Coverage Alignment: The Catalyst for Better Payer-Provider Relationships

I’ve spent over a decade in health information exchange, and while I’ve witnessed many incremental attempts to remove barriers and alleviate payer-provider friction, I’ve never seen true payer-provider partnership to reinvent and solve the core of revenue cycle management – coverage information.

Health insurance coverage is a notable example of unnecessary friction. While adoption of electronic eligibility transactions has reached 94%, payers and providers still struggle with sharing coverage data in a way that is automated, complete, accurate, and timely. A significant challenge has been a lack of interoperability, but that’s changing!

The Avaneer Coverage Alignment solution detects and matches changes in coverage information and instantly shares it with payer and providers. In doing so coverage information is accurate, up to date, and immediately accessible.

Our payer and provider participants are thrilled with the results. Providers appreciate the significant reduction in coverage-related denials and payers share how the solution helps simplify coordination of benefits.

I’m really excited to be a part of this transformational moment in healthcare. Also, I invite you to reach out to me or take a product tour to learn the value of Avaneer Health’s Coverage Alignment solution.

David Schramm
Senior Product Manager, Avaneer Health


In This Issue

From the Avaneer Podcast

The Spark: Lessons Learned from an Industry Disrupter

Sufian Chowdhury, founder and CEO of Kinetik, envisions a future where healthcare transportation mirrors the convenience of popular ride-sharing services like Uber and Lyft. Chowdhury sits down with Avaneer CEO Stuart Hanson and Marketing VP Rachel Schreiber to share the many insights he’s gleaned since setting out to transform the non-emergency medical transportation (NEMT) industry—an industry whose services can mean life or death for millions of individuals each year.

Listen to the podcast

Industry Highlights

Researchers Call for Outcome-Centric Approach to Health AI Regulation

Health IT Analytics

The recent White House Executive Order on the Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence seeks to prevent the irresponsible use of AI that “fraud, discrimination, bias, and disinformation; displace and disempower workers; stifle competition; and pose risks to national security,” especially in vital fields like healthcare. However, researchers believe the order omits a critical component: patient outcomes. This insightful article delves into the need for “outcomes-centric” regulations whereby companies with new AI-driven models should be required to prove clinical relevance before being allowed to bring the model to market.”

Read more

Healthcare Administrative Spending Increased by 50%

Rev Cycle Intelligence

Healthcare organizations are getting hit from all sides by rising expenses, especially labor and pharmaceuticals. The 2023 CAQH Index Report reveals that administrative expenses are also taking an increasing toll on the bottom line, reaching nearly $83 billion, with prior authorization, claim submission, and claim status inquiry taking the top spots. This insightful article delves into the challenges and recommends strategies for thriving in this post-pandemic “new normal.”

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Doctors and hospitals praise new prior authorization rule, but some want more from Congress

Chief Healthcare Executive

The recent CMS final rule focused on overhauling the highly burdensome prior authorization process has been much anticipated and, most would argue, long overdue. However, critics of the rule say that while it’s a significant step in the right direction, it does little to advance real-time processes and reduce the number of prior authorizations overall—both of which are essential to reducing the burden of prior authorizations on providers.

Read more

From the Avaneer Blog

What if getting accurate patient coverage could be easier?

What if providers and payers could connect to a single network and access always-refreshed, accurate, and complete primary, secondary, and tertiary patient coverage in real time—without needing a third party? Providers could spend less time chasing information and more time with patients while IT would have fewer connections to manage, reducing costs and freeing up valuable resources.

“What if” is now a reality at some of our nation’s largest payer and provider organizations.

Read the blog

Looking to Connect?

Find us at these upcoming conferences or book a time to meet.

ViVE 2024 is just around the corner, and we’re looking forward to talking with payers, providers, and like-minded innovators and entrepreneurs about the exciting things happening at Avaneer Health. If you’d like to meet with our CEO, Stuart Hanson, while at the show, please reach out here.

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Year in Review and Outlook for 2024

Insider News for January 2024

Happy New Year! I hope 2024 is off to a great start for you and your organization. It certainly is at Avaneer Health. Our team had a ground-breaking 2023 as we set, met, and exceeded some aggressive goals and milestones. We ended the year confident in our product-market fit, growth strategy, and priorities for 2024.

