Subscribe
Share
Share
Embed
Where we share our weekly news debriefs and discussions with industry experts. These are lo-fi recordings aimed at giving our readers more opportunities to engage with our analysis and a view into some of the conversations that shape it.
Martin: That is actually a great,
perfect segue for our guest today, Dr.
Jeremy Fries.
Welcome to the show.
So we are prior auth respecters
and appreciators here.
And so we, uh, at Health Tech Nerds, so
we are really happy to have you to come
and, and talk about how you're helping
kind of make that a, a, a better process.
Can you give us a quick refresh?
We wanna start with WISeR.
Can you give us a quick refresh on the
WISeR model, what it's focused on, how it
works, and what Humata is implementing,
um, to, to kind of help that in Oklahoma?
Jeremy: Uh, first, good
to see you again, guys.
Yeah.
S- My name is Jeremy.
I run a prior auth company.
All we care about all day long is
solving prior auth for patients.
Most of our customers
are big health systems.
We help them submit better prior
auths to every plan in the country.
And we've decided to participate,
uh, and are proud to participate in
the WISeR program, which is a CMMI,
CMS-sponsored program.
We have the great state of Oklahoma,
where we help, uh, say yes immediately
using our artificial intelligence for
the very limited set of prior auth
codes, again, in under traditional,
uh, fee-for-service Medicare.
And folks submit to us.
If our AI can say yes immediately,
great news, you go forward
and deliver care immediately.
If we can't say yes immediately,
then we've got an army of doctors
and nurses that take a look at every
single one of those and give an answer.
And this, the, the program in general is
being done across six different states.
As I said, we, we have one state.
Uh, there are five other participants
that also each have one state.
And like I said, ours is
the great state of Oklahoma.
Went live in January of this year, so
we've now got almost six months under
our belt, which is kind of crazy.
Kevin: Jeremy, I was reading a, I think
a CBS News article you were quoted in
about rollout of WISeR, what's going
on in Oklahoma, and it included this
interesting example of a, I think it
was a cattle rancher in Oklahoma, who's
talking about how they feel like they
might need to go to Kansas for their
care moving forward because of concerns
about how the program's been rolling out.
Can you give listeners here, uh, from
your perspective, what's going on with
the program, the rollout, and what you
would say to cattle ranchers like the,
the gentleman who was referenced in the
CBS News article about their concerns
about access to care in the state?
Jeremy: Yeah, so, um-
A-as you, as you all have been talking
about, prior auth is a process in
the United States that is a, is
a laborious, friction-laden one.
And so we're on a mission to make
that as seamless and as streamlined
as possible for both providers and
payers, and firmly believe that the
only way that you're gonna solve this
problem for the patient who's stuck
in the middle is if you automate the
submission and you automate the decision.
And what that, you know, what that means
is a provider has to submit an auth,
and, you know, that's done through the
traditional channels if, you know, if
they're not using us or someone like us.
And y- you know, if, if, uh,
and that has, and that needs
to be done in advance of getâ¦
of delivering care.
And so what that means is practices, uh,
across Oklahoma, but frankly across the
entire United States, this is already
being done broadly across commercial
insurance, Medicare Advantage, et cetera.
And so practices need to plan, and they
need to submit their prior auths upfront,
and if that's the case, then we can give,
uh, we can give an immediate answer, and
care can be delivered forward immediately.
And so this process, uh, is not a new one.
It is new under these 20 codes, and in
some circumstances, providers, you know,
submit these maybe later than they should.
And when that happens, it, you know,
it takes some time to turn around.
The, uh, the great news is, in
that example, we turned it around
immediately, and, and care could
have been delivered immediately, but
it was, you know, elected not to.
So it does take, it does take
some preparation and planning on
the provider's part, um, so that
we can get to an immediate yes
and, and care can be delivered.
Martin: One of the things that's going on
right now is there's been a ton of media
attention on prior auth, as you mentioned.
There's a, a-
Jeremy: Yeah
Martin: Big old laser pointed at
it, specifically WISeR as well.
