M&A: Olive Acquires AI Prior Authorization Company Verata Health

Olive Acquires AI Prior Authorization Company Verata Health

What You Should Know:

– On the heels of $225.5 million dollars in funding and a
$1.5B valuation this week, Olive today announced its acquisition of Verata
Health to create a combined AI prior authorization solution for providers and
payers under the Olive name.

– Prior authorization is a $31 billion dollar issue in
healthcare, and one of the top reasons patient care is delayed. Olive is now
able to reduce write-offs by over 40% and cut turnaround times for prior
authorizations by up to 80%, ultimately offering hospitals $3.5 million in
savings.


Olive today, announced
the acquisition
of Verata Health to solve prior
authorizations for providers and payers via artificial
intelligence
as a combined solution under the Olive name. The acquisition
follows Olive’s recent $225.5 million financing round to bolster the company’s
R&D war chest and drive the growth of Olive’s AI workforce for providers
and payers. With Olive’s recent momentum, Verata’s suite of AI tools will
deepen Olive’s impact as it automates the $31 billion problem of prior authorizations
in healthcare.

Leverage Powerful Prior Authorization AI

Verata is a leading healthcare AI company, enabling
Frictionless Prior Authorization® for providers and payers. Seamlessly
connected to the nation’s top electronic health record
(EHR)
systems, Verata’s AI technology automatically initiates prior
authorizations, retrieves payer rules, and helps identify and submit clinical
documentation from the EHR.
When payers leverage its AI platform, Verata enables point-of-care
authorizations for providers and patients, dramatically accelerating access to
care.

Solving the $31B Prior Authorization Burden

Prior authorizations were the most costly and time-consuming transactions for providers in 2019 and are among the top reasons patient care is delayed. As cash-strapped hospitals and health systems strive to meet patient, payer, and provider needs, the demand for AI technologies to increase efficiency and improve the patient experience has become critical. To help improve patient access to care and remedy the $31 billion prior authorization challenge, Olive and Verata’s combined prior authorization solution streamlines the process for providers, patients, and payers by reducing write-offs by over 40% and cutting turnaround time for prior authorizations by up to 80%.

Acquisition Will Provide End-to-End Prior Authorization

By integrating Verata’s solution, Olive is able to provide customers with a true end-to-end prior authorization solution. The solution starts with determining if an authorization is required, includes touchless submission of the prior authorization request, ends with automating denied claim appeals, and grants hospitals a 360-degree view of their authorization performance. This means patients not only get the care they need faster but also eliminates confusing bills patients receive post-service stating their claim has been denied by their insurance.

As part of the acquisition, more than 60 Verata employees
will join the Olive team following the acquisition, bringing Olive’s total
employee count to approximately 500. Olive’s senior executive team will
continue to grow as well:

– Lori Jones, Chief Revenue Officer, will retain her title
and will also take on the role of President, Provider Market

– Dr. Jeremy Friese, Chief Executive Officer at Verata, will
join Olive as President, Payer Market

– Dr. YiDing Yu, Chief Medical Officer at Verata, will
become Olive’s Chief Medical Officer

“A broken healthcare system is one of the biggest challenges humanity faces today and prior authorization issues, in particular, are costing our nation billions of dollars. After partnering with Verata earlier this year, we saw incredible potential for Verata’s technology to reduce the amount of time and money spent on prior authorizations, and to eliminate delays in patient care,” said Sean Lane, CEO of Olive. “This acquisition allows Olive to accelerate innovation in areas where we can drive the biggest impact, and further expands our solutions to providers and payers seeking to transform healthcare.”

Financial details of the acquisition were not disclosed.

Humana Taps Cohere Health to Modernize Prior Authorizations for Musculoskeletal Treatment

Cohere Health Launches with $10M to Increase Transparency Across Care Journey

What You Should Know:

– Cohere Health partners with health insurer Humana to modernize
the prior authorization process for musculoskeletal treatment across 12 states.