I am very proud of our team’s achievements in 2023 and I want to share just a few ways we worked together to #makeitreal.

We will continue building on our successes in 2024 and beyond. While interest in our network and platform continues to gain momentum, our Coverage Alignment solution has been especially compelling for many prominent regional and national healthcare organizations who see the potential to lower costs and transform administrative processes.

We’re also developing new solutions that meet the needs of both payers and providers. This is a distinctive approach to driving improvements in healthcare and we’re looking forward to announcing the details throughout the coming year.

Here’s to a great 2024!

Stuart Hanson
Chief Executive Officer, Avaneer Health

PS – Don’t miss our podcast conversation with an innovator in the health improvement space, Jeff Ruby, CEO of Newtopia. It’s a hot topic for January!

In This Issue

Industry Highlights

Setting the revenue cycle up for success in automation and AI
McKinsey & Company

For years, we’ve heard about the promising value of automation technology and analytics in reducing administrative complexities. Yet, that value has been slow in coming. This insightful and timely article delves into the challenges and posits that the value is finally at hand but says “capitalizing on the next wave of technologic innovation entails investing in the right mindsets, infrastructure, and capabilities throughout the revenue cycle and beyond.”

Read more

Why a Former ONC Chief Thinks TEFCA Is Inherently Flawed
MedCity News

The Trusted Exchange Framework and Common Agreement (TEFCA) is now operational. Several leaders in the industry are saying that it might not live up to its promises of improving interoperability and data access. In this thought-provoking article, Donald Rucker, MD, former National Coordinator for Health Information Technology (ONC), explains why he thinks TEFCA may actually “set interoperability back.”

Read more

From the Avaneer Podcast

The Spark: Innovating Health Improvement

We recently sat down with Jeff Ruby, founder and CEO of Newtopia, an innovative, personalized, whole health platform helping people create positive lifelong habits that prevent, slow, or reverse chronic disease while reducing healthcare costs. The discussion centered around our shared passion and commitment to leveraging technology and analytics in a new way that challenges the healthcare “status quo” and ultimately changes healthcare experiences for all.

Listen here

From the Avaneer Blog

3 ways IT leaders can improve the business transactions of healthcare

Interoperable data platforms, automation, and AI have the potential to transform our industry by enhancing patient experiences, improving outcomes, lowering costs, and significantly reducing clinical and administrative inefficiencies.

Read how

Reinventing the Back Office to Deliver on the Patient-Centric Promise

We all have experienced, or know someone who has experienced, a time when our ability to receive care was inhibited due to inefficient administrative processes. Sadly, delays in care are far too common simply because payers and providers can’t easily share patient coverage or other vital healthcare data. Avaneer Health sees a new way forward, where data is always available, always updated, and always complete. Patients get the care they need when they need it, and providers and payers eliminate the costly, time-consuming back-and-forth to chase down information. We’re reinventing the back office to deliver on the long-overdue patient-centric promise.

Read the blog


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What if getting accurate patient coverage could be easier?

The vast adoption of high-deductible health plans means consumers are financially responsible for a greater portion of their medical costs. Yet, our current revenue cycle was designed around commercial and payer reimbursement, not patient payments. Today, collecting patient payments has become a challenge for many provider organizations and creates significant financial stress for both the patient and the provider. The first step in collecting is identifying a patient’s coverage and determining the final amount they will owe.  

Why is coverage discovery so challenging? 

The underlying problem spans data silos, lack of interoperability, and data latency between provider and payer systems. These challenges create extensive lags in getting updated information on multiple coverages or changes in coverage status. Consider that consumers change their health plans numerous times throughout their lives. Since most benefits must be renewed each year, even if consumers don’t change carriers, they can still change their benefits plans.  

Often, patients are unsure of their current coverage or whether they have secondary or tertiary coverage. This means providers must manually call insurers or comb their websites to find updated coverage information, sometimes using bots and AI solutions. Even when they find the coverage information, there is no guarantee the information is accurate.  

Failure to capture complete, accurate patient coverage prior to service can lead to delays in care and denied claims. In fact, the lack of precise coverage information is the second leading cause of denied claims, leading to increased write-offs, delayed reimbursement, and lost revenue.  

