Milestone Achieved: Avaneer Coverage Direct™ Delivers Significant Cost Savings

Avaneer Health has reached an exciting milestone in our journey to drive administrative savings and better patient experiences for our industry. Last month, we officially announced the launch of the Avaneer Coverage Direct™ solution and some very promising initial results with Cleveland Clinic. The proven solution proactively delivers accurate, real-time health coverage information to participating payers and providers.

It’s been rewarding to see our team’s work come to life and deliver the results our initial clients were seeking – less manual work, more insight, and fewer denials and reimbursement issues. The participating payers are improving payment integrity with COB leads, gaining greater insight into secondary and tertiary coverage.

The initial results are astounding and will grow as we add more payers and providers to the network. The hard dollar value of Avaneer Coverage Direct is up to $1.65 per claim for payers and $5.75 per claim for providers.

And what we’re doing is helping patients, which is rewarding. More transparent financial information upfront and less billing confusion creates the type of healthcare experience we all want when we’re patients. Making this impact is what inspires me to keep pushing the mission of Avaneer Health forward.

I’m deeply proud of our entire team at Avaneer Health who have worked tirelessly to make this possible.

Coverage Direct is just the first of many solutions currently in development, all focused on reducing cost and complexity for our entire industry.

I look forward to many future announcements.

Stuart Hanson
Avaneer Health CEO

In This Issue

Industry Highlights

 

Avaneer Health Announces the Launch of its Coverage Direct Solution

On May 22, 2024, Avaneer Health announced the launch of Avaneer Coverage Direct, a solution that proactively delivers accurate, real-time health coverage information to payers and providers participating in its secure, peer-to-peer network. The solution can deliver short-term, hard value of up to $5.75 per claim for providers and up to $1.65 per claim for payers.

Read the press release

How Cleveland Clinic is addressing food insecurity and approaching food as medicine incentives

Becker’s Hospital Review

In this enlightening podcast, Vickie Johnson, Cleveland Clinic Chief Community Officer, and Dr. Monica Yepes-Rios, Medical Director of the Cleveland Clinic Community Health Equity and Food as Medicine program, discuss their journey to engage with communities to address food insecurity, which affects up to 12% of all individuals in the country and up to 25% of kids in some areas. The speakers discuss the systemic issues and social determinants that drive food insecurity, how it impacts lives and our healthcare system, and what steps they’re taking to make meaningful change in their communities.

Listen to the podcast

ONC Brief Reveals Current State of Hospital Data Interoperability

HIT Consultant

The Office of the National Coordinator for Health Information Technology (ONC) just released its latest figures on the state of interoperability among our nation’s hospitals. While the news is encouraging, much progress remains to be made. This informative article provides key takeaways from the report and suggests three areas that need additional focus.

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Imagine What EHR Interoperability Could Do for Healthcare

MedPageToday

There are more than 500 EHR systems in the market today, offering limited interoperability. This lack of interoperability has led to troubling fragmentation and other inefficiencies that “remain cumbersome and overload clinicians with excessive data and administrative tasks.” Read this perspective from a med student who imagines a better way to retrieve and use healthcare information.

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From the Avaneer Podcast

 

The Importance of Addressing Social Determinants of Health in Healthcare

In this podcast, Dr. Joseph Webb, Nashville General Hospital CEO and author of the hub-and-spoke health equity model, discusses the science of healthcare delivery. “This evidence-based approach to care is statistically, scientifically, and empirically proven to produce desired outcomes.” Webb shares how Nashville General is putting evidence-based models to work to remove barriers to care and improve outcomes in the populations it serves.

Listen to the podcast

From the Avaneer Blog

 

AI in Healthcare: A Model for Managing Risks as Well as Rewards

Few, if any, healthcare topics have garnered as much attention as artificial intelligence (AI). From a beacon of innovation to a harbinger of complex challenges, the opinions about AI’s potential in healthcare are extensive and broad ranging. A survey by Bain & Company found that “75% of health system executives believe generative AI has reached a turning point in its ability to reshape the industry.” The question now becomes, where do we go from here?

