Latest / Becker’s Healthcare Podcast / Fighting Denials and Leading with Purpose in Healthcare with Ed Norwood

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Fighting Denials and Leading with Purpose in Healthcare with Ed Norwood · Becker’s Healthcare Podcast

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Hello, and welcome to the Becker's Healthcare podcast.
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I'm joined today by Ed Norwood.
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He is the author of Be a Giant
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Killer and CEO of ERN Enterprises.
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Ed, can you tell us a little bit
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about yourself and your organization?
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Hey. Thank you, Jeremy. Just thrilled to be
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on the platform and for the opportunity. Really
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just wanna applaud,
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Scott for everything that he does at Becker's
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to really inspire leaders to to transform health
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care.
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I am a husband,
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a father
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who also moonlights as the chaplain for NFL
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agency,
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but my day job is as an advocate
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and CEO of earned enterprises. We are an
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advocacy
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consulting, and technology firm that provides
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training
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for health care providers
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how to advocate for medically appropriate care
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by identifying,
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citing,
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and applying critical administrative laws to overturn improper
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denials
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and preserve patient access to care.
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Quick example about that. About a year ago,
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we,
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had a 17 year old boy with a
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brain tumor that would cause him to have
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seizures, fall to the ground, dislocate his shoulder.
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A team of neurosurgeons
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wanted to remove the tumor, but his ERISA
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plan would only authorize a biopsy.
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We got involved on a Saturday, worked till
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early Sunday morning,
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challenged that the plan reviewer was not competent.
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In other words, Germany, they did not have
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the
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appropriate training and experience in the field of
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medicine
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to evaluate
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or deny that claim
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under a federal law
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29 CFR twenty five sixty point five zero
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three Dash one h.
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We gave the plan an opportunity to resolve
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it before we filed a regulatory complaint.
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And by Monday, it was overturned.
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The young boy received the surgery
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and is doing really, really, really well now.
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And so we've kinda created an entire business
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model around
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this concept.
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We have
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defensible
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IP that helps us assist providers with
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regulatory claims representation,
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clinical denial prevention to capture authorizations
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while the patient's still in house,
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regulatory training,
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consulting, pre litigation.
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And we have a proprietary
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appeals technology
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with appeal libraries,
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regulatory law templates
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that we're converting to an AI platform
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to provide regulatory intelligence. And so,
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we're just
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thrilled
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to have been doing this for twenty five
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years.
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And,
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with great organizations like Becker's,
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government agencies, and law firms, we've been able
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to work towards a mission
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of really
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defending the health care delivery system in the
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nation.
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And so you also wrote the book, Be
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a Giant Killer. Can you tell us a
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little bit about that book and, what inspired
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you to write it?
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Yeah. We, you know, I wrote that book
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after years of realizing that there are many
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things that
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we carry from our childhood
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into our adulthood.
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And I begin to experience that if
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I didn't deal with
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some of the fears,
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the traumas
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that
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I had growing up. I could perpetuate them
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to my children. So, really, it's a book
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on leadership, how to eliminate
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generational
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giants
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that bleed into
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your marriage,
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to your relationships,
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to your work,
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to make sure that you are leading, not
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bleeding in the workplace.
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Awesome. And now back to health care, you
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know, what trends are you currently paying attention
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to?
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You know, two of the biggest trends that
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we're watching now are CMS prior authorization rules
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and number two, the rapid growth of AI
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and automation and payer denials.
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And we're seeing regulators step up. For example,
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in California,
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SB eleven twenty added health and safety code
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section thirteen sixty seven point zero one k,
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to make clear that a medical necessity determination,
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a decision cannot be made solely by an
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algorithm
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or supplant health care provider decision making. A
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licensed competent clinician
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has to be involved.
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Clinical history
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and patients'
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individual circumstances
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must be considered.
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And this follow, Jeremy, a CMS
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memo in 2024
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that required
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that MA plans
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do the same.
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This creates a new dynamic for providers.
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Payer denials are getting more automated and complicated,
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and,
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providers need smarter tools to keep up.
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At earn, we're trying to stay on top
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of it. We're constantly monitoring
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the legal landscape,
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to ensure that plans are adhering to new
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and existing
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insurance protections.
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We also are currently in the process of
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overhauling
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our appeals
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and training technology,
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to build the AI platform I spoke about
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earlier,
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to really ensure compliance and assist providers
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with their UN and appeals
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process.
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There is just in closing,
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there's a bit of underground resistance with AI.
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You know, will I lose my job in
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the future with AI?
