How Hospitals Are Fighting Back Against AI-Driven Claim Denials with Brian Kenah EnableComp TRANSCRIPT

Dr. Jason Tibbels, Chief Medical Officer at Lantern, discusses how healthcare quality measurement has evolved and why specialty care providers need to use patient-reported outcome tools to provide real-time feedback for continuous clinical improvement.  The challenge is to determine whether procedures are clinically appropriate and effective, capture what matters to patients, and document side effects that may occur. Jason draws on his experience at Teledoc Health establishing virtual care quality standards to suggest similar regulatory battles ahead for AI in medicine and the use of AI tools to catch critical details human review alone might miss. Jason explained, "Lantern is the leading specialty care platform for three main areas: surgery, infusion therapy, and cancer care management. It's available through employers, union health funds, and, more recently, even through health plans. And these three categories make up about 50% of employer healthcare spend. So we address that spend by connecting employees, members, or patients with very high-quality care, close to home, at materially lower costs. And today we support about 12 million growing members across about a thousand employers nationwide."   "To me, the modern history of the healthcare quality movement started around the turn of the century. The big To Err Is Human report came out, which at the time estimated that medical mistakes were killing somewhere around a hundred thousand Americans a year, which is like a jet plane crashing every day. A couple of years later, the blueprint for how we should think about quality came out to address safety and effectiveness and patient-centeredness and equity and other domains. And it kind of became the blueprint, but over the next decade, it was really about building report cards. We started seeing hospitals share publicly reported infection rates and a lot of process and infrastructure measures. Around 2012 or so, Medicare started trying to tie payment to those numbers." #LanternCare #HealthcareQuality #PatientReportedOutcomes #HealthTech #AIinHealthcare #ValueBasedCare #SurgeryQuality #SurgicalOutcomes #DigitalHealth #ClinicianInnovation lanterncare.com  Listen to the podcast here

Dr. Jason Tibbels, Chief Medical Officer at Lantern, discusses how healthcare quality measurement has evolved and why specialty care providers need to use patient-reported outcome tools to provide real-time feedback for continuous clinical improvement.  The challenge is to determine whether procedures are clinically appropriate and effective, capture what matters to patients, and document side effects that may occur. Jason draws on his experience at Teledoc Health establishing virtual care quality standards to suggest similar regulatory battles ahead for AI in medicine and the use of AI tools to catch critical details human review alone might miss. Jason explained, "Lantern is the leading specialty care platform for three main areas: surgery, infusion therapy, and cancer care management. It's available through employers, union health funds, and, more recently, even through health plans. And these three categories make up about 50% of employer healthcare spend. So we address that spend by connecting employees, members, or patients with very high-quality care, close to home, at materially lower costs. And today we support about 12 million growing members across about a thousand employers nationwide."   "To me, the modern history of the healthcare quality movement started around the turn of the century. The big To Err Is Human report came out, which at the time estimated that medical mistakes were killing somewhere around a hundred thousand Americans a year, which is like a jet plane crashing every day. A couple of years later, the blueprint for how we should think about quality came out to address safety and effectiveness and patient-centeredness and equity and other domains. And it kind of became the blueprint, but over the next decade, it was really about building report cards. We started seeing hospitals share publicly reported infection rates and a lot of process and infrastructure measures. Around 2012 or so, Medicare started trying to tie payment to those numbers." #LanternCare #HealthcareQuality #PatientReportedOutcomes #HealthTech #AIinHealthcare #ValueBasedCare #SurgeryQuality #SurgicalOutcomes #DigitalHealth #ClinicianInnovation lanterncare.com Download the transcript here