– In addition, the company has closed an additional $10M
in funding led by Flare Capital Partners and Define Venture, bringing the
company’s total funding to $20M.


Health insurer Humana has signed an agreement with healthcare collaboration company Cohere Health to improve the prior authorization process for musculoskeletal treatment across 12 states, starting Jan. 1, 2021. Cohere aligns physicians, patients, and health plans on a patient’s optimal healthcare experience—enabling access to higher quality care while at the same time minimizing administrative burden and siloed decision-making.

The partnership leverages CohereNext Platform’s prior authorization capability which grants authorizations across an entire episode of care, in effect pre-authorizing a complete treatment regimen from the initial diagnosis to treatment plan selection, and, ultimately, to the patient’s return to good health. Cohere’s approach aims to expedite evidence-based treatment plans to improve the healthcare experience for doctors and patients alike.

Humana to Leverage CohereNext Platform to Streamline
Prior Authorizations

As part of the partnership, Humana will employ the CohereNext Platform to streamline prior authorizations in musculoskeletal treatment in Alabama, Georgia, Indiana, Kentucky, Michigan, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia. The platform will initially serve approximately 2 million members and more than 3,500 physician practices.

This partnership supports Humana’s vision to reimagine and modernize processes for prior authorization by reducing approval times and improving the delivery of care, all while preserving important benefits such as safety, predictability, and cost containment.

Cohere’s solution will initially focus on prior
authorization; the company is developing additional use cases such as
value-based contract performance, improving physician and patient engagement,
and optimizing health plan clinical programs. By facilitating physician and
health plan collaboration, Cohere’s technology will help accelerate the
evolution to value-based care models.

“Through this strategic initiative and collaboration with Cohere Health, Humana is building on its commitment to reduce the complexity and friction of prior authorization for our physicians and members,” said William Shrank, MD, MSHS, Chief Medical Officer, Humana and Board Member, Cohere Health. “Cohere’s solution was co-designed with physicians and represents a major leap forward in improved physician experience and the adoption of evidence-based medicine.”


Cohere Health Closes Additional $10 Million in Funding to
Accelerate Delivery of Patient Journey Platform

In addition, the company announced it closed an additional
$10 million in funding led by Flare
Capital Partners
and Define Ventures,
bringing the company’s total funding to $20 million. The funding will be used
to enhance the company’s scalable CohereNext® platform that is built on
next-generation cloud and data technologies and provides interoperability to
existing healthcare infrastructure as well as the emerging digital health
economy.

This
Series A extension comes just two months after Cohere Health’s initial $10 million Series
A funding, which was also led by Flare
Capital Partners with Define Ventures contributing as an investor and partner,
as well as participation from a leading national strategic partner.

The CohereNext Platform improves the physician experience
and quality by:

– Authorizations that begin with diagnoses and not billing
codes

– Facilitating and auto-approving evidence-based treatment plans

– Delivering a peer review process with a true peer
specialist or sub-specialist

– Sharing quality performance relative to peers for specific
care paths and patient cohorts

– Providing tools, data and technology that optimizes
value-based payment

“The tragedy of COVID-19 has reinforced that the basic infrastructure supporting healthcare innovation is fundamentally broken. The shift from fee-for-service to value-based-care requires enabling interoperable capabilities to facilitate care around the interests of patients, and as a result, Cohere Health continues to rapidly grow and attract additional investments,” said Siva Namasivayam, CEO and founder of Cohere Health. “The additional funding will enable us to expand the CohereNext platform to impact more failure points across patient journeys so that physicians can deliver better outcomes and we can continue building our team, which has grown by more than 95 people this year.”