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With revenue cycle folks, AI brings a lot
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of anxiety,
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but we really can't avoid it. AI will
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handle
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repetitive high volume tasks that slow us down,
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and people, professionals,
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will need to evolve into human experts
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to help identify knowledge gaps to make sure
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the AI doesn't drift.
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Because while computers are the bicycle of the
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mind,
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AI is the car of the mind.
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And so what would you say over the
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last six to eighteen months or so that
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you're most proud of?
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You know, over the past year, we've seen
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strong growth in our existing
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Rev Assurance online technology platform,
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which is an appeal letter
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library and resource hub for clinicians
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and revenue cycle teams.
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That traction has been an important signal for
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us. It confirms that providers are actively looking
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for
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better technology to manage denials and strengthen the
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appeals process.
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Building on that momentum, our focus is now
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rev.ai,
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our next generation intelligence support platform for the
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appeal process.
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We began development earlier this year,
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and it's gonna help revenue cycle teams move
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faster,
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respond to denials
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more strategically.
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It's designed to analyze claims and supporting documentation,
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predict likely denial risk,
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classify jurisdiction
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and payer
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behavior and misconduct,
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and support automated
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appeal generation and submission
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all while keeping human oversight
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in the loop and limiting
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costly litigation.
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The platform is designed to help organizations
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better understand claims contacts,
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surface likely denial drivers,
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and support more targeted
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defensive
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appeals.
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We're still early in the building phase of
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that, but
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those the signals so far are very encouraging,
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and we really believe that it will,
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meaningfully strengthen how organizations
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approach
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denial recovery
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and defend the rights of patients
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to remain
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in hospitals.
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Just about six months ago, we,
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used this proprietary tool to secure a six
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million dollar settlement for one of our providers.
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And,
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the money is one thing, but what I
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loved about this was we were able to
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negotiate new contract terms as a part of
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the settlement.
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The plan must adhere to the two midnight
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CMS benchmark. We got that into the contract.
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The plan must adhere to responding within one
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hour to an authorization
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request
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per 42 CFR four two two point one
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one three.
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They must adhere to
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reimbursing ER payments per the prudent layperson
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standard,
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not considering
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the final, but the presenting diagnosis
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of the patient.
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They must,
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ensure that they they don't conduct retrospective
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authorization
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denials,
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to rescind those authorizations
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after the provider is treated in good faith.
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And I love this one. We got them
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to incorporate in the contract
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to adhere to using sepsis two criteria
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for post pay
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clinical review and DRG validation instead of the
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restrictive
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sepsis three that has
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been problematic in the industry. So we're quite
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excited about that.
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Awesome. And what would you say you're currently
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most focused on or excited about over the
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next year or two?
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You know, around the time that we got
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the the the 6 point 0.2 settlement,
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we
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had submitted some legal inquiries
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to CMS.
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And, we were able to get them to
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clarify, and this is big because, with many
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of the prior authorization
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issues that exist,
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we feel this will be groundbreaking for many
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of our providers.
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We're getting we are able to get them
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to
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clarify
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that under 42 CFR four two two point
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one one three, an MA plan
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becomes financially responsible
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for any post stabilization services that are rendered
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by a provider
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if the plan is not responded within one
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hour of the request
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by the hospital to the MA organization.
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And they were able to mention in this
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policy decision
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that these requirements
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apply to both contracted
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and non contracted
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facilities. We're now,
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issuing reopenings on all improper denials for this
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reason, where we can prove we called you
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on January 15, you failed to respond within
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one hour, We sent you clinicals on the
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sixteenth, the seventeenth, the eighteenth, and the nineteenth.
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Patient was discharged on the twentieth without any
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disapproval by you,
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leaving you financially responsible for the entire state.
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We're now issuing reopenings, which are distinct from
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the appeals process
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to allow plans to remediate the issue before
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any regulatory complaint filing escalation.
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I will provide listeners
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after this podcast with a copy of that
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decision
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on LinkedIn. So I really encourage them to
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connect with me through LinkedIn,
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so they can get a copy of that
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and incorporate or into you know, at least
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assimilate that in their their appeals moving forward.
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Alright. And as we start to close out,
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what advice would you have for, young revolving
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leaders?
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That's a great question.
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Build
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culture
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with intentionality.
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You know, culture is simply,
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this is what we will do.
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This is what we will not do.
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With the accelerating
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pace of AI advancements,
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the future of insurance
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and
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revenue cycle management is being shaped in unimaginable
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ways.
