Satish Kumar

Generative AI has the potential to significantly improve many tasks. Still, it is unlikely to entirely replace humans in most fields, particularly in areas that demand emotional intelligence, complex decision-making, and creativity. In talent acquisition, AI can automate and enhance processes, but there are critical areas where human involvement remains essential. Thanks to Mahesh M. Thakur, High Tech Executive Advisor and Coach for this opportunity. It has been a great learning experience.

8

Why are RCM teams & providers losing in the game against insurance conglomerates? Insurers hold several structural advantages in the American healthcare system that contribute to their dominance in the claim denial process: 1. **Complexity and Bureaucracy**: The insurance industry operates with intricate policies and procedures that are often difficult for healthcare providers to navigate. These include specific documentation requirements, coding guidelines, and pre-authorization rules that vary across different insurers and plans. The right way to submit a claim for 1 insurer isn’t the right way to submit a claim for another. The same is true for appealing a claim. It’s a web of permutations and complexity. 2. **Technological Edge**: Insurers are increasingly leveraging advanced technologies such as artificial intelligence (AI) and machine learning (ML) to analyze claims data and identify patterns that suggest potentially non-compliant or fraudulent claims. This allows them to automate the denial process efficiently and at scale. Healthcare providers, while also adopting similar technologies, often lag behind due to the high cost of implementation and integration into their systems 3. **Regulatory Leverage**: Insurers benefit from a regulatory environment that, while intended to curb healthcare costs and fraud, often places a disproportionate burden on providers. Regulations require meticulous documentation and adherence to specific medical necessity criteria, which insurers can use as leverage to deny claims. Moreover, regulatory oversight on insurers' denial practices is relatively limited, allowing them to push back on claims more aggressively without immediate repercussions. 4. **Resource Asymmetry**: Insurers typically have more substantial financial and administrative resources compared to individual healthcare providers or even larger health systems. They can afford to maintain large teams dedicated to scrutinizing claims and managing denials. On the other hand, healthcare providers must allocate their limited resources across various operational needs, making it harder to match the insurers' focus and expertise in claims processing. 5. **Payment Timing and Cash Flow Control**: Insurers control the timing of payments, which can create cash flow challenges for providers. Delays in payments due to denials or prolonged adjudication processes can significantly impact providers' financial stability. Insurers use this leverage to negotiate lower settlements or delay reimbursements, exacerbating the financial strain on providers 6. **Strategic Denial Practices**: Insurers often deny claims initially as a standard practice, knowing that a certain percentage of providers will not have the resources to appeal. This practice reduces their payout obligations. The appeals process itself is time-consuming and costly, discouraging providers from pursuing every denied claim.

1

Navigating the complexities of the US healthcare insurance market is no easy feat. Payers have to manage evolving customer expectations while also focusing on growth. Read the blog to discover how leveraging modern revenue management solutions can help tackle these challenges, streamline operations, and drive sustainable growth. https://lnkd.in/eGTtww7r #ormb #revenuemanagement #betterrevenuemanagement #HealthcarePayers #LegacySystems #StrategicApproach #health #healthcare #healthinsurance #healthindustry #digitalization #billing #billingplatform #pricing #inflation #billingsoftware #healthservices #healthsector #revenuestreams #midmarket #midsizemarket #technology

29

In the age of AI & Automation, things are expected to be simple, straight and super fast. The digitization era bought this opportunity early on provided the industries to modernize but now it is time to maximize that impact from the ground up and translating the result to all the beneficiaries in the value chain. When we had to solve the problem of America being under-insured we had to bring up innovative solution not only to solve the problem but also redefine the process and the rules of engagement with our customers and end users. By doing so and building blocks of successive results will lead us to the goal. That's what we are doing at iCover with our launch of iCover Direct. One Amazing Product that works for the benefit of the end users supported by amazing partners who possess extraordinary values in offering best services. This is a sure set of combo that is to redefine the rules of engagement in our industry. Read more on our new press release featuring Hari S. & Nicole Mwesigwa https://lnkd.in/g5FfJ3cD Jim Sorebo Vijay Lakshmi Narayan S Pranav NS Aakash Easwaran Nandhitha Shanmugam Nivetha Durai #icover #icoverdirect #insurance #insuretech #entrepreneurship