The problem with prior authorization

Prior authorization is a requirement that health plans require physicians to obtain plan approval in order to prescribe a patient a given medication. Prior authorizations may be put in place to insure medications are not used inappropriately or for payers to try to reduce cost. While prior authorization may help save money, delays in the prior authorization approvals frustrate patients and clinicians. ICER reports:

… a 2018 Physician Survey conducted by the AMA on prior authorization found that 65% of providers had to wait, on average, at least one business day within the past week before receiving a prior authorization decision from a health plan and 26% of providers waited three business days or more. It should also always be remembered that prior authorization protocols impose an administrative burden on patients and clinicians that can, by itself, pose a risk to fair access. Clinicians have cited the burden of prior authorization as one of the leading causes of burnout.

An AMA survey states that 24% of physicians report that a PA has lead to a serious patient adverse event. Below are some statistics from the 2019 AMA PA Physician Survey.

Sources:

Waystar Acquires Medicare RCM Company eSolutions at $1.3B Valuation

Waystar Acquires Medicare RCM Company eSolutions at $1.3B Valuation

What You Should Know:

– Revenue cycle management provider Waystar acquires eSolutions, a provider of Medicare and Multi-Payer revenue cycle management, workflow automation, and data analytics tools at a $1.3B valuation.

– The acquisition will create the first unified
healthcare payments platform with both commercial and government payer
connectivity, resulting in greater value for providers.


Waystar, a provider of healthcare payments software, today
announced a definitive agreement to acquire Francisco Partners-backed eSolutions, a revenue cycle
technology company with unique Medicare-specific solutions at a $1.3B valuation,
according to sources close to the deal. In bringing these two industry leaders
together, Waystar will be the first technology to unite both commercial and
government payers onto a single payments platform. The transaction is expected
to close later this year, subject to customary conditions and approvals.

eSolutions Background

Founded in 1999, eSolutions’ technology maximizes revenue
collection, accelerates cash flow, and reduces administrative burden across
numerous sites of care. The company has over 6,000 payer connections and
maintains a powerful and growing data set of billions of transactions. In addition
to hospitals and ambulatory providers, eSolutions has deep expertise in serving
the post-acute market across the entire revenue cycle, including skilled
nursing, senior living facilities, home care, hospice, federally qualified
healthcare centers (FQHCs), and durable medical equipment providers. eSolutions
is backed by Francisco Partners.

“eSolutions is thrilled to be joining forces with Waystar, a company like ours that relentlessly focuses on delivering exceptional customer service,” said Gerry McCarthy, Chief Executive Officer of eSolutions. “The combination of our technology platforms and data solves a major pain point in revenue cycle management to drive stronger results for our clients, partners, and for healthcare.”

Acquisition Creates Unified Healthcare Payments Platform 

Medicare has become the largest payer in the United
States and as baby boomers age, the mix of insurance coverage is
increasingly shifting to Medicare. Historically, providers have had to leverage
two different systems – one to handle commercial claims, and another to handle
Medicare. For healthcare providers, leveraging a single, end-to-end platform to
manage both private and government payments solves a major pain point and
creates significant efficiencies, freeing up time to deliver care.

“Together, Waystar and eSolutions will deliver unprecedented innovation to the industry, helping healthcare organizations accelerate revenue collection while reducing administrative expenses and repetitive tasks,” said Matthew Hawkins, Chief Executive Officer and board member of Waystar. “Uniting our companies’ data sets will further power Waystar Hubble, our artificial intelligence solution, providing access to even greater insights and value for our clients. We have long-admired eSolutions for its unique Medicare-specific revenue cycle capabilities, which are a perfect complement to the Waystar platform. We are excited to move forward as one team.”

6th Waystar Acquisition Since 2018

Waystar has integrated several other transformational
technologies onto its single instance cloud-based platform since uniting
Navicure and ZirMed in 2017. This marks Waystar’s sixth acquisition in the last
couple years, as the company rapidly expands within the space (not including
their own $2.3B acquisition by two private equity firms last year). 

