Fence mending: How emerging tech is reshaping health care collaboration

Yunguo Yu: ©Zyter TruCare

When it comes to helping people maintain their health, care providers and insurers should be on the same page. With a common goal of keeping people free from illness, the two critical stakeholders should be working perfectly in tandem.

So why are the two so frequently at cross-purposes?

In the relationship between payers and providers—essentially a marriage of convenience—there are a number of longstanding tensions. These include:

• Reimbursement rates and speed: Doctors and hospitals complain that insurance companies underpay or drag their feet when it comes to reimbursing. While the two sides can negotiate, these dealings can be rough.
• Prior authorization: Insurers say the process helps ensure appropriate, quality care for their members, while providers say it does little more than delay or deny the care that patients need.
• In-network vs. out-of-network considerations: Just like patients, health care providers find it frustrating if they find themselves excluded from payer networks, as this limits the number of patients they can see.

While physicians, clinics, and hospitals are the ones to initiate the majority of health care spending, they find themselves at odds far too often with the insurers who actually control the purse strings.

It’s a situation that has gradually gone from bad to worse.

As the cost of health care continues to outpace inflation, health plans have tightened up various processes, including procedures for prior authorization. For their part, providers have become increasingly frustrated with the amount of work necessary just to comply with payer processes—frustration that is heaped on top of the vexations they feel related to care delays or outright denials.

For example, surveys by the American Medical Association (AMA) indicate that 94% of physicians report care delays associated with prior authorization requirements. In another survey, patients reported waiting over a week for an answer to their authorization request.

The government has stepped in to try to calm the waters via state and federal regulation, but it likely won’t be policymakers who can turn this shotgun marriage into a love connection. If anything moves payers and providers out of their opposing corners, it will be new technologies —especially tools that health plans are adopting to reduce the complexity of their reimbursement processes. It will also be technology that will let them together pursue a Holy Grail of the health care industry—enabling proactive, preventive care, especially among members and populations deemed to be at “rising risk” of costly complications.

The high-tech payer

Health plans’ ongoing adoption of new technologies, particularly agentic and predictive artificial intelligence, is beginning to lessen the prior authorization burden considerably, which should eventually improve payer-provider relationships. For instance, by automating and adding intelligence to manual steps in the process, agentic AI can enable immediate authorization of the vast majority of requests.

Complex authorization requests that still must be submitted for clinician review are increasingly being aided by AI “co-pilots” that assist health plan reviewers, by scanning massive amounts of clinical text to help determine the appropriateness of a requested medical service. This acts as a significant tailwind, enabling more immediate approvals and faster turnaround times for complex requests.

Health plans are also using AI to predict adverse health events in individuals or in patient populations, making early intervention easier. Many of these interventions in turn can be aided by AI agents to help notify providers and members of the need for a medical intervention or to help recruit members into plan-sponsored programs designed to keep members’ health from deteriorating. With preventable medical errors costing the U.S. healthmcare system an estimated $20 billion annually, according to a study published by the National Institutes of Health, there’s a tremendous opportunity for AI agents to help clinician reviewers catch and prevent more unnecessary or harmful medical services.

If providers have not yet noticed changing dynamics in their relationships with health insurance companies, it might be because too few health plans have so far adopted these sophisticated new techniques and technologies.

That is changing, and there are several areas where hospitals, clinics, and doctors can look forward to collaborating—instead of wrangling—with health insurers as payers go increasingly high-tech:

• Treating ‘rising risk’ patient groups: Providers and payers now can work together to predict adverse health trends among ‘rising risk’ patients and populations—for example, those managing chronic conditions like diabetes—and predict the trajectory of their illness and its impact on population health, using predictive AI and large language models (LLMs). Enabling early, proactive intervention with an individual or a population at risk is an ideal area for providers and health plans to work together, as it will help prevent costly escalations in care while promoting better health outcomes.
• Prior Authorization: As more payers use AI to detangle this complex process, the vast majority of prior auth requests will be approved instantly, enabling immediate scheduling of the service the provider wants for their patient, and dramatically shortening approval times for complex requests that require review by a health plan nurse clinician or physician. Even better, many prior auth requests will be initiated automatically from electronic health records—so provider staff won’t need to “touch” the request at all. This will smooth over one of the most intractable pain points of the provider-payer relationship.
• Tracking disease outbreaks: As the government takes steps that limit the flow of information from one health care organization to another, payers and providers can pick up the slack by working together to track the outbreak of disease. A pattern of reduced vaccination, for example, could lead to an automated prediction of disease outbreaks in months, thus giving plans and providers time to prepare.

Value-based care, by definition, is a partnership between health care providers and the plans that pay for treatment. But it’s been a relationship fraught with misaligned incentives and misunderstandings. Too often, patient care does not see the improvements that value-based care should bring.

Top-down policies from government agencies may ease payer-provider relationship tensions. But new technologies will do far more than that. They will allow the two parties to work together productively, and on the issues that matter the most to both.

Yunguo Yu, PhD. and M.D. is the vice president of AI Innovation & Prototyping at Zyter | TruCare. As a recognized leader at the forefront of AI and healthcare, Dr. Yu is driving industry transformation through award-winning, data-driven solutions that improve patient outcomes and financial performance. With a proven track record, Dr. Yu has built and led high-performing global AI and data science teams, delivering impactful solutions that enhance efficiency, foster innovation, and generate measurable results. He has conceptualized, developed, and deployed nearly 1,000 AI/ML models—contributing to significant financial gains and strategic growth across the healthcare sector.