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Innovation in Action: How Nashville General Hospital is Leading the Way in Health Equity

Nashville General may be 134 years old, but it leads the way in innovation and accessibility. Through the Webb hub and spoke model, individuals at risk are connected to healthy food in the hospital food pharmacy, health literacy and educational support through their faith communities, and medical care to prevent crisis visits to the Emergency Department. Learn about the work Dr. Joseph Webb and his team are doing in this blog post.

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Sharing coverage data can be more secure with direct connections

I want to take this opportunity to announce that our initial solution has a new name: Avaneer Coverage Direct™. The new name more accurately describes the solution’s value: Connecting payers and providers directly, avoiding intermediaries, and closing the gap left by existing solutions (EDI, clearinghouses, and portals).

Enabling providers and payers to have a full view of coverage at the point of care, along with direct primary source updates, allows for improved patient/member experience and eliminates waste through the care continuum. Existing eligibility solutions miss key updates that lead to write offs, bad debt, and unexpected denials.

Avaneer Coverage Direct integrates with your workflow to ensure you always have updated information. There’s no swivel chair. Data remains under the control of the data originators in their private environment, and only exchanged between authorized participants. Person-level data is exchanged only when there is a match, instead of exchanging entire data sets.

I invite you to read our case study to learn more about the impact of Avaneer Coverage Direct or reach out if you have any questions.

David Schramm
Senior Product Manager, Avaneer Health

In This Issue

From the Avaneer Podcast

The Spark: Putting the Value in Value-Based Care

Bob Gross, executive director of financial decision support and analysis at Cleveland Clinic, and Krista Matlock, senior director of operations and market network services at Cleveland Clinic, discuss what puts the value in value-based care and how close we are to success. “The beautiful thing is that the technology, FHIR standards, and the data is here today.” Stakeholders are now coming to the table to discuss ways to create mutually aligned incentives that alleviate friction, reduce risk, and create a “harmonious member-centric experience.”

Listen to the podcast

Industry Highlights

 

Earth Day, hospitals and sustainability: ‘We’ve seen the momentum change’

Chief Healthcare Executive

Hospitals have come to realize that the Hippocratic Oath adage “First, do no harm” applies to the environment as well as to patients. A recent Commonwealth Fund survey found that 41% of hospitals have created teams focused on sustainability, or have assigned positions like chief sustainability officers while 24% said they plan to do so within the next three years. Hospitals are also finding that sustainability efforts can produce millions in annual savings. It’s a movement that executives, managers, and front-line employees are getting behind.

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Interoperability: some improvement but much work remains

Medical Economics

How much progress has been made since the implementation of the 21st Century Cures Act in 2016 that sought to improve interoperability? That’s the question the American Board of Family Medicine asked more than 2,100 physicians in a recent survey. Just 10% of respondents said they were satisfied with the progress. This insightful article breaks down the complete survey to offer insight into just how far we have yet to go to achieve “universal, high-value interoperability.”

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From the Avaneer Blog

 

The Road to Building Trust in the Revenue Cycle

Effective relationships are built on trust, transparency, and a shared vision that leads to mutually beneficial outcomes. If we remove those attributes, each party prioritizes their own interests, often at the expense of the other party. Such is the case with payers and providers. Although they do business together, a lack of aligned interests has led to friction that significantly disrupts the revenue cycle and patient care. But that’s about to change as new solutions enable a trust-filled, patient-centric future that benefits all parties equally.

Read the blog

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The Road to Building Trust in the Revenue Cycle

The foundation of every good business relationship is trust. It’s what enables strategic alignments and mutually beneficial outcomes. Without trust, each partner tends to focus on protecting their own interests, even at the other party’s expense. That doesn’t mean they can’t still collaborate on projects or processes, but they won’t be as effective if they’re always on guard. Lack of trust can also inhibit innovation, which can cause parties to settle for the status quo doing the minimum to continue–such is the case with healthcare payers and providers. 