Recent acquisitions include Recondo, a patient estimation and prior authorization
technology, PARO, a presumptive charity scoring solution, UPMC’s Ovation, a claims monitoring tool, and Connance, leveraging predictive analytics to offer agency
manager, advanced propensity to pay (AP2P), and presumptive charity. Waystar is
backed by EQT, Canada Pension Plan Investment Board, and Bain Capital.

How Times of Crisis Spur Needed Change in Healthcare Delivery

How Times of Crisis Spur Needed Change in Healthcare Delivery

As the COVID-19 pandemic continues to change healthcare operations in the world, foundational systems are being adapted to meet these new demands. Sometimes it takes extreme circumstances to see the cracks in a system. COVID-19 has exposed areas with more room for improvement in the healthcare system, such as optimizing operational efficiency. Organizations and individuals have changed their interactions, processes, ways of working, treatment plans, and even foundational technology. As the United States is beginning to reopen, many questions arise – namely, are these changes temporary fixes during the pandemic, or are they here to stay?

Physicians have been inundated during this time of crisis, and their ongoing main priorities amplified: saving as many lives as possible and providing the best patient care. Recent estimates from the beginning of July say, worldwide there have been more than 10.7 million COVID-19 cases and at least 516,000 deaths from the disease, according to Johns Hopkins University (JHU). JHU also revealed that in the United States, there have been 128,000 deaths out of a total of over 2.6 million cases. To say this has been a time of great stress and pressure for physicians who are on the frontlines is an understatement.

This pandemic has increased providers’ already heavy workload, amplifying where physicians need support. Patients need to remain the top priority, even in the first generations of the digital age where the list of backend administrative tasks and paperwork can feel endless, thus reducing the number of patients physicians can see each day. Finding a way to streamline administrative tasks with advanced technology can bring physicians back to why they went to medical school in the first place: to help patients.

One example of an important, and time-sensitive task is communicating with payers around treatment plans and reimbursement. Using technology to streamline this process to get the patient the optimal treatment and maximize use of their insurance coverage is essential, especially in this time of crisis where there is an increased number of patients in need and a depressed economy. Whether processing prior authorizations or checking eligibility, hospitals and health systems need technology to keep operations efficient, including smooth payer-provider communication to ease physicians’ workload, help to ensure providers will be reimbursed for care, and optimize business operations, ultimately providing an improved patient experience.

Three foundational ways in which payer-provider information exchange technology provides immense value to healthcare organizations are:

– Creating Administrative Efficiency: To help physicians stay focused on patients, administrative efficiency is key. Solutions can come in many shapes and sizes – technology can help to automate workflows and avoid care delays. Modernizing the prior authorization workflow can shorten average time to care, reduce the risk of treatment abandonment, and improve the quality of care. With changing legislation, updated laws encourage the use of technology to increase efficiency while keeping data secure in near real-time exchanges.

– Streamlining Exchange of Information: Interoperability and the technology standards needed to achieve it is an ongoing discussion in healthcare. Technologies that provide efficient, secure, and near real-time and even automated exchange of information are in high demand and will bring about the next era of healthcare. For example, technology has the power to align providers and payers efficiently and consistently, create an open exchange of information, centralize information, provide rapid and organized data transfer, ensure appropriate reimbursement by treatment plan, show pre-authorized treatment plans for the most successful and affordable care and aid health plans’ adaptability in health crises, like COVID-19.

– Increasing Value-Based Care: Optimizing the quality and cost of patient care is a leading principle of healthcare. The COVID-19 pandemic has exposed areas of healthcare where improvements in patient experience and provider reimbursement desperately need to be accelerated. Using technology with built-in normative databases of accepted treatment paths allows for evidence-based treatment decisions, which in conjunction with efficient payer-provider communication to ensure reimbursement, allows for optimal patient outcomes – creating value for all stakeholders.

