Steve Suter

The $25B elephant in the room: manual claim denial waste. The HFMA Vitalic Health initiative is finally tackling the standardization of claims to reduce this massive friction between payers and providers. It’s a 50-plus stakeholder effort that's long overdue. But while the industry waits for standards to catch up, payers aren't slowing down their AI-driven denial engines. With AuditNavigator, you can defend your revenue stream now. For those inevitable denials, AppealNavigator slashes work time by 60%–90% and delivers a 5:1 ROI. Standardization is a great long-term play, but for today’s margin, you need to fight AI with AI. Waiting for the system to fix itself is a strategy for yesterday’s revenue cycle. Is your team still bringing a knife to a gunfight? #healthcare #healthcareIT #healthcareinnovation #RevenueCycleManagement #DenialsManagement #ClinicalDenials #HealthcareAI #HospitalFinance #DigitalHealth #HFMA

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Cigna announces “AI assistant, which will help users to navigate their care options, answer questions about coverage and display accurate cost estimates. “

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A Message from our CEO, Zack Higbie. Healthcare CFOs are elevating underpayment analysis and claims workflow to top priorities, and the latest Becker’s piece reinforces the “why”. As margins continue to compress, payor behavior has pushed revenue leakage deeper into the lifecycle. Denials, short-payments, and pricing discrepancies are no longer isolated misses; they’re systemic, frequent, and often occurring well past initial adjudication.   What years of running revenue cycles across various platforms and care settings has taught me is that traditional tools and workflows simply aren’t built to surface this lost revenue at scale. That’s where platforms like Helix COSMOS change the equation. COSMOS rapidly ingests and normalizes massive volumes of claims, remits, contracts, and clinical data – compressing implementation timelines from months to hours – and applies intelligence to identify where claims were not only paid incorrectly but also billed in a way that failed to optimize compliant reimbursement. Just as the article highlights, though, technology should only be used to identify targets for potential opportunity; pairing this with the robust expertise and credentials of talented auditors expands recoverable opportunity far beyond the narrow slice most underpayment audits ever touch.   Mission Control then turns that intelligence into action. It’s not a dashboard, rather an operational system that dynamically routes work across zero balance reviews, denials, DRG validation, and revenue integrity based on real-time payor behavior, dollar value, and filing deadlines. And unlike most zero balance audits, it isn’t static but capturing new opportunities in the audits with each day’s placement files. By tracking activity at the account level and measuring conversion from placement to cash end-to-end, teams can shorten cycle times, flatten backlogs, and scale efficiently, all while continuously learning which payer tactics are driving erosion.   The takeaway for finance and revenue cycle leaders is encouraging: the lost revenue is there, but it requires a more connected, intelligent approach to find it. When analytics, workflow, and expertise operate as one system, underpayment analysis stops being reactive and becomes a durable lever for margin protection and cash acceleration. https://lnkd.in/eGZpDTkN

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Board Audit: Are Our MA Algorithms Compliant — and Defensible — Today? Recent congressional scrutiny (e.g. Senator Blumenthal’s letter to MA insurers) has thrust the algorithmic underpinnings of Medicare Advantage decisions into the spotlight. When every claim denial can become headline fodder, payers must ask: Are our models safe from legal, regulatory, and reputational challenge? Here’s a 7-point rapid assessment for C-suite teams, audit committees, and AI governance councils: 1️⃣ Transparency & Explainability Can you articulate, in plain language, why a member’s claim was denied or approved? ➡️ If not, you’re one Senate subpoena away from reputational risk. 2️⃣ Bias Audits & Demographic Drift Do you test for disparate outcomes by race, age, or ZIP code? ➡️ “Neutral” algorithms can still reinforce inequity — regulators are watching. 3️⃣ Clinical Validation & Physician Oversight Are clinicians validating model outputs? ➡️ AI should support clinical judgment, never replace it. 4️⃣ Guardrails & Oversight Layers Are there thresholds for automatic review or human override? ➡️ Smart guardrails reduce both harm and litigation. 5️⃣ Audit Trails & Versioning Control Can you trace each decision to the model, dataset, and version used? ➡️ Traceability equals defensibility. 6️⃣ Cross-Functional Governance Do legal, compliance, actuarial, and medical leaders co-own AI policies? ➡️ Governance must be shared — not siloed in data science. 7️⃣ Continuous Monitoring & Feedback Loops Do you track appeal rates, false positives, and provider sentiment in real time? ➡️ Model management isn’t static; it’s a living discipline. 🚀 The Next Horizon: Platform + Governance = Sustainable AI Advantage Payers can’t treat compliance as an afterthought or bolt-on. The future belongs to those who build platform-based ecosystems that embed governance at every layer — data ingestion, model deployment, workflow orchestration, and decision audit. When governance is baked in, not bolted on, AI ceases to be a liability and becomes an edge — powering faster decisions, fairer coverage, and deeper member trust. A unified platform approach ensures every algorithm is born compliant, clinically aligned, and continuously auditable — turning regulatory scrutiny into a strategic moat. Because in healthcare, trust is the ultimate ROI. #HealthcareAI #MedicareAdvantage #PayerStrategy #AICompliance #AIGovernance #HealthTech #DigitalHealth #BoardLeadership #PrivateEquity #HealthcareInnovation #ResponsibleAI #PayerTransformation #AIinHealthcare #CMS #CPTCodes #PriorAuthorization #ValueBasedCare #HealthPlanOperations #PEHealthcare #HealthcareInvesting #AIEthics #HealthcareStrategy #AIAdoption #HealthData #HealthEquity #RegulatoryCompliance #PlatformStrategy #AITrust #ClinicalAI #AITransparency #BoardroomAI

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We're eliminating the guesswork on how to curtail health spend. Our actuaries are helping health plans identify the costs that actually move trend. Great insight Stuart Sutley. https://lnkd.in/ennsPScY

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