Friction: The back story 

Friction between payers and providers has been around for decades and has grown from mere distrust to downright adversarial, much of it driven by a lack of transparency at the core. At first glance, this is understandable. Fraud, waste, and abuse cost payers billions each year, which is why they now employ more sophisticated technology to identify potential claim issues. However, this has led to a stark increase in denials and payer “takebacks” at a time when providers are already struggling with historically low margins.  

Payers have implemented processes to reduce costs and eliminate unneccessary or inappropriate tests and procedures such as prior authorizations, medical necessity reviews, documentation requirements, and other complex processes. This has caused increased administrative work for providers and has negatively impacted patient care. In a 2022 survey by the American Medical Association, 94% of providers said the prior authorization process had caused delays in patient care, and 33% said those delays in care had caused a serious adverse event for patients.   

On average, providers spend nearly two hours a day on documentation, which has played a significant role in provider burnout.  

The role of transparent data sharing 

Another point of contention between payers and providers that promotes distrust is the inability to share data. Coverage is a prime example. Poor interoperability and data latency between provider and payer systems can cause extensive lags in getting updated information on multiple coverages or changes in coverage status. Most consumers switch health plans or have lapses in coverage multiple times throughout their lives (if not annually). Since benefits must be renewed each year, even if consumers don’t change carriers, they may still experience changes within their benefits plans.  

Without data transparency and interoperability, sharing coverage data becomes a manual, time-consuming process, requiring providers to call insurers or search their websites to find the information they need. Even when they find it, there is no guarantee the information is complete and up to date, and incorrect or missing coverage information is one of the top causes of denied claims. Inaccurate data can lead to delays in care or cause patients to have to pay for a covered service. In these situations, distrust is extended to patients who may doubt that their health plan or provider has their best interests at heart.   

The reality is that there may always be some level of distrust between payers and providers as each pushes the other to make things simpler and more transparent. The good news is that the tide is turning thanks to new technologies and solutions that eliminate the issues of transparency and interoperability and open a path for increased trust and effective collaboration. In fact, some of our country’s largest payers and providers are already well on their way and coverage is the first process they’re tackling. 

In the room where it happens 

Avaneer Health brought together some of our nation’s most renowned and innovative payers and providers to share their greatest challenges with the coverage and eligibility verification process. The discussion culminated with all parties working together to envision a solution that would address these challenges and lead to mutually beneficial outcomes—one of the cornerstones of building a trusting relationship. From those discussions, Avaneer Coverage DirectTM was born. 

Coverage DirectTM conducts daily real-time, unsolicited coverage updates from participant source systems to identify misaligned data between one or more participants that provide services for the same individual. Participants are notified of updates so they can proactively remediate coverage discrepancies before, during, or after care – when the update occurs.   

Coverage DirectTM reduces costs and administrative burdens for both payers and providers while also enhancing the patient experience. 

A shared vision for the future 

Payers want to mitigate financial risk by ensuring members receive cost-effective, appropriate levels of care. At the same time, providers want autonomy around the decisions they make about their patients’ care, and they expect fair, timely compensation for that care. Both want to simplify the extreme administrative complexities caused by a lack of interoperability and transparency. With Coverage DirectTM, these goals merge to become a single shared vision, enabling payers and providers to work together to build a more collaborative, trust-filled, patient-centric future. 

What if you could lower denials for good?

Until now, capturing accurate benefit information has been a manual, resource-intensive process that involves calling payers and combing payer websites to find the right information. Even when found, there’s no guarantee the information is correct. This inability of payers and providers to share coverage information is caused by complex data exchange processes. In other words, payer and provider systems don’t speak to each other. They lack the flexibility and specificity to accurately and fully communicate benefit information.

