I’ve Seen Claims Denials from Both Sides Now: aka Why We Created Daniel
Ted Pantaleo, VP Business Development, Red Sky Health
There was an old song from the 60’s by Joni Miller called “I’ve looked at Love from Both Sides Now.” Like Miller, and as a former Hospital Administrator and VP of Provider Network for major insurers, I’ve seen claims denials from both sides now as well. During my time as a provider, I have been in multiple situations where claims my team submitted were not paid despite our best efforts. As an insurance executive, I have been called upon to deal with frustrated and angry providers who are experiencing cash flow issues and/or to explain to regulators why a provider is not being reimbursed.
Despite being on either side of the fence, the reasons for these issues are often similar as each face the following challenges:
Ever-changing billing guidance with CMS, the AMA, and insurance companies having different and ever-changing policies.
Billing staff who cannot keep up with the guidance mentioned above.
Insurance companies employing AI to identify claims filed in error and then denying the claim.
Continued emphasis on eliminating fraud, waste, and abuse, which will continue to add administrative requirements to claims submissions and processing.
Simply put, what we are seeing in the industry around current manual efforts, or those with limited automation, will continue to fail. This means overhead expenses will increase as providers are forced to add more staff hours to deal with claims denials.
From my experience, one of the greatest frustrations for hospital administration to provider practices is seeing highly skilled clinical and administrative staff dedicating their time to chasing down denials instead of focusing on patient care. The inefficiencies caused by manual claims management often lead to delayed payments, reduced cash flow, and staff burnout. Physicians are increasingly discouraged by these inefficiencies, particularly when they believe they’ve followed the correct protocols only to see their claims denied over technicalities or misinterpretations. Without leveraging modern and readily available solutions, this problem will only intensify as payer complexity grows.
Red Sky Health’s recently announced solution “Daniel” is an AI-driven system that is designed to help both sides (now). Daniel identifies and offers real-time solutions to claims denials with greater than 95% accuracy. This results in increased revenue and reduced staff time dealing with payment issues. With Daniel, practices can rely on intelligent automation that adapts to evolving payer guidelines and efficiently pinpoints potential errors before they result in costly denials.
With Daniel, all providers - from the smallest outpatient facility to the largest health systems - are afforded a reliable and affordable solution to claims denials. Better yet there is no risk to medical practices, as Red SkyHealth is reimbursed by being paid a small portion of the dollars we recapture. By empowering providers with an effective solution, Red Sky Health operates with both sides in mind–helping reclaim valuable time and resources, and ensuring clinical staff can return their focus to what matters most: delivering quality care to patients.
