Thread regarding Humana Inc. layoffs

Several AI vendors and health-tech platforms offer AI-driven solutions for claims processing, payment integrity, provider settlement, and revenue cycle management (RCM) tailored to health insurance corporations and healthcare systems:

• Codoxo: Provides a Generative AI Unified Cost Containment platform featuring pre-claim provider education, automated audit/payment scopes, and claim pilots designed to streamline payment integrity, eliminate errors, and handle provider settlement workflows across millions of lives.

• openIMIS: Offers an AI Claims solution that automates health insurance claims processing, rule-based verification, AI-powered categorization, and direct payment/settlement approval workflows using machine learning and HL7 FHIR interoperability.

• HealthEdge: Delivers AI-powered core administrative and operational infrastructure for health insurance companies, supporting end-to-end claims processing, core administration, and financial settlement workflows.

• Cohere Health: Focuses on AI-powered clinical intelligence, utilization management, and prior authorization workflows that connect payers and providers to streamline care delivery and financial/administrative settlement economies.

• Elation Health: Combines integrated electronic health records (EHR) and revenue cycle management (RCM) with AI-informed documentation, automated claims handling, and electronic remittance advice (ERA) payment posting for provider-payer workflows.

• Value-Based Care & Risk/Shared Savings Settlements:
  • Arcadia: Best for risk adjustment, identifying encounter data errors, and modeling shared savings benchmarks across ACOs and value-based contracts.

• Multi-Location & Enterprise RCM:
  • CareCloud: Best for centralized multi-provider and multi-location groups needing unified payment posting, denial tracking, and financial analytics.

Not sure why Humana does not consider these ideas. ServiceFund is a dinosaur that no longer needed. It is obsolete and behind the times and contraindicative to any sort of progress. It is simply system that is duck taped, superglued, and band-aided together.

Someone Associate Director or Director must know and schmooze with some Humana executives and that is why ServiceFund has lasted so long. Perhaps, someone who has them over for Super Bowl parties every year. And runs a Fantasy Football league with them and also a March Madness betting picks every year. Yeah, I remember you telling me all about that. And in all honesty your house had to cost way more than your skillset as a leader should ever be able to afford!

Turnkey financial administration platforms like PLEXIS Healthcare Systems provide specialized backend solutions for provider payment settlements, claims adjudication, and multi-payer revenue reconciliation in Medicare Advantage (Part C) plans.

Key Functions of Turnkey Settlement & Claims Platforms

• Automated Claims Adjudication: Digital processing of health records and automated payment reimbursements according to Medicare guidelines.
• Network & Reimbursement Configuration: Support for complex provider contracts, including fee-for-service, capitation arrangements, value-based care, and direct contracting models.
• Revenue & Financial Reconciliation: Daily provider payment settlement processing and multi-facility financial administration without replacing a plan's entire core business model.
• Prospective Pricing Integration: Embedding Medicare pricing rules directly into the claims workflow to calculate accurate, real-time payouts.
• Cost Modeling & Analytics: Business intelligence tools to forecast the financial impact of CMS retroactive changes, risk adjustments, and alternative payment models.

https://www.plexishealth.com/solutions/health-plans/medicare-advantage/

I am a Provider Engagement Executive that meets with provider groups on a monthly basis.

And they are always complaining about the REBal640, manual adjustment, stop loss, IBNR, and specialist amounts not reconciling between what their analysts were expecting from their system and often don’t even reconcile with the settlement itself. Also, obtaining data from the cloud and also EDW are all a pain for our analysts they tell me all the time.

I am shocked we are even still in business. Is there even one single person over at ServiceFund department that is held accountable for provider settlements being correct each month?

Because it feels like each month there are probably a dozen different persons that you may have to reach depending on the issue. It is exhausting!

Honestly when I saw the OP’s post I was like YES! Maybe there will be a change.

Hopefully one of the higher up people will look into to see what improvements can be made.

@1j8 As some in provider relations, I do hope they will seriously consider going with some type of turnkey solution that replaces ServiceFund department.

Because it is really getting difficult and embarrassing to keep making excuses to providers as to why their settlements are not correct and telling them next month will compensate for this month’s incorrect settlement. The providers simply no longer want to hear these excuses.

We need HELP in the provider relations space. And by that, I mean we need to finally replace ServiceFund with a BETTER solution!

@1fq Very true! These turnkey options are too good of business improvements to overlook. Probably one of THE fastest way for Humana to recover savings.

And let’s face it, ServiceFund department had never really been able to get provider settlements correct. And that in turn causes an unnecessary friction point with the provider groups we partner with.

ATTENTION: David McGettigan: President & COO of Technology!

Read the OP’s turnkey suggestions. You will look like a genius if you implement one of them and drop ServiceFund department in its entirety.

Prominent Solutions & Vendors

• Formance Healthcare: Offers embedded, ledger-based infrastructure for multi-payer visit accounting, claims-to-cash tracking, and derived provider settlements.
• Echo Health: Provides a single digital payment platform for health plans, dental plans, and third-party administrators (TPAs) to streamline provider financial experiences.
• Forte (CSG Payments) / STP: Delivers electronic payment and remittance transmission integrations (collaborating with networks like Optum Financial) to process virtual cards and provider remittances automatically.
• MCAG (Managed Care Advisory Group): Specializes in turnkey recovery and management for complex health insurance class-action and provider network settlements.
• Ricoh Payer Provider Payment Solution: Uses document digitization and automated workflows to speed up claims routing, reduce backlogs, and streamline provider payments.

Turnkey Health Insurance

Turnkey health insurance gives small and mid-size employers a simplified path to self-funding with built-in cost containment and stop-loss protection.

https://roundstoneinsurance.com/blog/turnkey-health-insurance/

I checked out the websites for each of these turnkey products and I have to say, I am impressed.

They offer streamlined processes, auditing, automation, security aspects, and offer reduced operational costs.

Anyway, very impressive! Humana would be remiss to not look into these.

Hmmm, we might have to look into these. Might be a good idea.