Latest / Becker’s Payer Issues Podcast / Breaking Down Silos in Health Plan Pricing Operations

Transcript

Breaking Down Silos in Health Plan Pricing Operations · Becker’s Payer Issues Podcast

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Hello, everyone. This is Erica Spicer Mason with
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Becker's Healthcare. Thank you so much for tuning
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into the Becker's Healthcare podcast series today.
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So today, we're going to cover why health
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plans are rethinking fragmented pricing operations
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and some strategies to break through those silos.
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And joining me for this conversation is Jay
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Deedy,
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the president of price optimization
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at Xelliss.
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Jay, welcome to the podcast. Thank you so
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much for joining us today.
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Thank you. So nice to be here. Appreciate
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it.
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Oh, we're thrilled to have you. And before
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we talk a little bit more about pricing
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operations, I wanted to learn more about you
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and share more about your background with our
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listeners. So can you just give us kind
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of a broad overview
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of yourself, your work in health care, whatever
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feels helpful for our listeners to know?
0:46
Sure, Erica. Thanks. Yes. As as you mentioned,
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I I run the, price optimization
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division of Xelliss
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where,
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you know, the team and I really focus
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on,
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two items.
1:00
One is the pricing of of a claim
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in health care, and the other is payment
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integrity.
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You could think about it like a restaurant
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check, if you will, that payment integrity ensures
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that the correct items are listed,
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on the check you receive. And then
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the pricing part, of course, whether it's out
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of network, in network, network replacement,
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verifies
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sort of the optimized price of the correct
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items. So that's what we focus on on
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at Xelliss.
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I've been here it'll be five years this
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December,
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and it's it's been an amazing opportunity to
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help grow this great organization.
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Prior to Xelliss, I ran a number of
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AI based companies on the revenue cycle side
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and clinical side, Recondo Technology
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in Denver,
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on the revenue cycle side,
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as well as,
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Javion,
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which is a clinical AI company. And previously,
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I really kinda grew up,
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in the e m EMR explosion. I've been
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in health care IT for over thirty four
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years,
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and I've held senior management officer positions
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at companies like Cerner,
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ADAC Healthcare, McKesson, and Eclipses,
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where I focused on electronic medical records and
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then the patient
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billing experience. And now,
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at Xelliss
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looking at the entire
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sort of health care journey from both a
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provider,
2:30
payer, and member perspective.
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So dedicated my entire career to health IT
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on one side or the other and
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certain certainly enjoying my career here at Xelliss.
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Mhmm. It's great to learn more about you,
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Jay. Thank you so much. And I love
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how when you were describing
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the work that Xelliss does, you were
2:49
sharing a metaphor of it, thinking of it
2:51
as a restaurant check, and I think that's
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really helpful,
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as we're we're kinda talking about some more
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complex topics here, like payment integrity, pricing of
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claims.
3:00
So, again, appreciate
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the metaphor, your background, and sounds like you
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have a ton of experience in this field.
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So,
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just excited to dig into pricing operations here
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a little bit more.
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Let's go. Yeah. Let's go.
3:13
I know pricing ops have really been fragmented
3:16
across health plans
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to date. So what do you see as
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some of the most common inefficiencies
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or even missed opportunities,
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and what risks come with continued fragmentation in
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this space?
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Sure. I I think it's fairly
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analogous
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in some ways
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to the electronic medical record industry,
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quite a bit. And that's when I first
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interviewed at Xelliss and saw the opportunity,
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It was sort of like I was rewatching
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a play
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in my mind.
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And what I mean by that is,
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in the nineties and early two thousands on
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the clinical
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side of health IT,
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you had individually sold solutions
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like laboratory and radiology
3:59
and emergency room and surgery, and there were
4:02
probably 12 to 14
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different segments
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of solutions that each of which had probably
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three to five pretty developed good companies.
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And then there would be interfaces
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to share a portion of the data
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that was available on each of those systems
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across a single patient.
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But it was it was only a little
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bit of the data that could be shared
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from one system to to the other. It
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was highly fragmented. It was expensive and inefficient
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to try
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to weave that together.
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And here on the revenue cycle side, it's
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pretty similar.
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When I went through what we
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do at Xelliss in the price optimization division,
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we have multiple pricing solutions so that we
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can do in network pricing, out of network
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pricing,
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network
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replacement, or essentially no network pricing.
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And then you have payment integrity as well
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where you're verifying those right menu items related
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to kind of supplies, but also highly complex
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expensive
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clinical,
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procedures, etcetera. And so, you know, our approach
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is to take a single claim in
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and be able to offer all those solutions,
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which is a multiplier effect, if you will,
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of being able to to do that similar
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once electronic medical records became integrated in single
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platforms.