Avaneer Health recently launched its solution, Coverage DirectTM, which enables payers and providers to share coverage data directly without having to create or maintain multiple connections or use third parties. I’ve worked at various healthcare technology organizations and I see this approach to solving the problem as being very unique and impactful to payers, providers and patients. Connecting directly to update coverage information is more efficient, accurate, and timely. Features include:

Building on this new capability, we’re working on expanding Coverage DirectTM to include eligibility verification and patient estimation. With insight into the full benefit picture, we expect even more denials can be prevented, patient collections will be more streamlined, and the patient experience will be improved. In addition to our new eligibility and estimation solution, we are working on several other projects that we believe can reinvent some of healthcare’s most costly, inefficient administrative processes.

Stay tuned for more exciting news from Avaneer Health as we work to simplify the business of healthcare.

​​​​​​Matthew Blake
Senior Project Manager, Avaneer Health

In This Issue

From the Avaneer Podcast

The Spark: Transforming your IT infrastructure from a cost center to a strategic revenue contributor by focusing on patient-centric digital tools

With the advent of consumerism, patients are now the primary driver of a healthcare organization’s revenues. In this insightful podcast, Michael Archuleta, CIO at Mount San Raphael Hospital Trinidad, Colorado, explains how any hospital can transform its IT infrastructure from a cost center to a strategic revenue contributor by building asynchronous digital tools that benefit patients both inside and outside the organization.

Listen to the podcast

The Spark: Envisioning a more connected, collaborative future

In this podcast, Seth Joseph, founder and managing director of Summit Health Advisors and contributor at Forbes, explains why he believes companies like Slack, Airbnb, and Uber hold the answer to solving some of healthcare’s most pressing challenges. He also shares why government mandates often get in the way of healthcare innovation by driving a focus on regulatory compliance instead of on solving specific clinical and administrative problems.

Listen to the podcast

The 5 pillars of healthcare innovation

Ryan Howells, principal at Leavitt Partners and Program Manager at CARIN Alliance, and Jason Sherwin , senior director of Healthcare Business Development at CLEAR, discuss what healthcare will look like in the coming decade. They also share the five pillars of healthcare innovation and the three essential technologies that will drive equity, accessibility, and “micro experiences” for patients and providers.

Listen to the podcast

Industry Highlights

Lower reimbursement rates, denials behind razor-thin margins

RevCycle Intelligence

Hospitals continue struggling with labor shortages and historically low operating margins. Healthcare Financial Management Association and Eliciting Insights recently surveyed more than 130 health system CFOs about their greatest challenges. Eighty-four percent said lower payer reimbursement rates—driven by increased denials—are the top cause of their struggling operating margins. Learn what hospital leaders are doing to address denials and create financial viability.

Read more

What ‘Digital Transformation’ Means to 3 Health System Execs

MedCity News

During the recent HIMSS conference, three health leaders shared their thoughts on the value of digital transformation and how they’re employing AI to drive the transformation in their organizations. Learn about their challenges and the strategies they’re implementing in this insightful blog.

Read more

From the Avaneer Blog

Getting Coverage Right Takes a Team Approach

The idea of payers and providers working seamlessly together may seem unfathomable. Fortunately, that is no longer the case. We now have innovative new technologies that eliminate the issues of transparency and clear a pathway for mutually beneficial collaboration. This team approach puts the patient at the center and helps lower costs and create greater financial viability.

Read the blog

Getting Coverage Right Takes a Team Approach

We’ve heard for years about the friction between payers and providers—friction that stems from a lack of transparency and trust. Providers want autonomy in the decisions they make around caring for their patients, and they expect fair, timely compensation for that care. At the same time, payers want to reduce the billions in fraud, waste, and abuse they experience annually, while also ensuring their members receive the most cost-effective and appropriate level of care. These priorities shouldn’t negate one another, but without transparency and trust, the friction will continue to grow.  

