Welcome to the Empowered Patient Podcast with Karen Jagoda. This show is a window into the latest innovations in applying generative AI, novel therapeutics and vaccines, and the changing dynamics in the medical and healthcare environment. One focus is on how providers, pharmaceutical companies, and payers are empowering patients. In addition, conversations are often about how providers, care facilities, pharmaceutical companies, and payers are being empowered by technology to improve patient outcomes and reduce friction across the healthcare landscape.
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Leveraging AI and Subject Matter Expertise to Tackle Complex Healthcare Claims and Reduce Denials with Mike Esworthy EnableComp TRANSCRIPT
Download PDFMar 28, 2025
Mike Esworthy, Chief Strategy Officer at EnableComp, understands the challenges that health systems face when dealing with complex health claims such as workers' compensation, Veterans Administration, motor vehicle accidents, Medicaid, and out-of-state claims. These exception-based claims require deep subject matter expertise to identify the right payer and process the claims correctly. Using AI-driven technology, EnableComp helps hospitals manage complex claims, minimize the number of denials, optimize revenue, and allow them to focus on their core commercial claims.
Mike explains, "I think the easiest example to provide in that context, if you look at a worker's comp claim, more often than not, when a patient comes into the hospital, they don’t know who their company's workers' comp provider is, and so often they hand over the commercial insurance card. If that doesn't get caught early, the commercial insurance gets billed, it results in a denial, and the claim sits out there in the ether for 30, 45 days before it comes back to the provider to go figure out who is the right payer class for this. So that's the big picture of the challenges. And then each of those claim types has unique nuances that make this challenging."
"I think there are a lot of good things happening in the VA that are, in theory, improving access for veterans, and that's a great thing. From a claim standpoint, though, I think all of the core challenges still remain. And so I know that many of the EMRs have been putting a focus on interoperability, and all of that is great from a treatment care coordination, getting veterans seen in hospitals, and getting them through the door."
"But once they've been treated, all of the same challenges that were prevalent before, all of these announcements are still out there. And I think the complexity still exists in terms of not being a normal payer pathway for providers and not knowing all the specific rules. One such example is that you were only allowed one appeal level within the veteran's claims, which means you have to get it right the first time. And so there's a really important component of knowing how to process the claim, getting it done correctly, and ensuring that you're maximizing the yield and the outcome of the claim itself."
#EnableComp #VeteranCare #HealthcareInnovation #ComplexRCM
