Anomaly and the healthcare opportunity

Lisa Dolan
3 min readDec 2, 2024

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The healthcare sector is on the verge of significant change, and one company positioned to capitalize on these shifts is one of our portfolio companies, Anomaly.

Some background on Anomaly, they are an intelligent automation startup revolutionizing healthcare payment with AI. Their leadership team and advisory board hails from organizations such as Optum, Health Catalyst and Goldman Sachs

In offering some context, billing and insurance related costs (BIR), cost the US healthcare system $500 billion annually, with more than half of that wasted. 20% of claims are incorrectly adjudicated on the first pass, denial rates continue to spike and coverage decisions remain opaque.

Anomaly tackles this problem by using AI to reverse engineer the decision-making process for whether or not to pay a claim and provides real-time payment assurance and denial prevention. This replaces the manual work of thousands of salaried analysts, freeing them up for more value added tasks, improves payment rates and lowers the cost of adjudicating claims.

Recent political and regulatory developments, under the incoming Trump Administration, have created a unique environment where AI companies’ approach and services are poised for success.

Shifting focus toward payment reform

One of the most notable changes in the healthcare sector is the increased scrutiny on payment systems. The Republican-led administration has set its sights on overhauling key elements of how healthcare payments are structured. Areas in focus include the expansion of Medicare Advantage, Medicaid spending caps, site-neutral payment reforms, and potentially changes to the CPT code system itself.

Hospitals in the crosshairs — a market in flux

Hospitals are bracing for revenue loss under Medicare Advantage expansion, potential cuts to Medicaid, changes to the Affordable Care Act (ACA) subsidies, and other changes that could squeeze their financial margins. With these challenges looming, hospitals are under significant pressure to find innovative solutions to reduce costs, maintain margin and improve operational efficiency.

Medicare advantage expansion — a new opportunity

One of the most important trends is the expected expansion of Medicare Advantage plans. These plans allow beneficiaries to receive healthcare coverage through private insurers, rather than traditional Medicare. As Medicare Advantage grows, more pressure will be placed on hospitals to surveil the payments and denial activity as well as deliver high-quality, cost-efficient care.

AI solutions focusing on payment adjudication, improving operational efficiencies and providing better management of patient populations, are exactly what hospitals need to adapt to this shift.

Site-neutral payment reform and overhauling the CPT code system

Another significant reform under the new administration is site-neutral payment policies, which aim to equalize reimbursement rates for similar services provided in different settings, such as outpatient clinics versus inpatient hospitals. Capabilities in optimizing service delivery across multiple settings will be invaluable as hospitals adjust to these changes.

Additionally, if the new Administration makes good on its comments to potentially overhaul the CPT code system, the ensuing confusion can potentially be mitigated by AI systems cross walking between the old and the new code sets, helping the system adapt quickly to new coding practices.

As hospitals face increasing pressure from regulatory changes, the need for agile, cost-effective AI solutions is more critical than ever. The healthcare industry is entering a new era, marked by regulatory overhauls and a push for cost reduction.

Companies (like Anomaly) who are well-positioned to thrive in this evolving landscape will offer AI solutions that help healthcare providers navigate the complexities of payment reform, Medicare expansion, and operational efficiency.

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Lisa Dolan
Lisa Dolan

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