Adopting technology to provide administrative efficiency, streamline information exchange and increase the value of all aspects of care will continue to be a fundamental pillar of healthcare; the pandemic has ignited a critical need for even faster change. COVID-19 has brought with it increased stress and uncertainty across the healthcare industry, amplifying the burden on physicians and their staff. Organizations have moved quickly to adopt technologies, such as those that provide a more efficient way to organize and analyze massive amounts of treatment plan decision inputs and aid communication between stakeholders, in order to better support physicians, and ultimately patients.

Tools and technology that automate processes, streamline communications and provide dynamic solutions have proven their value and are now “need to have” rather than “nice to have” for providers. These technologies are foundational to the healthcare system, providing the base from which all stakeholders operate. The pandemic has helped to realize the true value of efficiency technologies, galvanizing the adoption of these tools. Ultimately, more operational efficiency can bring the focus of care back to the patient.

About Christina Perkins

Christina Perkins is VP of Product Management and Strategy for NaviNet at NantHealth. She joined NaviNet in 2003 and has spent the last 17 years expanding the company’s products and services. Prior to joining NaviNet Christina spent seven years designing and building web-based solutions for Partners Healthcare and other hospitals in the Northeast U.S. and Ontario, Canada. Christina on LinkedIn.

Cohere Health Launches with $10M to Increase Transparency Across Care Journey

Cohere Health Launches with $10M to Increase Transparency Across Care Journey

What You Should Know:

– Boston-based health IT start-up Cohere Health announced the official launch of its company with a $10 million Series A funding round led by Flare Capital Partners.

– The company’s patient journey-focused platform improves the notoriously difficult prior authorization process and replaces an existing patchwork of legacy, siloed processes, and antiquated technologies that contribute to the enormous administrative burden for physicians and health plans.

– The end goal is transparent, high-value care alignment across the entire patient care journey, to improve the quality of care delivered, the lower total cost of care, and transform the patient and physician experience.


Cohere Health, a
Boston, MA-based health
IT
startup,
today announced its company launch, with the mission of aligning the
relationship between physicians and health plans around the care journey in a
way that is appropriate for each patient. Cohere Health’s launch is
flanked by the news of its recent $10 million Series A funding round led by Flare Capital Partners, with Define Ventures as an investor and partner
as well as participation from an additional leading national strategic partner.

Every Health Journey Should Be A Win-Win-Win

Confusion and complexity shouldn’t define a patient’s journey. Patients deserve clearer paths to health, more transparency, and fewer bumps on the way. Assessing every transaction without any context creates an undue burden for physicians and health plans alike. Administrative complexity should never stand in the way of patient care.

Led by Co-Founder and CEO Siva Namasivayam, Cohere Health aims to improve the quality of care delivered, the lower total cost of care, and transform the patient and physician experience. Cohere’s patient journey platform, CohereNext replaces the existing patchwork of legacy, siloed processes, and antiquated technologies that contribute to enormous administrative burden for physicians and health plans. It further facilitates the transition from fee-based services to value-based arrangements by providing an evolutionary path that can support all payment arrangements while reducing unnecessary variation in clinical outcomes.

Benefits of Care Journey Recommendations

Cohere leverages care journey recommendations to fundamentally change the healthcare system through:

Evidence-based care paths: increase transparency and trust among patients and their physicians.

Advanced analytics and rules: help identify high-value care and, ultimately, improved outcomes

Payments and incentives: incentivize physicians by ensuring that behavior leading to optimal patient outcomes also benefits practice economics

Proven Leadership Team

Cohere Health has assembled an impressive team of proven
leaders, including Gary Gottlieb, MD, former CEO of Partners Healthcare (now
MassGeneral Brigham) as Chairperson of the Board of Directors. “As a physician,
it’s clear to me that the administrative complexity of the current system gets
in the way of delivering the care that patients deserve, that physicians want
to provide, and that health plans want for their members,” Gottlieb said. “If
we’re going to realize the promise of value-based care, we need an approach
that is based on all available evidence, shared expectations and transparency.”