In addition to the impact on the provider’s bottom line, the impact on patients is also significant. Patients may end up paying for a service that was covered or receive care they thought was covered only to find out later it was not. When the claim is eventually denied, the patient can end up with an unexpected medical bill at no fault of their own. This can cause distrust and lead to a dissatisfactory patient experience. It may also damage the organization’s brand reputation.  

What if… 

What if there were a way for providers and payers to connect to a single network and get real-time access to always-refreshed, accurate, and complete primary, secondary, and tertiary patient coverage information—without the need for a third party? Providers could spend less time chasing information, leaving more time for patient engagement. The IT team would have fewer connections to manage, reducing costs and improving operational efficiencies.  

What if denied claims due to timely filing issues or inaccurate coverage or eligibility information were eliminated? Providers could experience fewer write-offs and takebacks, a reduction in A/R days, better cash flow, faster and more accurate reimbursement, improved self-pay collections, and reduced denial-related costs. 

“What if” is now a reality 

We no longer have to ask “what if” because the solution is here today. The Avaneer Health Coverage Alignment solution enables payers and providers to share information over a single network without building and maintaining separate connections to a myriad of different services, trading partners, and counterparties within the industry. The Avaneer NetworkTM becomes a shared source of knowledge. 

In the network, payers and providers submit data to the SparkZoneTM, a cloud-based environment, where it becomes discoverable based on permissions set by each participating organization. Users connect to the network via the cloud, where the ID keychain and master index locate the information requested, match it to the data available, and then deliver it to requestors who are permissioned to access it. Data remains in its existing location and under complete control of the data originator.  

The Avaneer Network is a secure, permissioned network and platform built on data fabric architecture. Certification, cybersecurity, and compliance are all built into the design. Because data is permissioned at the gate instead of the gateway, it is more secure and less vulnerable to a breach.  

Success story 

A non-profit academic medical center and a national payer are early adopters of the Coverage Alignment solution and have been collaborative on solution design and outcomes. Early results show that access to more complete coverage information gives insight into data management processes and operational workflows, in addition to the following benefits. 

Learn how Avaneer Health can help your organization reduce denials and write-offs, improve collections and reimbursement, enhance the patient experience, and lower administrative costs.

How Interoperability Can Boost Revenue Cycle Results

The annual cost of administrative and process inefficiencies in the U.S. healthcare system has reached into the billions, with billing, coding, physician administrative activities, and insurance administration being the primary drivers. Provider organizations spend approximately $39 billion each year and dedicate an average of 59 FTEs just to comply with hundreds of administrative regulations and requirements.

Think of the progress we could make in improving the lives of our patients, the investments we could make in state-of-the-art equipment and facilities, and how greatly we could expand access to care if we could redirect the billions spent each year on administrative waste towards innovation and direct patient care.

Current gaps in processes

 According to an article in HFMA Magazine, the top use cases for costly waste and inefficiency include:

These are all costs that could be significantly reduced through more effective interoperability. But how do we create an environment that addresses these inefficiencies while developing an interconnected infrastructure for the benefit of payers, providers, and innovators?

Certainly, FHIR gives us a good opportunity to work from a common protocol and set of standards when we talk about the payload of transactions on a network. However, FHIR itself does not translate into interoperability. FHIR is just the payload; it’s what’s inside the envelope when we exchange data. How an envelope moves through the enterprise and across the industry, and how it’s kept updated is based on  the ability to create a dynamic, interoperable network.

We’re currently spending way too much energy creating point-to-point interactions across a mesh of an ecosystem and not enough energy creating a shared environment where we’re all—payers, providers, and innovators—working from the same platform of knowledge.

Use Cases for a Decentralized Peer-to-Peer Network

One of the biggest issues with today’s EDI transactions, according to the director of revenue cycle management at a large health system, is a lack of consensus. “EDI transactions, the 270/271 especially, have been out there for 20 years or more, yet we know there are limitations with their use as a vehicle to support the exchange of information between parties.”

We have a unique problem that is very well positioned to be solved by a decentralized peer-to-peer network in that there are multiple stakeholders who are part of the insurance coverage determination process. In other words, all participants on the network would be able to work within the same system using the same set of requirements—as if they were all the same organization—through a consensus-based network.

