Nick Granese
Revenue Integrity Solutions Lead @ Kubera Health
I've spent nearly a third of my life working in the healthcare revenue cycle industry. Somewhere in there, I stopped thinking of it as a broken system, and started thinking of it as a system working precisely as it was designed.
The brilliance of HBO’s seminal drama, The Wire, wasn't that it gave us heroes and villains. It showed us institutions behaving exactly as they were designed to behave. Police departments juked statistics. Politicians prioritized reelection over constituents. Schools taught to the standardized tests instead of to the students. Newspapers chased headlines and cut costs. Nobody woke up in the morning intending to erode the quality of life in early-2000s Baltimore. The outcomes stayed remarkably consistent anyway, generation after generation. From Omar Little to Michael Lee.
American healthcare is the same kind of story, and I've watched it from several vantage points. I've been uninsured. I've been on Medicaid. I've been covered by employer-sponsored plans. I pulled medical records as an admin. I worked quality assurance for overpayment audits on behalf of insurance companies – which is where I learned claims pricing. I've spent the years since in more advanced revenue integrity roles serving hospital systems. I've had the metaphorical shotgun and the metaphorical briefcase. Since the early-2010s, I've watched the same incentives produce the same outcomes.
It’s all in the game, though, right?
Everyone working inside healthcare navigates a standing set of obstacles that aren't inherently malicious, but are persistent, pervasive, and expensive:
Prior authorizations
Documentation requests with shifting requirements
Medical necessity qualifications
Timely filing limits
Claims and appeals processing delays
Inconsistent benefit interpretations
Antiquated dispute infrastructure and correspondence
Policy opacity
Administrative jargon and processes that require specialized knowledge just to navigate
These aren't just revenue cycle problems. They become clinical and care quality issues.
A physician expends energy over-documenting to satisfy vague policy requirements. A nurse waits on an approval for care she clinically knows is necessary. An analyst works a denial that requires sending a fax to a payor – in 2026. Most disheartening, a patient waits in pain, and receives an alarming bill. All while their family wonders why a physician's recommendation turned into a multi-week administrative exercise that still might bankrupt them.
Follow the money
Lester Freamon's investigative philosophy was always "follow the money.". Denial patterns are my specialty. If you follow them and the administrative hurdles I named above, for long enough, you stop finding bad actors and start finding incentives.
The uncomfortable part is that most of these bottlenecks began with defensible goals: fraud prevention, cost containment, quality assurance, utilization management, regulatory compliance. Each one is justifiable in isolation. Collectively, they've produced an administrative apparatus that taxes nearly every participant in the system.
I want to be precise about where the imbalance actually sits, because "payors are the only problem" is the lazy version of this argument. In fact, one of the central lessons of The Wire is that individuals are often operating rationally within the deeply entrenched, and deeply flawed, systems they have inherited.
Commercial payors operate in the private sector, for profit, with shareholders and real obligations: managing utilization, meeting compliance, and containing costs across enormously complex organizations.
Providers face their own set: shrinking margins, staffing shortages, regulatory load, and the expectation of exceptional care regardless of the administrative burdens.
The terms that govern payment: contract language, policy definitions, edit logic, medical necessity criteria, etc., are held asymmetrically. The imbalance is informational. One side of the transaction can compute what it's owed, in silos. The other side largely cannot, and has to reconstruct it after the fact, claim by claim, appeal by appeal. That asymmetry doesn't require anyone's malintent to be costly. It just has to persist. So, here we are. No one wins. One side just loses more slowly.
There are plenty of Stringer Bell-types in all forms of healthcare organizations. Executives with big ideas and a lot on their plate. What they have here in healthcare is an inelastic product. Medical care is a necessity for human life. We will all always seek or require medical care. The system governing medical care in this country is deeply entrenched, and is running around the clock, 24/7/365. I have to honestly admit that driving a balance between ethics and survival in this atmosphere is a herculean task. As a realist, that’s my conclusion. As an optimist, I want it to be one way, but it's the other way.
World goin' one way, people another
Good people come and go. Incentives remain. Hospitals hire prior authorization specialists. Payors build utilization management teams. Health systems retain denial management vendors. Consultants emerge to optimize workflows.The Sun rises on Baltimore.
Entire careers, including my own, have been built on helping organizations navigate this very complexity. Most of us are disadvantaged by the institutional noise, but a lot of us can also thank it for our careers. I find a deep irony in that, and I don't think you can write honestly about this industry without admitting that truth. Similarly, where would the career-climbers and companymen in the Western District be without the drug-trade they police? Incentives are a funny thing.
Patients, meanwhile, never agreed to any of this mess. They don't care about organizational charts, denial codes, quarterly revenue, or reimbursement methodologies. They just expect the healthcare system to work. They aren't players in the game by choice. It’s a proposition that the average Joe did not agree to.
Game’s the same, just got more fierce
After fifteen years, I'm still optimistic; mostly because the alternative isn't useful. But optimism has to attach to something specific. For me, almost every barrier I listed above traces back to the same root cause: the agreement that governs what gets paid, to whom, for what, and when, exists as convoluted prose. It sits in many-a -PDF. It gets interpreted differently by two parties with different incentives. Make that agreement computable, and a large category of this friction stops being a negotiation and becomes a calculation. That's part of the work I do now, and it's why I do it at Kubera.
There's an obvious question I've deliberately left alone, which is what AI does to all of this. Does it compress these inefficiencies or compound them? It's the elephant in the room, and a topic that deserves better than a closing paragraph, so, let’s save the full arc of that conversation for Season two.
I’ll leave you all with this: This burgeoning technology is neither salvation nor threat in the abstract. It matters enormously how narrowly it's scoped, how strategically it’s deployed, and how well those deploying it understand the pieces of the underlying systems. All the pieces matter.