By Joan Butters, Co-Founder and CEO, Xsolis
LinkedIn: Joan Butters
LinkedIn: Xsolis
A KFF survey from 2023 revealed nearly one in five adults had health insurance claims denied in the previous year. On a national level, that suggests millions of disaffected patients. As the calendar turned to 2025, the growing public frustration with the cracks in the U.S. healthcare industry had exploded into a national conversation.
The chorus of complaints might have reached its crescendo recently, but insurance companies and healthcare providers have quietly been working together for years to address problems in a fractured system. A small but important first step toward becoming a more patient-friendly industry is aligning the interests of payers and providers, two factions often at odds, around a shared goal: patient satisfaction.
Examples of payer-provider collaboration
Where to begin? Several recent examples provided by KLAS Research offer concrete answers:
- When Cigna Healthcare’s membership unexpectedly increased, it collaborated with MDLive (a national telehealth provider) and N1 Health (an AI-based platform) on a solution that would proactively reach out to new members and help schedule annual wellness visits, relieving the administrative burden on staff at partner providers while ensuring new members were not overlooked during their onboarding. This partnership was convenient for members and encouraged more clinical preventive care — which reduces the risk for diseases, disabilities, and death — which millions of people do not receive each year.
- OrthoTennessee patients who had received knee surgery were experiencing delays in needed care due to a lengthy prior authorization process. Providers at OrthoTennessee used Cohere Health’s “episodic authorization” tool to bundle multiple related prior authorizations into a single transaction. Their payer partner saved 6 to 8 minutes submitting PT authorization requests, and OrthoTennessee reduced separate prior authorization requests by 35 percent for surgery, pre-op physical therapy (PT), and post-op PT. Best of all, patient care was delivered in a timelier manner, restoring quality of life faster than before.
- Addressing the universal challenge of data interoperability, the managed care organization AmeriHealth Caritas enlisted the help of ELLKAY, who provided an interoperability platform designed to extract data from Prospect Medical Holding’s EHR. That data was then securely passed to Astrata, who used their natural language processing solution to standardize the data and review the records to reduce AmeriHealth Caritas’ manual burden. The partnership more efficiently identified patient care gaps, reduced those gaps that required manual review, and allowed for comprehensive member follow-up on care gaps, ultimately improving patient outcomes. Among them: better identification of patient care gaps, and comprehensive member follow-up where care gaps were found.
- One payer organization teamed up with digital healthcare IT solution Rhyme and Henry Ford Health System to streamline prior authorizations for inpatient stays by: automating the retrieval of data from Henry Ford Health System’s EHR, triggering the submission of admission cases, and standardizing the data using artificial intelligence and machine learning. Automatic submission of administrative data saved 4 minutes per case, or 200 minutes per week, and automatic status updates saved an additional 2 minutes per case or 100 minutes per week. The upside for patients? In AMA’s 2024 research, a delay related to obtaining prior authorizations often or sometimes lead to treatment abandonment, according to 82 percent of survey respondents.
- Networked FHIR (Fast Healthcare Interoperability Resources) exchanges introduce relationships in which single parties interact with multiple other parties, testing the value of standardization and trust frameworks in streamlining the implementation of data exchange capabilities across the industry. Cambia Health Solutions worked with UC Davis Health and eHealth Exchange to create a secure, common space for data exchange between providers and payers via FHIR APIs. The end result for patients when prior authorization determinations are accelerated? Faster patient treatment. Interoperability is especially critical to advance, leaders involved with this case study said, due to the looming January 2027 compliance deadline issued as part of the CMS Interoperability and Prior Authorization final rule.
Improving the patient experience
Although some of these collaborations touch processes far removed from the patient experience, the benefits trickle down to patients in meaningful ways:
- Less wasted time
Both payers and providers ultimately want to improve the patient/member experience. How they reallocate the time saved through more efficient processes is up to the unit/department affected. As an example, Utilization Review or Case Management teams who used an AI-based solution during medical necessity reviews have been able to reallocate time to discharge planning, care coordination, and even education and professional development for their teams. The staffing shortages in the revenue cycle these digital solutions seek to address can cause more denials, increased days in accounts receivable, and decreased productivity — all of which can negatively impact an organization’s operational and financial performance. In each case, solutions that focus on efficiency carry the potential to reduce employee burnout, which can impact patient outcomes in a number of ways. - Reducing bias when determining medical necessity
“Objective determinations” based on predictive analytics get a bad rap. However, AI-based tools with a human in the loop can save time and reduce bias, getting providers and insurers to a point of agreement faster on claims decisions. When both payers and providers have access to the same data needed to determine medical necessity, it facilitates tough conversations and focuses time and energy on outlier cases that objectively deserve more careful consideration. Shared, objective data and predictive analytics also provide a framework for successful negotiations back and forth. - More frictionless patient experiences
When payers and providers collaborate on solutions, it reduces the friction between the two parties. So too does it lessen the chance that friction will trickle down to the patient experience, whether via unnecessary prolonged stays in acute care settings, unexpected or higher patient balance bills, and frustration with processes — figuring out claims, denials, and how patients can appeal — that create unnecessary administrative work on the patient’s end.
Conclusion
If recent events served as a call to action for health insurance companies to modify their current process, it was one of many messages received over the years with the intention of putting patients first. Fortunately, payers and providers have already been working together to develop solutions with that goal in mind. Although patients might not always see the fruits of their labor, payers and providers are constantly adopting solutions that reduce friction, save time, and create a more efficient healthcare industry for all parties involved.