In a healthcare system drowning in over $4 trillion of annual spending and burdened by crushing administrative costs, there’s a dangerous false choice being presented: either eliminate all prior authorization and payment controls to reduce provider friction, or maintain the status quo of manual, inefficient processes that frustrate everyone involved.
During his keynote address at the Codoxo Xcelarate Customer Conference, A.J. Loiacono, CEO of Judi Health, cuts through this binary thinking with a pragmatic perspective that should resonate with every payment integrity leader: “If someone could tell me and prove to me we live in a world without fraud, waste, abuse, and errors, then yes, I would agree that we don’t need safety layers.”
But we don’t live in that world.
The Reality Behind the Rhetoric
Loiacono’s insights challenge the increasingly loud chorus calling for the complete elimination of utilization management and payment controls. Pharmaceutical manufacturers are able to advertise to patients, which fuels an on-demand attitude among healthcare consumers, and some providers argue these processes either shouldn’t interfere with their instructions – or shouldn’t exist at all. However, the data tell a different story.
“The reality is all these things exist and we have millions and millions of claims that demonstrate there are all kinds of errors, and our system is fraught with fraud, waste, and abuse,” Loiacono explains. This isn’t speculation, it’s backed by concrete evidence from actual claims data across the healthcare ecosystem.
The critical distinction he makes? Intent. “What I’m not saying is intent. Now someone can say fraud suggests intent. I’ll leave that to the attorneys. But my point here is these things exist, and we need checks and balances.”
The Solution: Intelligent Automation, Not Elimination
The answer isn’t choosing between provider experience and payment integrity, it’s about leveraging technology to achieve both simultaneously.
“Do people appreciate automation? You betcha,” Loiacono states plainly. “If someone doesn’t have to bother calling someone back about something, even if it’s, ‘Hey, I received 30% less phone calls,’ that’s a win for any provider setting.”
This is where AI-driven payment integrity solutions deliver transformational value. The goal isn’t to create more administrative burden, it’s to eliminate unnecessary friction while maintaining essential safeguards.
Universal Abrasion: Why Everyone Benefits from Better Systems
One of Loiacono’s most compelling points is that current inefficient processes create friction for all stakeholders:
- Payers don’t want to spend resources making calls and clarifying forms
- Patients don’t want to wait longer or experience frustration
- Providers don’t want to take time from patient care to complete redundant paperwork
“Everyone has abrasion,” he notes. “People are appreciative of anything that provides proper automation of workflows.”
The key word: proper. This is not automation for its own sake, but intelligent, AI-powered solutions that:
- Reduce manual touchpoints and phone calls
- Accelerate legitimate claims processing
- Flag potential issues before they become problems
- Provide transparency into decision-making
- Maintain necessary oversight without creating unnecessary burden
The Path Forward
Until healthcare can demonstrate statistically that fraud, waste, abuse, and errors have been eliminated—which Loiacono makes clear is not the current reality—payment integrity functions remain essential. The question is whether we continue with outdated, manual approaches that frustrate everyone, or embrace modern, AI-driven solutions that protect program integrity while dramatically reducing administrative burden.
“Until someone can show me a statistically sound set of data where there’s no fraud, waste, abuse, or errors… this is how we’ll move forward,” Loiacono concludes.
Thankfully, the technology to make payment integrity faster, smarter, and less disruptive is here now.
Ready to transform your payment integrity approach with AI-powered automation that reduces abrasion while strengthening oversight? Contact Codoxo today to learn how leading health plans are achieving both goals simultaneously.