Siva Namasivayam, CEO of Cohere Health, explained: “The current system is resource-intensive, unwieldy and creates a frustrating experience for patients, physicians and health plans. There’s no reason it should be so miserable for everyone involved. We have the evidence-based clinical algorithms, human-centered design and innovative technology to improve the system dramatically.” Namasivayam, who has more than 20 years of experience working on transformational healthcare businesses, was previously the CEO/Founder of SCIO Health Analytics.

4 Ways Healthcare Organizations Can Establish Partnerships to Drive Innovation

Nebraska Medicine’s experience points to four ways healthcare organizations can establish partnerships with vendors that drive innovation and performance excellence.

With public and private healthcare spending significantly outpacing that of other countries, U.S. hospitals face intense pressure to find new ways to capture greater value. More and more, organizations are finding that partnerships with existing vendors can help unlock next-level performance gains in a transformative environment.

Take Nebraska Medicine, for example. In the early 2000s, the health system created multidisciplinary committees to boost revenue integrity and adopted new revenue cycle management processes that strengthened performance—with strong results. But best practices alone are no longer enough to fuel revenue cycle gains at a time of decreased reimbursement, rising out-of-pocket costs, and staffing issues. “You’ve got to be able to get to the data,” says Jana Danielson, Executive Director, Revenue Cycle for Nebraska Medicine—a $1.8 billion academic medical center with two hospitals, ~450 revenue cycle staff, 913,000 hospital billing claims, and 1.6 million physician billing claims per year. 

“Without real-time access to data and data analytics, revenue cycle teams risk making decisions based on emotions, not facts,” Danielson says. “Our partnership with a vendor enables our revenue cycle team to more effectively use data to identify our pain points and empower team members to take the right steps for improvement.”  

Nebraska Medicine’s experience points to four ways healthcare organizations can establish partnerships with vendors that drive innovation and performance excellence.

1. Look for a partner that will challenge your assumptions around performance

The right partner will dig deeper, not only tracking key performance indicators (KPIs) but also taking a hard look at how these KPIs were calculated. 

For example, in revenue cycle management, there are many ways to track clean claim rates, a measure that reflects the quality of claim data that is collected and reported. Some organizations consider a clean claim rate to be the percentage of claims accepted by the payer on the first pass. Others calculate it as the percentage of claims that pass through the organization’s billing department without manual intervention before being submitted to the payer. Depending on how this metric is calculated, sometimes a percentage that seems to indicate above-average performance in comparison with peers may not reflect breakdowns in processes that have occurred before a claim is submitted.

At first glance, Nebraska Medicine’s clean claim rate in 2017 was strong: 

95.87 percent for a physician billing and 87.59 percent for hospital billing. However, using claims analytics, the health system uncovered a hidden challenge. Some billers were bypassing the claim edits. In those instances, claims were being submitted before corrections were made. The result: a lower-than-expected clean claim rate. 

Nebraska Medicine’s revenue cycle leaders worked with the organization’s vendor to tackle this challenge. The revenue cycle department developed scorecards by individual employees that showed their performance against key metrics, including their rate of bypassed edits, and reiterated expectations for revenue cycle processes. Within three months, the number of bypassed edits significantly decreased. Today, Nebraska Medicine’s clean claims rate averages 93.78 percent—well above the industry standard—for more than 900,000 hospital claims per year.

EXHIBIT ONE:

At Nebraska Medicine, Reduction in Bypassed Claim Edits Drives High Clean Claims Rate 

2. Make sure the vendor has both product knowledge and operational expertise

Many vendors make the business case for partnership based on the quality of their product or system, such as a 99 percent clean claim rate or a 3 percent denial rate. Some back up their product expertise by regularly working with clients to optimize their use of a technology or service—and it’s a solid step toward a true partnership.

But the best vendors also commit to understanding the context in which their products or services are used in your organization. They examine your team’s work processes and draw upon their operational expertise to make suggestions for improvement, even when the modifications they propose fall outside their paid relationship with your organization.

