The ongoing conflict between healthcare providers and insurers has evolved into a sophisticated contest dominated by algorithms, where AI-driven tools for prior authorizations face off against those designed for appeals.
Ashis Barad has firsthand experience from both perspectives of this struggle. He began his professional journey as a physician at Sutter Health and later worked at Baylor Scott & White Health, where he was instrumental in advocating for advanced digital solutions. In 2022, Barad took on the role of chief digital and information officer at Allegheny Health Network and its parent organization, Highmark Health, gaining insights into how insurers develop and implement AI technologies. Two years later, he transitioned back to the provider side by joining the Hospital for Special Surgery (HSS) in the same executive role.
Barad asserts that the ongoing race to automate authorizations and appeals is ultimately a misguided approach.
“We're engaged in a limited competition while ignoring the broader, ongoing challenge,” Barad pointed out. “If we continue to focus solely on the immediate concerns, we will persist on an inflationary trajectory. We must collaborate to determine how AI can lead us towards a more efficient, cost-effective model because that is what our patients deserve.”
Rather than funneling resources into AI for swifter authorizations and appeals, Barad envisions a future where providers and payers share data to create more individualized care protocols.
He highlighted HSS as a prime example, noting that the institution conducts over 40,000 orthopedic surgeries annually, surpassing any other hospital in the United States. HSS has successfully created a comprehensive database that links imaging results with surgical outcomes.
Such extensive real-world data is a significant gap in the information available to insurers. Barad believes that if payers and providers collaborated to develop these models, authorization processes could become more precise and tailored to individual patients, rather than relying on generic guidelines.
He has already tested this concept in discussions with payers. During a recent meeting with a prominent insurance provider, he inquired about the potential value of HSS's integrated imaging and outcomes data for their actuarial teams.
“They expressed a keen interest, saying they'd find it extremely valuable,” he shared.
Payers generally have access only to basic claims information, such as rates of infection or readmission following initial surgeries, but they lack data on outcomes for patients undergoing multiple procedures. This lack of detail is significant, especially as many HSS patients are complex cases that fall outside typical metrics.
Barad believes that a transformative opportunity exists in utilizing this richer dataset to fundamentally change authorization processes. He pointed to the practice of “gold carding,” which allows exceptional providers to bypass prior authorizations, as an area ripe for reimagining.
Currently, this practice relies on rudimentary criteria, such as flowcharts and cost limits, rather than actual patient outcomes. Barad envisions a redesigned approach personalized for each patient, integrating authorization seamlessly into care pathways rather than treating it as a separate, post-service request.
However, he warns that as long as providers and payers continue to invest in AI merely to outsmart one another, this competition adds unnecessary costs to an already strained system. He emphasizes that the road to genuine cost reduction lies in cooperation and shared data initiatives.
