Sift Healthcare

The healthcare revenue cycle has reached a crucial tipping point: legacy, closed software platforms simply can’t keep up with the needs of modern health systems. As costs rise and inefficiencies persist, an API-first approach helps unlock true interoperability, transparency and operational speed. https://bit.ly/4fDd48Z #healthtech #revenuecycle

This Thanksgiving, we’re filled with gratitude for the people and partnerships that make our work possible. To our investors who believe in our vision, our brilliant and dedicated team, our industry partners helping to transform the healthcare revenue cycle and our clients who guide us—thank you. Wishing everyone a wonderful and meaningful holiday!

The partnership between @Salesforce and Shield of California shows how #AI is transforming prior authorization. By identifying cases that meet approval criteria, AI can reduce the administrative burden on clinicians, speed up decisions, and free up time for more complex cases. This kind of data-driven efficiency has the potential to turn weeks-long delays into same-day approvals, easing one of healthcare's most burdensome processes. https://yhoo.it/4fVrIIO #healthcarefinance #healthtech

A new report from Patient Rights Advocate shows that just 21% of hospitals fully comply with federal price transparency rules—a drop from earlier this year. Weak oversight and inconsistent data formats make it harder for patients to compare prices and protect themselves from overcharges. Aggregated data and #machinelearning solutions can empower health systems to not only meet these requirements but also drive efficiency and build trust by providing clear, actionable pricing information. Transparency isn’t just a mandate—it’s an opportunity for innovation. https://lnkd.in/gQrdyq9J #Healthcare #PriceTransparency #HealthTech

Denials can significantly drain a healthcare organization's finances, but much of that can be *prevented*. By integrating adaptive #ML insights and documentation alerts into clinical workflows, providers can show the quality of the care they provide and fully justify payment for the services rendered (meaning fewer denials, especially in avoidable categories).

From a new Healthcare Financial Management Association (HFMA) report, relationships between providers and payers are deteriorating, with nearly 60% of health system CFOs reporting worsening dynamics over the past three years. The driver — deep frustrations over increased denials and growing administrative burdens. -75% of providers have had to hire additional financial services staff just to manage denials. -87% of CFOs say payer friction impacts their ability to deliver optimal patient care. The solution? Better tools for providers — data-driven tools that keep pace with payers and *prevent* denials and greater payer transparency (around payment rules and behavior drivers). #hfma #healthcarefinance https://lnkd.in/gJcbE3wS

Major Medicare Advantage insurers—UnitedHealthcare, Humana, and CVS Health—are denying prior authorizations for post-acute care at significantly higher rates than for other types of care. UnitedHealthcare’s denial rate for post-acute services went from 10.9% in 2020 to 22.7% in 2022. Payers increasingly rely on predictive algorithms to influence denials. Without access to complete data or AI-based tools and integrations around prior auth and denials, providers often struggle to track, keep up with, and respond to payer denials. This reactive approach means they are frequently left managing denials after the fact, leading to administrative burdens and in some case, delayed care. https://bit.ly/3YIqoBN #revenuecycle #AI

The troubling role that prior authorization companies play in our healthcare system, all pointing to the critical need for a more transparent and data-driven approach to payer/provider communication and adjudication: 1️⃣ Profit-Driven Denials: Companies like EviCore (covered in the article), often hired by insurance payers, make money by reducing care approvals. Through adjustable algorithms, they can increase denials to save costs, leading to delayed or denied treatments. 2️⃣ Algorithmic “Dialing” of Care Access: EviCore’s proprietary algorithm—the “dial”—allows the company to control denial rates by adjusting the criteria for approval. The algorithm often sends requests for further review, increasing the likelihood of rejection, particularly for costly procedures. 3️⃣ A System of Fragmented Guidelines: Healthcare providers often face outdated, rigid rules, making it harder to navigate the system and access timely care for patients -- an added burden to physicians and administrative staff who must advocate for necessary treatments. 4️⃣ Lack of Transparency: Prior authorization companies operate with little public oversight, despite directly impacting patient outcomes. In states like Arkansas, the denial rate for private plans with EviCore was nearly 20%. https://bit.ly/4fDSLIg #RevenueCycle #HealthcareInnovation

For us at Sift, it's an honor to recognize the veterans across the country who have served and sacrificed to protect our freedoms. Thank you to those in our community and beyond who have served, defended and sacrificed. We’re grateful for your courage, dedication and the example you set.

The recent lawsuit over “ghost networks” exposes a troubling gap in healthcare: despite seemingly robust provider directories, patients struggle to find accessible, in-network services. This issue is symptomatic of a larger challenge—outdated #revenuecycle and tech systems that fail to keep up with payer practices. Providers face constant hurdles to get reimbursed accurately and promptly. From unreachable providers in directories to denied claims and complex billing, it’s clear: our systems need smarter, more responsive technology to prevent adverse outcomes and improve access to care. Until #healthcare adopts better intelligence and automation, these gaps will continue to affect both patient access and provider sustainability. https://lnkd.in/gPuUt47Y