Most managed care teams can win a better contract. Far fewer believe they can get a payer to stop the denials, underpayments and downcoding that quietly take their negotiated rate increase back, and then some.
When I tell a managed care executive that we have helped get payers to change their behavior, the reaction is almost always the same. Skepticism. These are people who are good at their jobs, who win rate increases and hold their own in negotiations. What none of that touches is the conduct after that negotiation is over, in the transactions: the denials, the downcoding, the underpayments and the takebacks that quietly claw back everything they just won. They have raised these issues with payers before and they know exactly how that call ends, with the payer telling them, in so many words, to pound sand. After enough of those calls, you stop believing that part of it can move at all.
I get it. I hear the same line from health system after health system: this sounds amazing, but I have never seen a payer actually do anything, and even if they do, it certainly doesn’t happen fast so why would I believe you? For most of these executives it is earned. It is also the single most expensive assumption in their building, because it is wrong.
Payers have been able to say no, deflect or delay for so long because they’ve engineered a system that runs on an asymmetry of information in their favor. Payers see the whole picture, data from every health system and payment integrity vendor they work with. They run the rules, the edits, and the policies, and more and pay their payment integrity vendors hefty contingency to find new reasons not to pay. The provider, on the other side of the transaction, sees denials land one at a time, with vague reason codes, spread across dozens of payer IDs that do not line up with the contract their managed care team signed. So providers do the only thing they can, work the appeals, rebill the account, and the cost of doing business goes up.
What changes that is evidence. Unimpeachable evidence payer’s can’t hide from.
When we put Manage to work for a health system, it looks at every claim across every payer they contract with, identifies patterns and synthesizes complex contract and policy data, and compares the way every other payer in their book handles the same situation. Telling a payer your Days in AR are high with them or that you think a denial is wrong gets you nowhere. Showing them they are denying a service at many times the rate of every other payer in your book, against terms you both signed, with the claims to prove it is a different conversation. For years, managed care teams have walked into these meetings with spreadsheets and a stack of anecdotes. The moment the payer asks the next question, which plan is doing this and when did you first see it, an anecdote has no answer, and the conversation dies right there. Without the data, answers, and receipts to back it up, a payer will handily dismiss the problem outright.
In an early deployment of Manage with a major U.S. health system, we found dozens of these patterns and one in particular that stood out: a single payer was applying bundling logic to inpatient claims in a way the contract did not allow, quietly folding services together so it could pay less on each one. The team knew something was off but couldn’t prove where it was coming from. All of these seemingly small edits across the full book added up to real money, part of more than $100 million in annual financial impact we found in that one system.
The health system brought the documented evidence into its next joint operating committee with the payer: every affected claim, laid out against the contract terms the payer had agreed to. After a very short back and forth (less than a week!), the payer agreed the edits were inappropriate. The payer turned off the edit and hundreds of denials that had been hitting the work queue every month simply stopped and claims paid at the expected rate, worth more than $1 million a month in recurring, incremental net revenue to that system.
The managed care leaders we worked with were surprised at the speed and agreeableness of the payer when presented with the evidence. There was no lawsuit or drawn out standoff. The payer looked at what we put in front of them, saw they could not defend it, and turned it off. Most of the time the payer had not even fully realized the edit was running, because they outsourced that logic to multiple vendors without clear oversight of how it impacts providers.
And the thing is - this is not an isolated story. Once you start looking with the right tools, the same patterns show up again and again, in different forms.
One payer was performing deceptive and inappropriate payment takebacks that never hit the providers accounts receivable or standard workflows. After identifying the outlier behavior and verifying the root cause, the provider confronted the payer and secured a pause in takebacks, increased internal response times to dispute the takeback, where appropriate, and is negotiating recoupment for prior financial impact.
One learning for me is that this didn’t happen because we had a dashboard. What makes Manage work is the partnership around it. We do not throw a tool over the wall and say “good luck!” Our team sits in the trenches with the managed care and revenue cycle teams, validates each issue against the real contract and policy, and sorts what the provider needs to fix on its own side from what the payer is genuinely doing wrong. We are on the phone and in the room for these conversations with the payer. By the time an issue reaches a payer, it has been narrowed to a handful of problems we can prove cold, each one documented down to the claim. That is why payers engage with what we bring instead of brushing it off the way they would a longer and looser list of anecdotes and complaints.
I am not naive to the fact that insurance companies are not solely at fault for all of the administrative waste and burden in healthcare. The real villain in this story is the system itself - the most insanely complicated payment system mankind has ever dreamt up. However, when you combine this mind-boggling complexity with misaligned incentives and powerful interests that benefit from this opacity, it’s no wonder things have felt lopsided for so long.
But the massive improvements in AI and modern technology are changing the landscape and the information gap is closing. For the first time, providers can see what payers see (and more), and they can walk into a negotiation with the same quality of evidence the other side has always had. When that happens, payers actually change what and how they are paying you. I have watched it happen time and time again, and it still energizes me every time, because the executives across the table had given up on the idea that payers could or would make a change. They were told their whole careers that the denials, the downcoding, and the takebacks were just the cost of doing business, a tax they could negotiate around but not lower. They were wrong about that, and not upset about it! Show a payer something they cannot argue with, and they will change what they are doing.
That is what we built Manage to do. It puts “the receipts” in a provider's hands, every claim across every payer, matched to the contract and ready for the negotiation table.
