AH116 - The Claims "Spin Cycle" & Battle Between PI & RCM, with Lynn Garbee

On Episode 116 of Astonishing Healthcare, Lynn Garbee, SVP of Managed Services at Judi Health, joins Justin Venneri in the studio for a lively discussion about the costly battle between payment integrity (PI) and revenue cycle management (RCM) in the U.S. healthcare system. She explains the "claims spin cycle," a pattern of denials and resubmissions that generates an estimated $300–$400 billion in administrative waste annually, and why the denial-driven savings everyone seems to be after aren't really a sustainable strategy.Lynn also walks through concrete steps that plan sponsors can take right now to be more aware of their plans' expenditures and address waste, including auditing for hidden PI and contingency fees, and managing high-cost claimants in an era of GLP-1s and gene therapies.Discussion Highlights:Healthcare costs are outpacing the entire economy. Spending has climbed from 8% to 18% of GDP over Lynn's career, forcing everyday people to make hard decisions between healthcare, food, and housing - this is the crisis that drives her.The PI vs. RCM battle creates a lose-lose cycle for payers and providers.PI is necessary - we need to ensure that what is coded is what really happened between a patient and provider - but what began as a way to confirm codes has drifted toward more of a "savings obsession."The numbers expose how little the system actually gains - most of the effort just adds administrative cost. Roughly 15% of claims are denied, and about half of those are eventually overturned; on the prior authorization side, ~94% of authorizations get approved, and ~81% of the small share denied are later reversed.Contract constraints may be blocking access to more innovative, cost-effective arrangements.Related ContentAH113 - From Legacy Mainframe to Judi Cloud™: Modernizing Claims Adjudication, with Andy KageleiryExplaining the Healthcare Claims Adjudication Process for Modern TPAsPrior Authorization Guide: Pharmacy, Medical, Dental, and Vision PAsPharmacy Benefits 101: The Importance of the NetworkPlease visit Judi Health - Insights for more information about this episode and content from the Judi Health team!