Consider that 90 percent of patients expect out-of-pocket estimates before care is delivered—not surprising, given the rise in high deductibles and patients’ expected contribution toward their healthcare costs. Providing a patient financial “concierge” at the point of contact not only helps patients better understand their out-of-pocket obligation but also bolsters an organization’s ability to:

– Collect copays upfront

– Explore barriers to payment and patient-tailored solutions

– Increase point-of-service collections and revenue

The right vendor will offer both tried-and-true and out-of-the-box suggestions to drive increased efficiency and revenue, regardless of whether this boosts the vendor’s bottom line.

3. Ask bold questions—and expect thoughtful responses

We’re at the tip of the iceberg when it comes to using artificial intelligence (AI) in healthcare. AI offers a massive set of capabilities for innovation and improvement in healthcare, including in revenue cycle. For example, the use of machine learning has the potential to elevate revenue cycle performance by predicting:

– When a claim will be paid—and how much—down to the hour of remittance

– The probability that a claim will be denied payment—and why

– Whether a patient encounter will require prior authorization before the date of service

– Whether new edits need to be incorporated into existing workflows based on payer responses and denials

But is now the right time for your organization to invest in AI for revenue cycle, or are there other, more foundational competencies your team should hone first? The best vendors keep a pulse on the industry’s newest innovations and partner with you in determining the right approach for your organization. They also help make the business case for innovation to senior leaders, when appropriate.

As Nebraska Medicine examines opportunities to leverage AI in revenue cycle, it has worked with a claims analytics vendor to assess how payer behavior affects revenue, both in the short term and long term. At a time when the nation’s biggest health plans vary greatly in their time to payment, instant access to payment trends by individual payers empowers Nebraska Medicine to have more candid conversations with payers around performance. It also strengthens Nebraska Medicine’s contract negotiating power.

“We want to make sure we’re not at the bottom of the pile when it comes to our relationships with payers,” Danielson says. “If we are, we need to be able to dive into the specific issues that need to be fixed to improve performance.”

4. View your vendor as a strategic ally

Sometimes, you don’t know what you need until you see it. Other times, the pain points you’re sure to require dedicated focus turn out to be pebble-sized problems, not boulders. The key to finding a true partner in innovation is to actively seek a vendor that demonstrates not just a superior level of service, but also a strong willingness to listen to clients and share candid feedback.  

For example, senior leaders at Nebraska Medicine once asked revenue cycle leaders to uncover what they viewed as “skyrocketing denials rate.” Danielson partnered with the health system’s claims analytics vendor to drill down, by payer, into first-pass denial rates, partial denial rates, and more to provide a complete picture of denials status. These efforts showed one payer’s clean claim rate was 10 points lower than that of its peers.

However, the payer did not account for significant patient volume, translating to a small impact on revenue cycle performance. Nebraska Medicine determined it could make a bigger difference in lowering denial rates by focusing on the organization’s largest payer—avoiding a complete overhaul to the revenue cycle team’s payer relations approach.

Creating an Innovation Mindset

The bar for revenue cycle performance is rising, especially with continued dips in reimbursement rates, an uptick in challenges to claim payment, and an environment where consumers are the new payer. Moving past the traditional mindset of what a vendor relationship should look like toward an innovation mindset enables leaders to more fully benefit from a vendor’s subject matter expertise and accelerates gains in performance.


About Eric NilssonEric Nilsson joined The SSI Group, LLC (SSI) as the Chief Technology Officer to lead SSI’s long-term technology vision. He brings nearly 30 years of experience in the software industry with the last 10 in healthcare technology. Prior to joining SSI, he served as the chief technology officer at Nextech and Surgical Information Systems (SIS), where he focused on SaaS, on-premise EMR and practice management solutions as well as inpatient and ambulatory surgery providers from large hospital networks to surgery centers.