18

1 Comment

The potential for AI to make a big impact in Healthcare has always been huge, and with Gen AI even more so. Check out how we at UHG are making health care smarter for everyone. We have roles open in both Research and Engineering. Join us! Rahul Bhotika Sandeep Dadlani

26

1 Comment

1/3 of Healthcare Customers Likely to Switch Insurers Next Year! (per the report below) “Intensifying competition and ever-expanding consumer choice in the health insurance market are pushing health plans to rethink their approach to member engagement and satisfaction,” the report reads. “Consumers, accustomed to high-touch, personalized experiences in other areas of their daily lives, now expect the same from their health plan. Our survey of 3,500 members reinforced this trend.” My $0.02: Don't ignore fragmented data as a major contributor to Member dissatisfaction. Member data fragmentation can lead to: -Incomplete claim and service history -Incorrect consent and preference data -Misdirected communications and outreach -Unlinked clinical data, contributing to care gaps and duplication. -Disjointed customer experiences across touchpoints   All of this contributes to poor member experience, higher operating costs, care and service gaps, and compliance and risk exposure. Reach out if you want to discuss proven solutions.

8

🌟 Exciting News from the Guidewire Marketplace! 🌟 We are thrilled to announce that ODG for Auto and ODG for Workers' Compensation are now available on Guidewire Cloud through the Guidewire Marketplace. This integration represents a monumental leap in empowering claims professionals with Evidence-Based Medicine and massive datasets. Our goal is to enhance claim outcomes and operational efficiency, all while keeping the patient's well-being as our central focus. 📈 Improve Claim Outcomes 🚀 Gain Operational Efficiency 💙 Patient-Centered Approach Interested in learning more? Reach out to us and discover how we can support your team in making informed, data-driven decisions that prioritize patient care. EvidenceBasedMedicine #ClaimsManagement #PatientCare #Guidewire #ODG #DataAnalytics #HealthcareInnovation

4

Insured losses have topped $100 billion for four years straight. Claims litigation is up 50% while jury awards in excess of $10 million have doubled since 2020. Insurance fraud is now a $300 billion-a-year industry. On an engaging episode of InsurTalk, hosted by Guidewire's Chief Evangelist Laura Drabik, the founder and CEO of Guidewire Insurtech Vanguard and 2023 Pitch Day competitor Charlee.ai, Sri Ramaswamy, casts a spotlight on leveraging AI-based predictive analytics to reverse these costly trends and optimize claims outcomes. Listen now! https://lnkd.in/dxG9a7_c #PandCinsurance #predictiveanalytics

1

Product innovation is crucial for insurance companies and tricky to navigate. Kunal Kapoor shares common roadblocks to look out for and best practices for a successful roll-out. https://lnkd.in/e23zhuwD #Insurance #ProductLaunch #DriveYourBusinessForward

5

Guidewire's Umang Jain and Yoganand Ghati recently collaborated on a Medium blog post, "Organizing Work for Simplicity and Improved Collaboration," to discuss the on-premise-to-cloud journey that Guidewire is making and how program management in its cloud platform engineering team has been instrumental in enabling teams and stakeholders to deliver consistently and predictably. #GuidewireCloud #cloudcomputing #insurance #innovation #insuranceinnovation #insurtech #insurancetechnology #propertyandcasualtyinsurance #development #engineering #software

2

Columbia Insurance Group selected Guidewire to modernize its technology platform to meet its long-term business strategy needs. #GuidewireCloud #insurance #innovation #insuranceinnovation #insurtech #insurancetechnology #pandcinsurance #propertyandcasualtyinsurance #cloudcomputing

1

Insurers are looking to #AI, automation, and advanced analytics to reduce total workload, streamline operations, and deliver greater value. Check out this report from Celent that shares best practices and insights for leveraging tech to modernize an insurance organization. #TeamWDAY

