Puru P

Director of Operational Excellence @ BilledRight | 19 yrs in RCM & AI innovation | | Passion for automation, learning & scaling team

[Puru P @Purush168]

@AbhiChtrj can you send it now

[Puru P @Purush168]

@thoughtson_tech Workflow orchestration is indeed the differentiator that moves prior auth from demo to revenue impact, particularly when it incorporates denial telemetry and policy updates automatically.

[Puru P @Purush168]

The billing-authorization arms race is accelerating precisely because AI excels at pattern recognition but lacks inherent guardrails for clinical defensibility. Pairing these tools with mandatory secondary clinician review and real-time compliance scoring keeps charges aligned with actual care delivered while minimizing audit exposure. Revenue integrity teams that embed these controls early turn potential cost drivers into sustainable efficiency gains.

[Puru P @Purush168]

@helpingmom1965 Yes. Denial fatigue is a widespread operational reality,

[Puru P @Purush168]

@SnehaSaiMannam @Strive_Podcast The No Surprises Act has curbed patient balance billing but shifted costs to plans via arbitration, potentially raising premiums.

[Puru P @Purush168]

@mbc_services yes. CMS audits for ASCs emphasize comprehensive records and medical necessity—key to defending claims.

[Puru P @Purush168]

@Aidenspencer15 AI-driven claims review is accelerating denial timelines, emphasizing the need for precise clinical notes upfront. Integrating AI tools on the provider side for real-time documentation audits can match payer speed and reduce rejection risks

[Puru P @Purush168]

@PanickedFoodie Payers often scrutinize appeals by narrowing scope to billed elements, leading to underpayments despite reversals.

[Puru P @Purush168]

Spot on about the transition math—many overlook how initial revenue dips strain cash flow amid rising tech investments. In practice, phasing in hybrid models (e.g., blending FTE with per-claim fees) helps maintain 50-60% margins during the shift, while piloting with select clients builds proof-of-value. Unbundling also allows capturing upsell on analytics, reducing overall compression by 15-20%.

[Puru P @Purush168]

Billing opacity often stems from fragmented payer rules and documentation demands, leading to 15-20% denial rates that frustrate both sides. On the provider end, integrating AI for real-time claim scrubbing and eligibility verification can reduce errors upstream, creating clearer EOBs and fewer disputes.

[Puru P @Purush168]

@omar_or_ahmed Recent projections show US healthcare spending approaching $6T by 2026, with admin costs accounting for 15-30% overall—often higher in hospitals due to multi-payer complexities.

[Puru P @Purush168]

ACO incentives focusing primarily on physicians and hospitals can overlook contributions from post-acute and other partners in chronic care. Broadening reward structures to encompass full care teams aligns with CMS's burden reduction goals and enhances overall outcomes. This evolution could foster more integrated revenue integrity across the continuum.

[Puru P @Purush168]

The lag between FDA clearances and CMS reimbursement for AI tools indeed creates adoption barriers, as providers weigh clinical benefits against financial viability. Updating payment models to better reflect AI's value in efficiency and outcomes could bridge this gap. We've seen similar challenges in emerging tech integrations historically.

[Puru P @Purush168]

@SBloombergo @AngryRedInc High-value claims often falter on documentation gaps, as payers require comprehensive clinical notes to substantiate medical necessity under standard guidelines.

[Puru P @Purush168]

Traditional Medicare denial rates indeed hover around 6-10%, often stemming from incomplete documentation or coding mismatches that could be mitigated through proactive audits. Providers investing in dedicated RCM teams see fewer initial denials, as early validation of medical necessity aligns claims with CMS guidelines more effectively. This approach not only streamlines reimbursements but also reduces administrative overhead in the long run.

[Puru P @Purush168]

Prior auth delays for chronic conditions like endometriosis can exacerbate symptoms and disrupt stability. Expedited reviews for established therapies often help; providers can submit supporting documentation proactively. This minimizes gaps and supports consistent care management

[Puru P @Purush168]

@MNMegan @VoicesUnheard @ChildrensHD @RobertKennedyJr @BusyDrT @nmmaa2019 @DrBenTapper1 @BCBSAssociation Payers like BCBS use prior auth to ensure appropriate utilization, but overapplication can burden providers and delay care. Alignment with evidence-based guidelines helps balance oversight with efficiency.

[Puru P @Purush168]

@iankachadorian @mcuban Separating UM from revenue incentives is crucial to prioritize evidence-based care. Transparent criteria and external audits can mitigate biases in prior auth and formulary design. This ensures decisions align with patient outcomes rather than cost containment alone.

[Puru P @Purush168]

AI's role in predictive denial prevention can reduce rates by up to 19%, allowing teams to focus on complex cases. Integrating machine learning with payer data enhances accuracy in coding and validation. This approach streamlines workflows while maintaining compliance with evolving CMS guidelines.