And I think in, in our view, or I,
I won't speak for Kevin, I'll say
in my view it feels like it is an
election year and so some of this is,
like, convenient and some of it is
there's just, like, a negativity bias.
Like, the, theâ¦
There are not stories about where
doctors are running out and saying-
Jeremy: Yeah.
"Yay, let's do prior auth."
Martin: Right ⦠"My, my prior
auth was approved instantly."
Uh, they're saying like, "Oh,
in this one case where maybe I
forgot to submit it on time."
All right, so, soâ¦
But taking a step back, you're
focused on prior auth all day, 24
hours a day, seven days a week.
It is a, I think, sort of in a,
as I mentioned in the lead-in,
we're prior auth respecters here.
We understand that, like, you can't
just say yes to everything, that,
that, th- that we wouldn't have any
money left for things like roads or, or
schools if we said yes to everything.
So how are you, like, how are you
managing or navigating this, like,
persistent sort of negative overwhelming
bias against prior auth and then
the sort of the necessary, like, th-
that sort of necessary component?
It's like, it's not like they
picked these 20 codes at random.
They were codes that, that,
that were sort of hi- Yeah.
So I'll, I'll kind of pass it over to you.
But that's, I, I think a question
on our mind is, like, how,
how are you navigating that?
Jeremy: Yeah, the, the mac-- uh,
you know, I'll call it the macro
environment around prior auth, I think
you've described very well, Martin.
It i- it is challenging, and
it's because of the way prior
auth has been done in the past.
And yet, if we're gonna save the
American healthcare system, we need
to be able to help control costs.
And, and we need to make sure that grandma
and moms and dads aren't having surgeries
that aren't, aren't medically necessary.
And so we need this balance of checks
and balances on both providers and
payers to make sure that we can get
the right care, but we can't keep doing
it like it's been done in the past.
The reason prior auth has such a bad name
is because it does delay care in today's
world, and it, and it does have all
the negative connotations for a reason,
so it needs to be done differently.
And that's what, that's the reason
that we're participating in WISeR.
We're trying to prove that
it can be done differently.
You can say yes immediately and get
care swiftly, and make, and make
sure to protect both the American
taxpayer from paying too much
for things that aren't necessary.
But you guys, there's a whole bunch
of patients across the United States
that are having things done to
them that aren't, aren't valuable,
aren't driving to better care, and
we know there's enormous variability
of care across the United States.
That's been known for decades and decades.
That's not new.
And so how do we balance this process of,
you know, saving the American taxpayer,
but also saving the American patient and
making sure that this process isn't done
like it's been for the last thirty years?
We need to do it with technology
in such a way that we can submit
instantly, we can make decisions
instantly so that care can get delivered
Kevin: Jeremy, I wanna ask you a question
on the, the adversarial relationship
between payers and providers, and how
much of that can be automated away.
Iâ¦
One of the most interesting Substack
articles I've read in the, in recent
weeks was from a, I think it was a spine
surgeon, and he was lamenting how Highmark
Health moved to their own internal AI
prior auth, um, approval process away
from eviCore, which he preferred because
eviCore had a human who interpreted the
ambiguity of some of, like, the spinal
biologics that were being used in favor
of the surgeon, whereas the AI was denying
it because it was, it, it interpreted
the ambiguity differently and did not
think it was, uh, appropriate for care.
To me, it was, it was a crazy
moment because, you know, eviCore
has been referred to as evil
core in various press over time.
Physicians in general do not like it,
and yet here is a doc being like, "I
actually prefer what happened in the
past because human was involved because
they would interpret the ambiguity in
my favor and ultimately approve care."
To me, it is, it was such a reminder
of the tension that exists in these
payer-provider conversations, how
goalposts are moved over time, and it
invites the question of how much can
be actually be automated away in these
tense negotiations and conversations,
and a little bit of what I hear going
on in Oklahoma is revolves around that.
