Some health systems have cut ties with payers while others fought public, and private, battles for higher rates. Renton, Wash.-based Providence’s COO Darryl Elmouchi, recognized the strife but is hopeful for the future.
“At the end of the day, I think all of our peers would say one of the biggest challenges we are seeing are commercial insurers really not paying us for what we are due,” said Mr. Elmouchi during an episode of the “Becker’s Healthcare Podcast.” “That could be a combination of denials, increased red tape, all sorts of things that are making it hard to do our work, and coupled with rates that don’t cover the care we’re giving. So I’m hopeful that 2025 will be a reset year for so many payers where they’ll start actually working with health systems like ours to find solutions as opposed to putting up barriers.”
Artificial intelligence-driven tools are also streamlining revenue cycle functions and the right integrations could make payer-provider communication easier. However, insurance companies are also using AI to track claims and issue denials, which may lead to bigger points of conflict between the two.
“We advance more AI tools and they’re not just in the front lines of care, but they are on the back end; they are in the revenue cycle. They are in the supply chain. As payers are doing the same thing, you can imagine an AI war of denials, using AI to try to get around those, and that doesn’t benefit anyone,” he said. “It just adds expense and I’m hopeful we don’t get there.”
If aligned with the payer and focused on value creation, Providence has a track record of realizing efficiencies and savings. The health system has been making progress with its Medicare Shared Savings Program accountable care organization, which generated approximately $100 million in savings for CMS last year, among the largest in the country. The health system now aims to double down on value-based care and extend care into broader communities.
The C-suite leadership at Providence will remain focused on strengthening its foundation for financial security in the future.
“There are so many challenges that we’re facing across the country, with pharmaceutical costs, medical supply costs, labor costs and obviously a lot of unknowns coming out of the federal government right now,” Mr. Elmouchi said. “Our goal is to shore ourselves up as best we can to make sure we can be here for future generations.”