Today’s healthcare providers are in a bind. Demand for services is rising while reimbursement is declining. Amid these circumstances, many healthcare organizations find themselves trapped in a cycle of reactive decision-making and growing expenditures. These organizations aren’t producing the savings they need to support the bottom line.

In contrast, other providers are adopting proactive management strategies based on advanced healthcare data and analytics.

To learn how these provider powerhouses are transforming data into strategic gold mines, Becker’s Healthcare recently spoke with Jigar S. Patel, M.D., FAMIA, chief medical officer and chief product officer at Claritev. Dr. Patel shared how leading provider organizations are bolstering their financial well-being through comprehensive data integration, public price transparency data and tailored optimization strategies based on data-driven insights.

Question: Healthcare leaders are under immense pressure to reduce costs and grow revenue without compromising care. Where do you see the greatest opportunities to strengthen financial performance — particularly in areas that tend to be underestimated or missed?

Dr. Patel: As a physician and informaticist, most of my work has related to technology on the provider side. The biggest provider challenges relate to the administrative burden associated with getting paid for their services.

At Claritev, we’re applying our expertise in machine learning, predictive AI models and generative AI, so provider organizations of any size can use actionable insights gathered through robust data and analytics to understand this administrative burden and decrease it. One example is analytics based on price transparency data that can show providers how they’re getting reimbursed and compare their reimbursements to their peers.

Q: Even with access to more data than ever, many organizations still struggle to turn it into actionable insights. What do you see as the biggest roadblocks? What can organizations do?

JP: Providers can’t manage their patients’ health if they aren’t informed with the right data and analytics. However, everyone’s working with razor-thin margins. At some small, independent hospitals, employees are juggling multiple jobs just to keep the doors open for the community. The unfortunate reality is that analytics expertise isn’t cheap, and it’s hard to access in some localities. A good approach is to use analytics solutions that are designed for the provider market that are easily accessible and digestible.

Q: Data and operational metrics are siloed across payers, vendors and more. What opportunities exist to improve collaboration and transparency?

JP: The $1 trillion question is how do we get everybody to come together and remove the administrative burden on all sides? Every time a claim is denied, there’s a cost to a provider and there’s a similar cost on the insurer side.

Most technology companies focus on either the payer side or the provider side. They aren’t thinking about how they can come together in a way that’s optimal for both groups. What sets Claritev apart is our commitment to supporting the shared goals and helping to reduce or remove the administrative burdens across the healthcare ecosystem.

When it comes to data, people have tried standards, information exchanges, data sharing and other strategies that take a long time to come to fruition. Usually only the organizations with deep pockets can hire people to focus on those things. Smaller organizations with competing priorities can’t fund the internal capabilities needed for things like standards.

Technologies, such as generative AI, are helping providers think differently. But they aren’t cheap. Claritev gives providers access to the latest technology without building systems from scratch. Better information yields better decisions, reduced costs and more efficient markets.

Q: The intense volume of siloed data often means margins and costs are only visible after care is delivered. What needs to happen to change this?

JP: Historically, it hasn’t been part of a provider’s strategy to understand margins and costs. Now, providers must think proactively and holistically. Providers must take a closer look at contracts, which are the vehicles by which providers and payers work together. Eventually, intelligent systems need to help the provider side professionals optimize the capture of appropriate, technically correct elements that help to ensure a clean claim that reflects their work effort completely.

Q: Disconnected reimbursement and cost data often limits the profitability insights available to providers. Are there novel ways in which this is being addressed?

JP: Claritev has a tool called CompleteVue^TM that analyzes the 500 billion claims included in publicly available price transparency data reported by insurers. We make sense of the vast amounts of data in machine-readable files, so providers can identify hidden financial gaps and contract improvement targets.

With analytics, big data and machine learning, CompleteVue^TMgenerates automated risk assessments of patient populations and highlights contract reimbursement disparities among regions, hospitals and payers in the same markets. We can compare, for example, payments for a Level 3 emergency department visits across a region.

Coding is another opportunity area. Claritev’s Advanced Code Editing solution combines AI technology with an expert coder and clinician review to proactively identify coding issues in claims. When providers get cleaner claims out the door, it reduces friction in the healthcare ecosystem and brings down administrative costs.

Many hospitals are the largest employer in their region and are huge users of health benefits. Claritev has solutions that analyze the cost of current benefit plans based on claims and provide actionable insights into plan designs for the following year.

Ultimately, our goal is to help make healthcare more affordable, reduce provider costs and balance bills for out-of-network services, provide patients with access to the care they need and bring efficiencies to all parties.

Learn more today Claritev.com

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