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And instead of having to do business with
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eight, ten, twelve, fourteen, 16 different companies,
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you could get a single complete platform. And
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that's really what we're trying to do here
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at Xelliss on the revenue cycle side is
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allow our clients not have to
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try to integrate, which again is expensive, and
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coordinate
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and have, you know, time consuming
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relationships with five, six, seven, eight, nine, ten
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different vendors.
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But in addition to that, get the multiplier
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of the data effect of it coming from
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us. So
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it's it's that's the approach. The fragmentation
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really drives up the cost and the inefficiency
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of health care at the end of the
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day.
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Yeah. Jay, thank you so much for the
6:13
overview. I was going to ask you what's
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kind of driving this urgency
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to address
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fragmentation, but it sounds like to your point
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that you just made, cost concerns,
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perhaps administrative burden. Do you see those as
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really making this a more urgent need in
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health care?
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Yeah. Absolutely. I I would say there's there's
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maybe three. One is that health care in
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general is becoming
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more consumer driven. It's taken quite a quite
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a while, but I think the digital tools
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that are in
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members and consumers' hands have really helped them,
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you know, shop as well as help to
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manage the financial,
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aspect of health care. And so there's just
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increasing demands
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for more comprehensive
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single solutions coming from the members themselves.
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I also think that just the cost pressure
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is mounting. If you look recently in the
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earnings
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and what's happening in the number of CEO
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changer changes in the health care insurance industry,
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you can see that the industry is under
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a lot of pressure right now.
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And so cutting costs and increasing efficiency
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is a big focus and driver for the
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payers of health care.
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And then not to be underestimated though is
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the continued regulatory pressure and compliance where
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you have federal
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regulatory,
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compliance, items like no surprise billing act and
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requirements associated with that and
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processes on how to
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arrive at fair pricing and appeal those decisions.
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But for fully insured markets, you also have
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state based
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solutions that,
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take the place of some of the federal
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requirements in 14 or 15 states, including Texas,
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which is getting incredibly
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complex. So,
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for small companies only doing a piece of
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what I've described in terms of the solution
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capabilities or for some payers that are trying
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to do it themselves,
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you know, the combination of those financial pressures
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and increased regulatory and compliance investments, it's very
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challenging to do that unless you're at scale.
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Yeah. Absolutely.
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Appreciate those add ons, Jay.
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And I know you've touched a bit already
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on kind of how the technology
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works and and how Xelliss is helping to
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address some of these issues with fragmentation.
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But can you say a little bit more
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about how
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infrastructure data and technology are really shaping the
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future of pricing for health plans? And how
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is this paving the way for a more
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connected or seamless financial experience across that care
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continuum?
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Sure. I think part of it is just
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now starting to use AI,
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on top of what historically had more recently
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been referred to as predictive analytics
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is incredibly important so that when you're trying
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to arrive at,
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a a balanced price, let's say,
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that would maximize,
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savings and be appropriate, but at the same
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time,
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have abrasion, meaning, let's say, an appeal from
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a provider who doesn't like the price,
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I think there's a big misper misconception
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in health care that payers
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are really trying to
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drive to every penny that that they can
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when in fact they're highly concerned about member
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satisfaction,
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but also provider satisfaction.
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And they'd like to maintain abrasion at a
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relatively low level so that they have good
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relationships
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with providers and, of course, their members. And
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so using predictive analytics and and AI on
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how to balance,
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those two
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vectors of abrasion
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and price optimization
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are incredibly important, and you can't really do
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that across nine, ten, 11 different systems. You
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need to be able to do that at
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a consolidated data level,
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in order to help make those decisions. And
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I think that's really,
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how
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it it is starting to pull those those
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three factors that you described together,
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is is really that advanced technology that offers
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benefits
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to all the major stakeholders, the the the
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member themselves,
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as well as the provider and the payer.
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And that's really causing, you know, even in
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the last year year or two, you know,
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leapfrogging,
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investments in this area.
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Mhmm.
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Yeah. It's an important perspective that I think
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you're you're sharing, Jay, about how payers are
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invested in equally,
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you know, pleasing members and also providers avoiding
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that abrasion. And it's interesting to see how
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technology is playing a role in this.
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And I'm curious if, you know, you've ex
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you've described the advanced technology
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single solution need.
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When you've seen payers implement that strategy, what
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kind of benefits have you seen? Do any
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case studies or success stories come to mind?
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Sure. There's there's a couple.
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One where
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instead of dealing with
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multiple,
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disconnected vendor solutions,
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we can take a a claim in a
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single claim, and let's say it's an out
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of network, highly complex clinical claim.
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We can simultaneously
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apply,
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both our out of network engine
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as well as our expert claim review,
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capabilities in order to deliver both of those
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solutions
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off of the single claim at one time.
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The result is that it's going to come
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back
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through an adjudication engine to the payer in
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a greatly reduced period of time.
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It maximizes
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savings opportunities.
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It gets the communication
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out to the provider and to the member
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in terms of what they may owe faster.