Consider eligibility verification and prior authorizations. According to the 2022 CAQH Index , each manual eligibility verification transaction costs $12.86 and each manual prior authorization transaction costs $14.52. And this doesn’t even include the cost of gathering information for the transaction or for follow-up. Since 569 million manual eligibility transactions and 66 million manual prior authorizations are conducted each year, the impact on the bottom line is staggering.

Instead, providers and payers could leverage an application built on a decentralized, peer-to-peer network to conduct eligibility verifications and prior authorizations—without the need for time-consuming back and forth faxes, emails, and phone calls. With this type of network, the entity conducting the inquiry receives the most up-to-date information based on a number of data elements that are relevant to them.

For example, a primary care provider, a specialist, and a hospital would all receive information based on data elements that are specific to their specific scenario. This would be based on the type of provider, the kind of procedure, the type of facility, the patient’s remaining deductible, and the patient’s out-of-pocket responsibility, and more. It’s basically an “if/then” inquiry. If the inquirer is a surgeon, and if the procedure is covered in the patient’s benefit plan, and if the patient’s deductible has been met, and if the provider is in network, and if all prior authorization requirements are met, then this is what the provider will be paid and what the patient will owe.

The senior director of revenue cycle transformation at a large, multispecialty academic medical center believes that we have a misconception that patients don’t want to be bothered with the financial impact of a service at the time the service is rendered. “In the past we thought we were doing patients a favor by not approaching them about their financial responsibility. Then the patient receives a bill several months later and tries to remember even having the service and then figure out if the bill is legitimate.”

By giving patients an accurate amount that they will owe at or before the time of service, patients have the information they need to make more informed decisions about how to pay for their care. It also enables providers to collect on bills or set up payment plans, which can help reduce the cost to collect and write-offs, as well as surprise bills for the patient.

Coordination of benefits (COB) is another process fraught with administrative waste and inefficiencies that could benefit from a decentralized, peer-to-peer network. COB processes often cause cogs in the revenue cycle on the back end that can lead to delays in reimbursement and excessive rework. Because of the latency of data, there can be a long lag in getting updated information on multiple coverages or changes in coverage status. COB works better if all parties have full insight into multiple enrollments. With a peer-to-peer network, updated enrollment information on each participating member/patient is already in the system and can be accessed by all participants on the network.

Imagine a decentralized, peer-to-peer network that allows payers to co-develop processes to streamline coordination of benefits. Working together, payers can develop the rules, processes, and the analytics that provide greater standardization and insight into primary, secondary, and tertiary coverage for network participants. Today, what is a heavy administrative burden that can result in costly, labor-intensive denials, instead becomes a simple network inquiry that facilitates faster, more accurate claims.

How it works

The foundational benefit of a decentralized, peer-to-peer network is the concept of connecting once to many instead of one to one. Instead of having to build and maintain separate connections to a myriad of different services, trading partners, and counterparties within the industry, all network participants have access to a shared base of knowledge.

In the network, payers and providers submit data to the cloud where it becomes discoverable based on permissions that are set by each participating organization. Users connect to the network via the cloud, where the ID keychain and master index locate the information requested, match it to the data available, and then deliver it to the requestor. The network design provides certification, cybersecurity, and compliance.

Where we go from here

No one could have imagined Amazon before the Internet was invented. With a decentralized, peer-to-peer network, the sky’s the limit in terms of innovation in healthcare. The use cases discussed in this blog are just the tip of the iceberg. We’re now at the point where we need to look beyond just transactions. Working in partnership with payers, providers, vendors, banks, innovators and other stakeholders will allow us to see the full potential of a network from a different lens—one that enables us to truly optimize the patient/member experience.

The more organizations we add to the network, the value grows exponentially because the connections grow exponentially. It’s not 0 to 10 growth; it’s 10 squared. The more connections you have, the more chances for innovation. And the more innovation you have, the more chances there are to achieve true transformation and “eureka” moments.

Time to act is now

Advancing administrative interoperability is the only way we will ever reduce the cost of healthcare and achieve long-term revenue improvements. We have to ask ourselves what value we could generate if we weren’t spending billions of dollars on administrative waste and how that would enable us to make things better for the patient. A secure, decentralized, peer-to-peer blockchain-enabled network provides the infrastructure that can make that happen.

