Let's Build a Small Bridge, First...

Not long ago in a strategy meeting with a previous employer, I heard someone ask, "Are we a peace keeper or an arms dealer?" That gentleman was referring to our role in connecting payers and providers to resolve insurance claims - something commonly referred to as Payment Integrity. I never thought about it this way before, and I didn't like the seemingly binary decision. I always viewed my role in the process as being a connector (Reference Erica Dhawan for more about Connectional Intelligence - It was an amazing opportunity to see her speak at Lyric this week), and felt compelled to find a better way.

For as long as I can remember, there has been a tension between payors and providers over medical records, supplemental documentation, and prior authorizations. Prior authorizations reduce medical expense, protect patients from bad actors, and slow care. Payor access to medical records will only open the door to more reviews, meaning more abrasion, more administrative burden, and lower reimbursements. The other side will argue that open records will create a better member experience and eliminate abrasion related to false positives. Each side has its reasons for the tension and that's why we have arms dealers and peace keepers. We have entrenchments, checkpoints, walls, and moats. Fortifications and defenses are expensive and they don't signal trust.

I want to build a bridge.

The first bridge is going to be small, and it's going to have a gate. One payer, one provider, one set of well-defined conditions, and one limited section of a medical record. Maybe we verify a member's weight to rule out a medically unlikely event. Maybe it's for a specific drug that has proven to be more effective with additional, non-clinical support. And maybe, just maybe, this step finds a better outcome for one member, reduces the administrative burden on one provider, and reduces costs for one payor. After we do this once, we find another opportunity, and then another.

Technology and automation will enable this journey, but trust is the first step. I am looking for partners on my journey to improve healthcare one interaction at a time.

Dan Gallagher is Vice President, Head of Partnerships at Lyric , and an Executive Advisor to DatumSure . Opinions represented in this article are my own.