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And so providers,
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you know, will benefit based based on, you
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know, the faster speed, and the member will
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also benefit,
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similar to the payer based on the reduced
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savings.
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It wouldn't be possible to do that if
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you were gonna run that through multiple different
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vendor engines, and it would take longer and
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arrive at a higher level of discontent with
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the provider.
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So, that's certainly one. Another is we offer
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for our out of network clients,
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health bill assist. Many members
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don't understand
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when they receive a balance bill, they're not
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sure what a balance bill is. They don't
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know when they should receive it or not.
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And so we offer a free service to
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the members of our auto network clients where
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there's website education that explains these different billing
13:00
functions.
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They can scan a QR code on their,
13:04
explanation of benefits or EOB,
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and then even engage in a phone conversation
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with one of our
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experts to explain it to them, and then
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we'll even engage on their behalf with providers
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and negotiate,
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reduced out of pocket
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payments from them in exchange for, let's say,
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a more rapid payment.
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I think so far, our biggest single benefit
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has been a $55,000
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reduction,
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to a family out of pocket based on
13:35
doing that. But, you know, we we've so
13:38
far achieved millions of dollars for this benefit,
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and it's really because of the the technology
13:43
and the capability that we've talked about.
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Yeah. Such great examples. Thank you, Jay. And
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it's sounding like this approach really does help
13:52
to drive speed, savings.
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I love learning a little bit more about
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that education component that, Xelliss is offering. So
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thank you so much again for that overview.
14:02
And in light of all of this, you
14:03
know, as you look ahead, how do you
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see pricing operations evolving within the next few
14:08
years? And perhaps there's advice that you'd give
14:10
to leaders who are really working on breaking
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down these silos to build a more connected
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experience and pricing system.
14:17
Sure. I I think from a health IT
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standpoint, we've heard
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for five to ten plus years about personalized
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medicine, where for the individual member or patient,
14:29
that a solution could
14:33
be created individualized for them versus just receiving
14:36
standard care, if you will. And I I
14:37
think the same is starting to happen on
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the revenue cycle side and the pricing side
14:41
that,
14:43
similar to the clinical side,
14:45
not every member is is created equal. People
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have, you know, different financial,
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situations.
14:52
And so I I think we're gonna start
14:54
to see more personalized medicine where
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things such as if somebody can
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afford to pay
15:01
out of pocket and quickly,
15:03
they might receive an incentive of a discount
15:06
in order to do that. If someone else
15:08
is in a situation where perhaps from a
15:11
financial standpoint, they can,
15:13
they can't do that, they'll be offered a
15:15
no interest,
15:16
you know, loan in order to extend the
15:18
payments and make it more, you know, appetizing
15:21
for them. There's still,
15:23
Erica, a large percentage of care in The
15:25
US
15:26
that sometimes gets scheduled,
15:29
many times just ordered from a physician, and
15:31
it actually never gets completed with the member
15:34
and patient. And one of the leading reasons
15:37
is
15:38
because the the patient, you know, comments that
15:41
they are unsure
15:42
of what the cost of the care will
15:44
be or how they will pay for that
15:46
cost to care. And so I just think,
15:49
for the entire system,
15:51
we need to move to the personalized revenue
15:53
cycle to kinda match up with the personalized
15:56
medicine
15:57
that we've been seeing on the clinical side
15:59
for a while.
16:00
Yeah, Jay. I was just going to say
16:02
we hear about personalization
16:04
and patient and member experience so much from
16:06
the clinical standpoint, but I think as you've
16:08
highlighted from the RCM standpoint and the patient's
16:10
financial journey, it's just as important. So,
16:14
really important things that you've highlighted for our
16:16
listeners. I wanted to give you the opportunity
16:18
before we close today. Is there anything we
16:21
didn't touch on or any final thoughts that
16:22
you wanted to share with listeners?
16:25
Appreciate that opportunity, Eric. I would say,
16:27
you know, at Xelliss,
16:29
what we're focused on is trying to be
16:32
at the center
16:34
of the wheel
16:36
where
16:37
we can help find solutions that benefit
16:41
members,
16:42
payers, and providers
16:44
at not just one spoke.
16:47
And sometimes that's harder than others,
16:49
but it it is really the mission
16:52
of of why Xelliss was created, and we're
16:54
very committed to executing on that mission.
16:58
That's a great mission. Jay, I wanna thank
17:00
you again for spending time with Becker's today
17:02
and for sharing all of your insights and
17:04
your expertise,
17:05
especially in the health IT and financial space,
17:07
with our listeners today. Thank you.
17:10
Erica, thanks so much, and appreciate,
17:12
you and your listeners.
17:14
Yeah. Of course. And we'd also like to
17:16
thank our podcast sponsor for today, Xelliss.
17:20
Listeners, be sure to tune in to more
17:21
podcasts from Becker's Healthcare by visiting our podcast
17:24
page at beckershospitalreview.com.