How do you think about, as a company
working on resolving those issues via data
infrastructure, via real-time processing,
et cetera, how do you think about getting
in the middle of that conversation
and resolving it in a productive way?
And how much can actually be resolved?
Jeremy: I, uh, believe very
strongly in several things, but
two things that specifically, uh,
relate to what you asked, Kevin.
Number one, we need, we need dramatic
transparency in prior auth We need to know
what requires prior auth, what doesn't.
We need to know what the
rules of the game are, period.
That, that's a huge step forward.
That can be d- that can and
only be done with technology
to make it visible to folks.
Part of what we've done in Oklahoma
is, is show what the rules of
the game are right in our portal.
These, this is the existing NCD/LCD.
This is the clinical criteria that CMS
has set to drive that transparency.
So number one is transparency, and I do
think that technology, both willingness
from, you know, both parties, but
also technology helps drives that.
And then number two, AI can,
can and should only be used to
say yes And I, I'm not-- I can't
speak to the Highmark example, the
accuracy or inaccuracy of that.
Kevin: Yep.
Jeremy: Um, that's not us.
But what I can tell you is our AI can
and will only be used to say yes, and
that means that if you've got the right
clinical information and it meets the
clinical criteria that CMS has set or
a payer has set, yes, go deliver care.
If the answer is, "Hey, it's not
quite right," then 100% it needs
to be adjudicated by a human, and
whether that's Evicore or Highmark
or, you know, somebody else, um,
but it needs to be done by a human.
So that's the way I thinkâ¦
The reason I think prior auth is the
use case that you can get providers
and payers to actually sit down,
guys, and I've seen it so many times.
In, in fact, just a couple
weeks ago in DC with Dr.
Oz, leading providers and leading
payers sitting down together say, "How
can we automate the 90 or 95%," or
whatever the number is that get to yes?
Because it's expensive and a pain in the
butt for providers, and it's expensive
and a pain in the butt for payers
when the answer should just be yes.
And so use computers to submit
better auths, use them to make yes
decisions, and then have the humans
involved on the ones that you have
to battle over, these 5 or 10%.
And that's the way-- And you deliver
transparency in that process.
That's the way prior auth turns from
being, you know, sort of the evil word
that it is today to something that
actually is done behind the scenes and
affects very, very few people because you
have that, you know, that friction area.
Martin: We had Zeke Emanuel
on a couple weeks ago.
He was, he wrote that article in The
Bulwark we really liked about how
we're all gonna have to make some
trade-offs to have- Yeah ⦠the
healthcare system that we want.
It, it strikes me that a platform like
Humata, like you're kind of sitting
at the center of asking the payers
and providers to come together and say
like, "We can do something positive
sum for everyone, but it's gonna
require some coordinated activity."
I'm curious, like where are the sort of
pockets where there's actually really
good alignment and it just takes getting
someone like you in the room between them?
And where are there areas where
there is just like, you know,
f- uh, still a lot of friction?
Like w- how, uh, d- does the, the, uh,
do the codes sort of like map onto that
80/20 where it's like these sort of codes
end up in the like a lot of friction and
need humans, and these ones are actually
areas where there's a tremendous amount
of room for, for this positive sum win?
Jeremy: Yeah.
Weâ¦
Well, first of all, I like to say, uh,
our goal is to be Switzerland between
the providers and payers, and just
get to the right answer, and get to
the right answer as fast and cheap as
possible so that care can get delivered.
And there is, there is a bunch
of varied variability, Martin,
but among different codes.
And, you know, as you, as you
referred to, these codes in
WISeR were chosen for a reason.
They're, they're ones where there's, you
know, reasonably known, uh, variability.
And when you have that variability,
there's, you need to have some oversight,
and that oversight means you have
to check some clinical information.
And so that process of checking
clinical information requires
effort on the provider side and
effort on the payer side today.
And so the, the, theâ¦
I mean, my answer would be all across
the board, all of these prior auths,
uh, there's most of them get to yes.
The number of yeses depends on
a back surgery versus a, a head
CT, but most of them get to yes.