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In response,
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we must, as leaders,
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incorporate regulatory shifts directly into our models by
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training employees
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into autonomous
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subject matter experts
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who can collaborate,
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who can mentor,
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and become proficient
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human experts in an AI driven world.
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That word proficient
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simply means this, to consummate
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skill
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with command.
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Michael Jordan, arguably the greatest to ever play
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basketball, hired expert trainers to become proficient or
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the best in his generation.
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And if you're listening to this podcast today,
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my questions are simply this,
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who consults with you?
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What advice do you give that transforms lives,
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systems,
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departments,
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and organizations?
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No matter what
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your job title is, what is your expert
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title?
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If you're in a health care revenue cycle,
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do you tell people that you're a seasoned
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revenue cycle professional
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or a subject matter in Medicare Advantage laws?
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In other words, what can you do that
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no one else can do?
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I used to work for,
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Jeremy, a a guy by the name of
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Jay Abraham when I was 18.
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And I'm working with his marketing consultant who's
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also worked with Jack Canfield and,
12:55
an author that wrote Jesus CEO and some
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other large motivational speakers.
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And,
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she worked with them to reproduce
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40,000 Jay Abrahams, 40,000 Jack Canfields, and she
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wants to generate 40,000 Ed Norwoods.
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Personally, I don't know if my wife
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wants 40,000 Ed's out there. She can barely
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handle the one that she actually she actually
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has.
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But as this marketing consultant and expert kept
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talking to me about reproducing myself,
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all I could think about was my staff
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and the people that
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I've been entrusted to train
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and mentor
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and shape for society.
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All I kept thinking about was how I
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could make them subject matter experts
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in health care,
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in law,
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in justice,
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in leadership,
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in analytics,
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in character,
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in influence,
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and reproduce that
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to a thousand generations to make sure that
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what is in them outlives them.
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And I believe
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that for leaders, a pivot is coming.
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Education and degrees are not enough.
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Tenure will not be enough.
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We need to build a proficiency
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in something
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that we can sell or that could be
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automated.
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Number number two, I would tell them to
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master the art of the pivot.
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Healthcare leaders, master the art of the pivot.
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In a business context, that simply means to
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completely change the way
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one does something.
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And I and I pose this to you.
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If the industry is changing,
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but we are remaining the same,
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We will eventually become extinct.
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At EARN, we're constantly mastering the art of
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the pivot.
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The $6,000,000
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settlement I shared with you earlier, Jeremy, was
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a process of two and a half years
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of pivoting.
14:52
The reopening process I shared with you that
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we're now engaged in since the CMS policy,
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it's been a pivot from the appeals process.
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Our our mission
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that we've established here, EARN, is
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we fight for providers and protect patient access
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when payers deny medically necessary care.
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And we do that even when there's no
15:13
overturns
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by building
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and protecting the administrative
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record no matter what.
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We may not win every case,
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but we fight each case as if we
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had never lost.
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And so I think for evolving leaders,
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number one, I think it's important to shift
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to a subject matter expert. Number two,
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master the art of the pivot.
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And, in closing, I'll leave a great exercise
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for leaders.
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I call it the five
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I's in when.
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Answer these questions.
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Who is your
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greatest inspiration and why?
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What is the impact? Number two, behind your
15:56
work.
15:57
Number three, what incident shaped who you are
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today? They they say that policies are organizational
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scar tissue.
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Number four, what systems have you influenced significantly?
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And number five,
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what is interesting about you? That's the five
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I's and when, inspiration,
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impact,
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incidents
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that shaped you,
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systems that have influenced you,
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and the most interesting
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thing
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about you
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in your industry.
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I believe that these
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five I's and when will shape
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our
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why in health care and accelerate
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our wins
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in this a.
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Well, Ed, I wanna thank you again for
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joining us today on the Becker's Healthcare Podcast.
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Do you have any final thoughts you'd like
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to leave for our listeners?
16:49
No. You've been quite amazing. Thank you for
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just,
16:53
the opportunity to just
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spend this time with me. We have
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spent twenty five years
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building a culture, giving our lives away, expecting
17:04
nothing in return, showering people
17:07
with unexpected generosity.
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Because I've learned that to do anything in
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life, we need
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trust,
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permission,
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and authority.
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And when you become a resource to people,
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people will trust you,
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and they will give you permission
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to do your finest work,
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to shine
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as an authority
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in your industry and in your workplace.
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Build that for twenty '20 six and years
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beyond.
17:35
Perfect. Well, thank you again for joining us
17:37
today. You have a lovely rest of your
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day. Hey. Thank you. Appreciate you.