Ross Donahue, Chief Administrative Officer at Guardian Recovery,  highlights the dangerous gap between the time veterans request medical treatment, particularly for mental health and substance abuse issues, and actually receiving the necessary care. Guardian Recovery is addressing the need to treat mental health crises by deploying a 24/7 response with availability of beds and in partnership with other community service providers. Ross emphasizes that veterans are a diverse community, often with multimorbidities, and that reducing delays in accessing care could save lives and prevent cascading consequences. Ross explains, "I think you were spot on with your statement right there, as the veterans are just a great example of an existing problem for every patient: they have a diagnosis, they have a referral, but struggle with getting access to the treatment that they need. So the veterans are a unique population to look at because of the access that they have within the VA system and the mission of the VA system, which is ultimately to help every veteran in need."   "So, the combination of those makes it uniquely frustrating and uniquely poignant to take a look at. The veterans in particular have specialized needs. So, understanding the PACT Act that recently came out, there may be significant toxic exposure, and what those were too, would allow the VA system to deliver some pretty targeted treatment for issues of that nature. Understanding the dynamics of war and combat and associated mental health issues, PTSD, substance abuse, again, allows for very targeted treatment."    #GuardianRecovery #VeteranHealth #MentalHealth #SUDRecovery #HealthcareLeadership #PACTAct #CommunityCare #CrisisResponse #GuardianRecovery #HealthcareAdvocacy #PopulationHealth #VeteransAffairs guardianrecovery.com  Listen to the podcast here

Ross Donahue, Chief Administrative Officer at Guardian Recovery,  highlights the dangerous gap between the time veterans request medical treatment, particularly for mental health and substance abuse issues, and actually receiving the necessary care. Guardian Recovery is addressing the need to treat mental health crises by deploying a 24/7 response with availability of beds and in partnership with other community service providers. Ross emphasizes that veterans are a diverse community, often with multimorbidities, and that reducing delays in accessing care could save lives and prevent cascading consequences. Ross explains, "I think you were spot on with your statement right there, as the veterans are just a great example of an existing problem for every patient: they have a diagnosis, they have a referral, but struggle with getting access to the treatment that they need. So the veterans are a unique population to look at because of the access that they have within the VA system and the mission of the VA system, which is ultimately to help every veteran in need."   "So, the combination of those makes it uniquely frustrating and uniquely poignant to take a look at. The veterans in particular have specialized needs. So, understanding the PACT Act that recently came out, there may be significant toxic exposure, and what those were too, would allow the VA system to deliver some pretty targeted treatment for issues of that nature. Understanding the dynamics of war and combat and associated mental health issues, PTSD, substance abuse, again, allows for very targeted treatment."    #GuardianRecovery #VeteranHealth #MentalHealth #SUDRecovery #HealthcareLeadership #PACTAct #CommunityCare #CrisisResponse #GuardianRecovery #HealthcareAdvocacy #PopulationHealth #VeteransAffairs guardianrecovery.com Download the transcript here

Andy Parham, Chief Executive Officer at Brado AI,  has developed an AI platform that acts as an orchestration layer between patient demand and health system capacity.  The platform uses conversational AI and precision routing to match patients to the appropriate provider, reducing time to reaching the correct treatment. Utilizing this approach also provides an opportunity to optimize the use of existing clinical resources, enabling providers to work more productively without requiring additional hiring or infrastructure. Andy explains, "We think of our platform as the orchestrator layer that sits between demand for healthcare and supply. When we talk about the demand side, we observe that demand is very unstructured. To your point about a person going a long time dealing with symptoms, not knowing exactly what's happening and not knowing where to turn, that's where we meet people. What we have found is that we're able to significantly reduce the time it takes for a person to get to the right care."   "Also from a health system perspective, we're able to reduce the number of consultations before seeing the right provider. One of our clients, I was speaking with one of the chief operating officers of one of the health systems that we work with, and in our first year of deployment, he told me that we've reduced the number of consultations before seeing the right provider and getting the right care by 4X in the first year."  #BradoAI #DigitalHealth #HealthIT #PatientAccess #HealthcareInnovation #HealthcareAI #PatientEngagement #HealthTech #ProviderSatisfaction #PrecisionRouting #CapacityOptimization brado.ai Listen to the podcast here

