Anomaly Insights Launches AI-Powered Tool to Empower Managed Care Executives in Payer Negotiations

Anomaly Insights, a startup focused on using artificial intelligence (AI) to improve payer intelligence, has launched a new tool called Manage. This solution is designed to empower managed care executives by providing them with robust data-driven evidence for negotiations with insurance companies. According to Mike Desjadon, CEO of Anomaly Insights, the U.S. Healthcare industry's payment system is often adversarial and characterized by significant data asymmetry between insurers and health systems.

Desjadon explained that this imbalance allows insurance companies to manipulate the system through claim denials and downcoding services to lower-reimbursement codes. “It’s that asymmetry that enables an insurance company to make the healthcare system chase its tail with denials and all the things they do with data,” he said.

Tackling Data Asymmetry with AI

The Manage solution aims to address this issue by analyzing all claims across every payer in a health system's contract. It identifies patterns and synthesizes complex data, providing providers with clear insights into when payers are denying valid claims or downcoding services. The tool is designed to be user-friendly and efficient, minimizing the labor required to gather and interpret this critical information.

• Data Analysis: The solution examines all claims across every payer, identifying patterns and anomalies.
• Pattern Recognition: Machine learning algorithms detect irregularities in claim processing, such as unjustified denials or downcoding.
• Actionable Insights: Providers receive clear, actionable data to support their negotiations with payers.

Dan Unger, Chief Product Officer at Anomaly Insights, emphasized that the company has received positive feedback from health systems using the tool. “We have tangible success stories where we have helped payers stop doing things and change their behaviors, leading to significant financial outcomes,” he said.

In Practice

Anomaly Insights was founded in 2020 with a mission to use machine learning to detect irregularities in medical billing, preventing overpayments and billing errors. The platform includes several solutions:

• Detection: Identifies anomalies in claims data.
• Prediction: Forecasts potential claim denials to proactively address issues.
• Recovery: Helps recover funds from unjustified denials.

The Manage solution is the latest addition to this suite, specifically tailored for managed care executives. It leverages advanced machine learning algorithms to provide a comprehensive view of payer behavior, enabling providers to negotiate more effectively and ensure fair reimbursement.

Desjadon highlighted that the goal of Manage is to create a data-driven mechanism that can repeatedly and reliably change insurance company behavior with minimal effort. “The whole point is to get an insurance company to change their behavior proactively,” he said.

Context: Medicaid Work Requirements

While Manage focuses on improving payer-provider relationships, it's worth noting the broader context of healthcare policy changes. The Centers for Medicare & Medicaid Services (CMS) recently released guidance on implementing Medicaid work requirements, a move that could affect how health systems and insurers interact with low-income populations.

• Key Issues: States must operationalize work requirements by 2027, requiring significant policy and operational decisions.
• System Upgrades: Health systems will need to implement necessary system upgrades or changes to comply with the new regulations.

These changes highlight the increasing complexity of the healthcare landscape, where tools like Manage can play a crucial role in ensuring fair and efficient financial interactions between providers and payers.

Key Takeaways

• Data Asymmetry: Insurance companies often have an advantage due to better data access, leading to issues like unjustified claim denials.
• AI Solution: Anomaly Insights' Manage tool uses machine learning to detect anomalies and provide actionable insights for managed care executives.
• Positive Feedback: Early adopters have reported significant financial outcomes and behavior changes from payers.
• Policy Context: The implementation of Medicaid work requirements adds another layer of complexity to the healthcare landscape, emphasizing the need for robust data-driven tools.