BPaaS solutions and can make decisions on choosing a partner
  • 0%: Not interested in as-a-Service solutions at this time

Resources

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Fiscal Health for Providers: Precision Cost Takeout in 3 Areas

Posted on by rajath neodesynz

By Titus Leo and Jason Besterfeldt

As today’s hospital margins are increasingly in the red, and health systems are asked to do more with less, all eyes are on cost removal. According to a recent survey on healthcare outsourcing conducted by Black Book Market Research LLC, 90% of healthcare executives are exploring cost savings through relationships with third-party vendors. Here we address three main areas for cost takeout: call center/customer service, AR resolution, and clinical functions.

Call center/customer support: In the past 10 years, providers have responded to consumer demand with more focus on the patient financial journey and a unified, seamless experience.  Omnichannel outreach leveraging both technology and phone conversation are essential to addressing the needs of a diverse patient base.  Technology has improved but the phone calls have suffered since the pandemic because of the labor shortage.  This continues to create problems whether it’s with scheduling, prearrival financial counseling, prior-authorization, or inbound/outbound calls related to patients balance after insurance.  Recent research points to increasing average hold times and the negative impact this has patient satisfaction. 

In this new environment, hospitals and health systems are leveraging RCM services companies to augment and scale their workforce.  These partners bring essential capabilities to improve the patient experience pre-visit but also address essential clinical functions like prior authorizations preventing denials.  These resources can be a mixture of onshore, offshore and nearshore talent who can assist with insurance/support functions, patient calls (both inbound and outbound) as well as provide much needed bilingual support. The review of this process, cost, and scalability can provide substantial operational cost savings, greater operational stability, and an improved patient experience.

Accounts receivable (AR) resolution: Hospitals and health systems are facing increased labor costs and payer requirements while reimbursements have fallen.  Technology has accelerated progress with bots performing  real-time claim statusing, AI driving intelligent workflows, and automation removing highly repetitive/repeatable steps.  With all of these advancements, there is still the need to review, handle exceptions, and write appeals, to maximize reimbursement in a timely manner.  Not only has COVID-19 caused a labor shortage in business offices but the cost of resources has increased at an alarming rate.  According to a recent PWC and Becker’s Hospital Review survey, 83% of respondents reported experiencing labor shortages across the revenue cycle.  Insurance companies have moved many of their calls centers off shore to contain these costs and hospitals are increasingly embracing this move.  Business offices looking to increase capacity, remove cost or mitigate risk are seeing a huge impact as they look to India/Philippines to not only meet the needed scale of their office but, do it at less than half the cost.  The right partner can bring expertise, technology, and visibility to provide confidence for those facilities looking to remove expense from their cost to collect with this approach. 

Clinical support resources: Recent American Hospital Association (AHA) research states that 95% of providers spend increasing time seeking prior authorization approval. The reason for this is often stated as a lack of front-office staff and clinical resources to have payer conversations or improper documentation.  Again technology is assisting here but, the need for resources, especially clinical, are getting expensive and difficult to find.  This presents an opportunity to partner with organizations that have access to clinical resources both here in the US and in the established clinical environment of the Philippines.  The most frequent functions for cost take out are nursing support, case/care management, care coaching, transitions of care, navigating network, case management referral, care plan generation, transport coordination, and remote patient monitoring. With blended delivery models, outside experts can provide the requisite scale and significantly reduce cost. 

From shortening patient appointment hold times to taking the frustration out of prior authorization and billing—the right cost takeout strategies also deliver improvements in patient experience.  As hospitals continue to reduce their cost to collect, they are increasingly turning to RCM service providers for the required scale, cost removal, and risk mitigation.

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