The war between healthcare providers and payers has increasingly become a battle of algorithms, with AI tools for prior authorizations on one side and AI-powered appeals on the other.
Ashis Barad has sat on both sides of that fight. He began his career as a physician at Sutter Health, then practiced at Baylor Scott & White Health, where he led the push for better digital tools. In 2022, Barad transitioned into the role of chief digital and information officer at Allegheny Health Network and its parent company Highmark Health, getting a taste of how payers build and deploy AI internally. Two years ago, he joined the Hospital for Special Surgery (HSS) to serve as chief digital and information officer, sitting firmly on the provider side once again.
In his eyes, providers and payers racing to out-automate each other is a losing strategy.
“We’re playing a finite game when there’s an infinite game to be played,” Barad declared. “If we play the finite game of today, we’re going to continue on the inflationary route. So we have to figure out how to work together to figure out what the deflationary path for AI is, because that’s what we owe the people, honestly.”
Instead of pouring resources into AI for faster authorizations and appeals, Barad wants to see providers and payers pool their data to build more personalized care pathways.
He pointed to HSS’ own data as an example of what’s possible. The hospital performs more than 40,000 orthopedic surgeries a year — more than double the volume of any other U.S. hospital — and has developed a structured repository connecting imaging data to surgical outcomes.
Having that kind of real-world data is something insurers lack. Barad thinks that if payers and providers built those models together, authorizations would become far more targeted at the individual level, rather than relying on blanket rules.
Barad said he has already tested the idea with payers directly. During a recent meeting with a large insurance company, he asked how valuable HSS’ linked imaging-and-outcomes data would be to their actuarial teams.
“They were like, we would salivate over it,” he said.
That’s because payers typically only have access to basic claims data — infection or readmission rates after a first surgery, for instance — not the outcomes data for patients on their third, fourth or fifth procedure. But those are the kind of complex cases that make up much of HSS’ patient population, Barad pointed out.
Barad thinks the real opportunity lies in using richer data to reshape how authorization works in the first place. He pointed to gold carding, the practice of exempting high-performing providers from prior authorization, as a concept ripe for reinvention.
Today’s version is a blunt instrument based on flowcharts and cost thresholds rather than actual outcomes, he explained. Built the right way, Barad thinks it could instead be personalized down to each patient. Authorization would be baked into a care pathway, not requested after the fact.
But as long as payers and providers keep investing in AI to outmaneuver each other, Barad warned this spending only adds a new layer of cost to a system already straining under it. He said the path to actually lowering costs runs through collaboration on data.
Photo: Malorny, Getty Images