One of the most significant manifestations of the lack of transparency is denied claims, which have become a top concern of healthcare leaders, and rightfully so. Payers are denying a record number of claims. According to a 2023 report by KFF, “nearly 17% of in-network claims were denied in 2021.” However, denial rate averages range from two percent to 49%. The puzzling fact is that more than half of denials are eventually overturned, which means they should have been accepted and paid the first time around, before providers spend extensive resources on multiple appeal attempts.  

70% of healthcare leaders surveyed say reducing denials is their top priority and of even greater importance than before the pandemic. 

The bottom line is that denials are a point of contention fueling a disjointed healthcare system and driving up costs. Besides impacting revenues, denials also affect patients who may experience surprise bills for a service that was covered. When this happens, patients may put off future care to avoid further medical costs. Of course, when patients put off care, their conditions can worsen and lead to costly hospitalizations, emergency room visits, and poor outcomes.  

 More than 25% of adults in the U.S. say they have delayed or put off “medical care, prescription drugs, mental health care, or dental care” because of the cost. Another 15% skipped care or didn’t fill a prescribed medication for the same reason. 

Getting to the root cause 

While there are multiple reasons a claim may be denied, incorrect eligibility and coverage information is one of the top reasons. This is understandable considering how often individuals change their insurance throughout their lifetimes. Even when the carrier remains the same, annual renewals allow individuals to change their plan options, which often includes changes to co-pays, deductibles, and network options. This is why providers check coverage multiple times, even for the same encounter—at registration, check-in, and prior to claim submission.  

The volume of eligibility and benefits verifications increased by 18% between 2022 and 2023 and now accounts for 54% of all medical administrative transactions—the highest of all administrative transactions. Spending on eligibility and benefits verification increased by 60% to $43 billion annually.  

Here is where we circle back to the issue of transparency. Today, providers need to do manual work, call payers, or search their websites in an effort to capture up-to-date coverage information. Some providers have entire teams devoted solely to this effort. Even when they find information, there is no guarantee it is complete or up to date. The process is highly manual, time consuming, and a significant burden on both payers and providers, especially with staffing shortages as they are. This inefficient process can also lead to delays in care and poor outcomes while also extending payer-provider friction to patients who may question whether their provider or insurance plan has their best interests in mind. 

Implementing a team approach 

The idea of payers and providers working seamlessly together may seem unfathomable. Fortunately, that is no longer the case. We now have innovative new technologies that eliminate the issues of transparency and clear a pathway for mutually beneficial collaboration. This team approach puts the patient at the center and helps lower costs and create greater financial viability. 

Avaneer Health’s Coverage Direct solution enables greater transparency,  seamless data sharing, and better collaboration between payers and other providers. This team approach provides a more complete picture of a patient’s coverage and final financial responsibility, reducing denials and improving the patient experience. 

How it works 

The Coverage Direct solution is a part of the Avaneer NetworkTM, which connects payers and providers directly, allowing real-time, secure data exchange without the need for third parties. The solution automatically determines coverage changes or missing, conflicting, or incorrect coverage details and sends immediate updates to all permissioned providers and payers. Providers benefit by receiving a proactive feed of patient coverage into their electronic health records (EHRs), improving the patient experience, and reducing first-pass denials. Payers benefit by receiving real-time coordination of benefit (COB) leads and visibility into data discrepancies. Providers can save between $3.36 and $5.75 per claim, while payers can save between $0.57 and $1.65 per claim.  

With Coverage Direct, data remains under the control of data owners and never has to leave that organization’s systems, which increases security and eliminates the need for need for third-party involvement.  

Teamwork makes the dream work 

It’s time for payers and providers to work together to improve outcomes, lower costs, and create a better patient experience. The Avaneer Health Coverage Direct solution is the answer. By promoting transparency, seamless collaboration, and shared priorities, Coverage Direct can help make friction a thing of the past. 

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