The real challenge that we’re trying to solve is how to accomplish this in a decentralized, shared manner. Anyone can build a walled garden. We could say, here’s all the perfect use cases we want to tackle and then set about building proprietary, closed technology that everyone has to connect into. In this scenario we’d never hit the point where we reach mass adoption because not everyone wants to work within another organization’s walled garden.

Instead, we must build an ecosystem where everyone can participate and get equal access to the information they need when they need it with permission—all on a single, secure network. As the revenue cycle director at one healthcare system said, “When you start looking at what this type of network allows you to do, it is really a transformational approach to sharing data. And it’s going to fundamentally change the way payers and providers interact going forward.”

Reinventing the Back Office to Deliver on the Patient-Centric Promise

Healthcare organizations have been talking for years about the importance of the patient experience. Yet, healthcare organizations have hit several challenges that have kept our patient-centric promise from becoming a reality. As a result, we all have at least one story about a personal experience when our ability to receive timely care for ourselves or a loved one was inhibited by an outdated, ineffective administrative process.

Consider the patient who has recently changed health plans. She wasn’t feeling well and made an appointment to see her primary care provider. When she arrived at the office, she realized she hadn’t yet received her insurance card from the new health plan. She also remembered that when she signed up for the new plan, she canceled her secondary insurance coverage. She thought the coverage might still be active through the end of the month but wasn’t sure. She didn’t have that card either as she didn’t think she’d need it any longer.

Because of the lack of information, the front desk staff had no way of knowing what the patient’s new insurance would cover, what her co-pays and deductibles were, or whether the secondary insurance might still pay a part of the visit. The patient was told she would need to pay the entire amount of the visit up front and then work it out with her insurance companies on her own after the visit.

It is unfortunate that our healthcare ecosystem is so dependent on a patient’s memory and a physical insurance card to be able to ascertain a patient’s primary and secondary coverage information, along with their financial responsibility. These issues can also impact claims processes and can increase manual work for the payer. This is just one of many examples of how administrative processes make it difficult to deliver on the patient-centric promise.

Where’s the disconnect?

These administrative processes need to be improved. We know the answer: healthcare systems need to become more interoperable. We have made progress. However, research from the ONC shows that in 2019, more than one in every three physicians still relied solely on fax (paper or electronic) or standard mail to share patient information—like ultrasound results—with providers outside their organization. In fact, just 34% engaged in bidirectional electronic sharing of patient information. Why?

A significant challenge to achieving interoperability is that healthcare’s current data-sharing infrastructure is built upon one-to-one connections. These connections are expensive and resource-heavy to implement and maintain. The result is a lack of transparency that has caused distrust between payers and providers. At the same time, providers are faced with increasingly complex payer requirements that are hard to keep up with, which adds to their already overwhelming administrative load.

A new way forward

These issues could be mitigated or eliminated through a new type of interoperability that allows all healthcare stakeholders to easily connect to a single, decentralized network and then access, in real time, the needed information without the request/respond processes of today. In a world where this type of interoperability exists, the provider in the above scenario would have been able to easily discover the patient’s new coverage information and find out whether her previous secondary coverage was still in effect—all either before the patient arrived or while she was checking in.

In a fully interoperable healthcare system, data wouldn’t need to be requested, aggregated, and validated each time it’s needed. Instead, it would be continuously refreshed, always current, standardized, and always accessible via a secure and direct peer-to-peer network to those who are permissioned to access it.

Imagine a coverage solution where every authorized participant would have accurate insurance coverage information through a decentralized peer-to-peer network of payers and providers. Leveraging formats such as FHIR, all data would be standardized and ready to be accessed in your EHR. Payers and providers benefit from improved transparency and reduced costs while patients/members benefit from reduced delays in care and fewer surprise bills. This type of immediate data access would eliminate the payer-provider friction that has plagued our healthcare system for far too long—friction that ends up creating a poor patient experience, reduced outcomes, and increased costs for all. 

Delivering on the promise

At its heart, all healthcare is human. At the center of every procedure, every diagnosis, and every transaction is a human being who expects to be treated with dignity in moments when they are most vulnerable. The only way we will be able to meet that expectation is by improving the back-end processes that support and facilitate high quality care. But that requires us to completely reinvent how healthcare is administered. It’s the way we will truly transform the care experience.

We’re building a new way of doing the business of healthcare and you can join. Learn more by contacting us.