And so how can we be transparent, use AI
to submit better auths and make better
decisions, faster decisions, and then let
the, let the humans on both sides, you
know, sort of duke it out on the, on the
few percent that need to be discussed.
So that that spine surgeon you referred
to, Kevin, uh, can talk to a spine
surgeon on the payer side and say, "Hey,
this is why I think it should be done."
"Okay, I agree.
Let's move on."
I'll have to say having done that for
a decade, and, uh, uh, I mean, having
done that as a provider at Mayo Clinic
for a decade, that's still not fun.
Like, uh, there were still many, many
times where it should've, you know,
it should've just been yes and didn't,
didn't get to that point of needing
the doctor to doctor phone call.
Kevin: Yeah.
Jeremy, I wanna ask on, as I think
about Humata in general, uh, outside
of WISeR program, as I understand
it, you're working a lot with health
systems, provider organizations on,
on prior auth side of the world.
Jeremy: Yeah.
Kevin: It sounds like in WISeR, in
particular, um, part of the challenge
is getting providers aware of the
process, how they go through the
process, how they submit information.
At least as I, like, sit here, I'd be
curious if that's your take as well.
Jeremy: Yeah.
Kevin: But it, it seems like an
interesting, on the one hand, you're
normally working with providers
and rolling out via providers.
In this one scenario, one of the
challenges, getting providers
aware, trusting in the tools, using
the right processes, workflows.
Is that, is, is the explanation
for that as simple as the starting
point of the implementation?
In one scenario, it's CMS as payer
saying, "Hey, we're doing this," versus
provider saying, "We wanna do this."
And how do you think about kind of the
trust-building exercise that has to
happen with providers in the market to
get them using these tools in the, in
the right process, right manner, right-
Jeremy: Yeah.
Kevin: Portal, all that kind of stuff?
Jeremy: I mean, I see the w- I see the
world through the lens of a doctor.
And so, uh, when we were awarded that,
that contract in, in Oklahoma, you
know, the second CMS allowed us to
start talking to folks, we did so.
And doing webinar, just as you said,
doing webinars, doing individual
phone calls with providers.
You know, literally everything that
we could think of to make sure that
they knew that, you're right, this
was a new process where they had to
s- they had the choice of, they could
either submit the prior auth before
care is delivered, or they can submit
clinical information with the claim.
One, uh, so they still had the same
process that they could do, but they
could choose to do the submission upfront.
And, uh, one of the things I'm really
proud of is in the few short months
since we've been live, providers
in Oklahoma could submit these auth
directly to CMS, or they could submit
it to Humata, a company that they had
never heard of before this process.
And this last month, every single
auth was submit directly to us
through our portal, except for one.
Except for one.
And, and that's because we've worked so
hard at providing that sort of physician
and health system customer service so that
they know, here's the proce- Again, how do
you bring transparency to this pr- process
that is typically not transparent, and
just, and give them a, a technology tool
that is pretty seamless and easy to use.
And then, oh, by the way, when you
get transparent visibility in the
portal and you get an immediate
answer, turns out that's pretty cool.
Martin: That's an impressive
stat, all but one.
I would love to know what that one doctor
is like, "No, I really prefer faxes.
I really think that-
Jeremy: I love a fax machine.
We love a fax.
The fax is pretty easy.
Yeah, I mean, you just
push a button, you know?
But yes, thank you.
But we're pretty proud of that.
Martin: Um, that's all
the time we have today.
This was very informative.
Thank you so much for giving
us an update on WISeR, fighting
the good fight on prior auth.
Where can folks find you if they
wanna learn more, if they're a health
system thinking this sounds like a
great, a great thing, or a doctor?
Jeremy: Love to have a conversation.
We're at humatahealth.com,
and I'm at jeremy@humatahealth.com.
Thanks for having me, guys.
Martin: Jeremy, thanks so much.
Kevin: Appreciate it very much.
Good seeing you.
Jeremy: See ya.
Bye.