5

In @FiercePharma, my colleague @Stephen Callahan explores the growing impact of specialty benefit management on #pharma. As payers using SBMs report greater cost savings and better clinical outcomes, this trend is likely to continue. Learning how to influence SBMs will become a much larger part of pharma’s #MarketAccess strategy:  https://bit.ly/4c3ZsSq

6

Delivering the right care while avoiding denials and securing revenue is a balancing act. Explore how Sutherland can automate insurance verification and prior authorization tasks to improve the patient experience and increase physician utilization. https://lnkd.in/ei87AAQH #SutherlandHealthcare #Healthcare #Automation

7

Nils Davis, I appreciate you for a great conversation about the current state of product management! Nils put a spotlight on key factors impacting product managers in the B2B space. He also shares what he believes are the essential skills of product management success. It may a surprise to learn that Nils puts a premium on developing soft skills and the ability to communicate through storytelling. Key Take Aways from this episode include: •          Storytelling is Product Management a superpower •          How to avoid the feature factory •          Go-to-Market skills are a key differentiator Don’t miss this episode of GTM Disrupted! Click the link below to listen:  Listen here: https://lnkd.in/gN_jk-QN  #GTMdisrupted #gtmstrategy #prodmgmt #cpo #GTM

10

1 Comment

Greetings, followers! I am thrilled to announce the latest release of Guidewire video from the Product Development and Operations team. An essential watch for anyone eager to understand the profound transformation we're undergoing. Think of this video as the new Bible for all our followers, stakeholders, and potential team members. It encapsulates our vision, our disruptive innovations in the insurance industry, and why now is the perfect time to join us on this exhilarating journey (https://lnkd.in/gqzggFzy) Guidewire is not just adapting to change - we are driving it. The video below showcases the dynamic shift we are orchestrating within the insurance sector. From leveraging cutting-edge technology to implementing customer-centric solutions, we are redefining what it means to provide insurance in the modern world. This transformation is not merely cosmetic, it is a fundamental overhaul aimed at making insurance more accessible, efficient, and transparent. Insurance has long been seen as a slow-moving industry, resistant to change. But we are here to disrupt that narrative. Our innovative approaches are breaking down traditional barriers and setting new standards for the industry. The video highlights our pioneering efforts in areas such as: Cloud, Data, AI, Customer experience, turn around times, security and much more... If you’ve ever contemplated being part of a revolution, to battle test your arsenal. Joining this journey means being at the forefront of change, where your contributions will have a tangible impact. Guidewire offers: Work with some of the brightest minds in the insurance industry Exponential opportunities for professional development and advancement. A workplace that values diversity and fosters collaboration. To our dedicated fandom—this video is a testament to our commitment to excellence and our relentless pursuit of innovation. It’s a call to action for all believers in our mission. We are not just changing the game; we are creating a new one. Your support and enthusiasm fuel our drive, and we want you to be an integral part of this journey. I invite you all to watch this insiders video. Let it inspire you, motivate you, and give you a glimpse into the future we are building. Share it within your networks, engage with us, and let’s make this movement unstoppable. Together, we are not just witnessing history, we are making it. Come, join us, and be a part of something extraordinary. https://lnkd.in/g3vkMzhW #insideguidewrie #innovation #technology #insurance #guidewire

41

Listen Here: https://lnkd.in/gCs-Xy4n In today's podcast, we explore how optimizing provider data management (PDM) is key to boosting operational efficiency for health plans. Parvathy Sashidhar, Senior Director of Product Management for HealthEdge, dives into the common challenges plans face with outdated provider information and how these issues can be mitigated. Learn how advanced PDM solutions can streamline data integration and ensure accurate provider details, ultimately improving care delivery and strategic growth. This episode is sponsored by HealthEdge (https://healthedge.com/). For more information about Becker's Healthcare, please contact Jessica Cole or Scott Becker. #podcast #healthcare #womensleadership #innovationinhealthcare

1