Andy Parham, Chief Executive Officer at Brado AI,  has developed an AI platform that acts as an orchestration layer between patient demand and health system capacity.  The platform uses conversational AI and precision routing to match patients to the appropriate provider, reducing time to reaching the correct treatment. Utilizing this approach also provides an opportunity to optimize the use of existing clinical resources, enabling providers to work more productively without requiring additional hiring or infrastructure. Andy explains, "We think of our platform as the orchestrator layer that sits between demand for healthcare and supply. When we talk about the demand side, we observe that demand is very unstructured. To your point about a person going a long time dealing with symptoms, not knowing exactly what's happening and not knowing where to turn, that's where we meet people. What we have found is that we're able to significantly reduce the time it takes for a person to get to the right care."   "Also from a health system perspective, we're able to reduce the number of consultations before seeing the right provider. One of our clients, I was speaking with one of the chief operating officers of one of the health systems that we work with, and in our first year of deployment, he told me that we've reduced the number of consultations before seeing the right provider and getting the right care by 4X in the first year."  #BradoAI #DigitalHealth #HealthIT #PatientAccess #HealthcareInnovation #HealthcareAI #PatientEngagement #HealthTech #ProviderSatisfaction #PrecisionRouting #CapacityOptimization brado.ai Download the transcript here

Brian Kenah, Chief Technology Officer at EnableComp, specializes in complex claims and has developed an AI plaform boosting efficiency and quality by incorporating new codes and regulatory changes while learning from approval and denial patterns.  The ability to deliver predictive revenue intelligence enables hospitals to identify issues before claims are submitted, prevent denials and negotiate better payer contracts using data-driven insights. The need for this solution is in part a result of the use of AI by payers which have increasingly deployed AI to accelerate claims denials and rigorously enforce contract terms. Brian explains, "We're seeing a number of different mechanisms right now. I think one of the things is that as AI gets a little bit more intelligent, there's a lot more focus on the actual terms, terminology, the CPTs, the fee schedules. They are being a lot more judicious about what's actually passed into them and what they're accepting as viable services offered under the payer-provider contract. So what we're seeing is an influx of those claims being denied that aren't following those contracts, fee schedules, regulations, and payer rules, and all the other stuff to the letter."   "I think it runs the gamut. I mean, it could be anything from clinical, it could be administrative, it could be state rules. It's a number of different things that are all sort of compounding all at the same time. In the meantime, you have providers that are trying to adapt and adopt as they're moving along here, and that's where the provider side of the equation is looking to adopt some of the same tool sets, just on the provider side instead of on the payer side." #EnableComp #HealthcareFinance #RCM #RevenueCycleManagement# #HospitalAdministration #HealthcareAI #DigitalHealth #HealthcareTechnology enablecomp.com Listen to the podcast here

Brian Kenah, Chief Technology Officer at EnableComp, specializes in complex claims and has developed an AI plaform boosting efficiency and quality by incorporating new codes and regulatory changes while learning from approval and denial patterns.  The ability to deliver predictive revenue intelligence enables hospitals to identify issues before claims are submitted, prevent denials and negotiate better payer contracts using data-driven insights. The need for this solution is in part a result of the use of AI by payers which have increasingly deployed AI to accelerate claims denials and rigorously enforce contract terms. Brian explains, "We're seeing a number of different mechanisms right now. I think one of the things is that as AI gets a little bit more intelligent, there's a lot more focus on the actual terms, terminology, the CPTs, the fee schedules. They are being a lot more judicious about what's actually passed into them and what they're accepting as viable services offered under the payer-provider contract. So what we're seeing is an influx of those claims being denied that aren't following those contracts, fee schedules, regulations, and payer rules, and all the other stuff to the letter."   "I think it runs the gamut. I mean, it could be anything from clinical, it could be administrative, it could be state rules. It's a number of different things that are all sort of compounding all at the same time. In the meantime, you have providers that are trying to adapt and adopt as they're moving along here, and that's where the provider side of the equation is looking to adopt some of the same tool sets, just on the provider side instead of on the payer side." #EnableComp #HealthcareFinance #RCM #RevenueCycleManagement# #HospitalAdministration #HealthcareAI #DigitalHealth #HealthcareTechnology enablecomp.com Download the transcript here

Jeanne Vennella, Clinical Strategy Director at Canopy, shines a light on workplace violence in healthcare and the need to recognize the problem and implement solutions to reduce risk. The majority of violent incidents originate with patients, families, and visitors, often triggered by poor communication and the stress of receiving difficult news. Canopy offers a wearable duress button worn behind a staff member's ID badge, allowing discreet and immediate alerts to security and providing actionable intelligence to enable proactive security measures. Jeanne explains, "Workplace violence has been an issue in healthcare almost as long as my career. And as we discussed, my career is very lengthy. I've been both a pediatric and emergency nurse, certified and adult certified, for nearly 40 years now. I think workplace violence remains persistent because, first off, the public is unaware of what's happening inside the healthcare walls or in the parking lots, as recent events have shown us." "But when I discuss in the public or in my suburban neighborhoods the fact that nurses are five times more likely to be injured at work than a police officer or a sheriff's officer, people are appalled and disbelieving of those statistics. But there is kind of a closed system on healthcare and violence, and it really isn't permeating the public. I think it remains a persistent problem because there are no federal policies or laws protecting healthcare workers."  "Canopy is a wearable duress button for staff members, which I like to say is kind of like a lifeline or an airbag. The employee has it assigned to them. They wear it behind their ID badge. It stays on their body from car to car to car when the organization is really covered in their parking lots and in their public spaces, in addition to their hospital."  #CanopyWorks #WorkplaceViolence #HealthcareSafety #NurseSafety #HospitalSecurity #PatientSafety #HealthcareLeadership #StaffRetention #WearableTech #ClinicalStrategy #DeescalationTraining #DataDrivenSafety #HealthcareTechnology #SaferStaffBetterOutcomes  Canopyworks.com Listen to the podcast here

Jeanne Vennella, Clinical Strategy Director at Canopy, shines a light on workplace violence in healthcare and the need to recognize the problem and implement solutions to reduce risk. The majority of violent incidents originate with patients, families, and visitors, often triggered by poor communication and the stress of receiving difficult news. Canopy offers a wearable duress button worn behind a staff member's ID badge, allowing discreet and immediate alerts to security and providing actionable intelligence to enable proactive security measures. Jeanne explains, "Workplace violence has been an issue in healthcare almost as long as my career. And as we discussed, my career is very lengthy. I've been both a pediatric and emergency nurse, certified and adult certified, for nearly 40 years now. I think workplace violence remains persistent because, first off, the public is unaware of what's happening inside the healthcare walls or in the parking lots, as recent events have shown us." "But when I discuss in the public or in my suburban neighborhoods the fact that nurses are five times more likely to be injured at work than a police officer or a sheriff's officer, people are appalled and disbelieving of those statistics. But there is kind of a closed system on healthcare and violence, and it really isn't permeating the public. I think it remains a persistent problem because there are no federal policies or laws protecting healthcare workers."  "Canopy is a wearable duress button for staff members, which I like to say is kind of like a lifeline or an airbag. The employee has it assigned to them. They wear it behind their ID badge. It stays on their body from car to car to car when the organization is really covered in their parking lots and in their public spaces, in addition to their hospital."  #CanopyWorks #WorkplaceViolence #HealthcareSafety #NurseSafety #HospitalSecurity #PatientSafety #HealthcareLeadership #StaffRetention #WearableTech #ClinicalStrategy #DeescalationTraining #DataDrivenSafety #HealthcareTechnology #SaferStaffBetterOutcomes  Canopyworks.com Download the transcript here