Rajesh Voddiraju, MS is founder and group president of Health IPass, a Sphere Company of Oak Brook, IL.
Tell me about yourself and the company.
Sphere is a payments company that, across multiple industries, streamlines the payment process for consumers and in healthcare in particular. We are all about taking friction out of the payment process through an integrated solution that meets the needs of large health systems all the way to the smallest of the healthcare practices.
To what degree is healthcare still using clipboards and badly designed paper forms instead of electronic systems for collecting check-in and billing information?
As we look at how the industry has evolved, the first generation of solutions effectively came up with electronic ways to change these forms from paper-based to an electronic clipboard. Maybe a kiosk, maybe a tablet, and having folks, when they come into the clinic, be able to use electronic mechanisms in terms of the data capture.
We’ve always believed that’s just a starting point. The more you enable patients to be able to do it in advance, the better. The second generation of the evolution focuses not just on doing it in the clinic, but enabling people to do it on any device, any time, with a mobile-first kind of a strategy. Baked in there were some really cool innovations, such as enabling the patient to take a picture of their driver’s license to validate their identity or to take a photo of their insurance card. Being able to read information and ensure that we’ve got a good capture, just like your banking apps do when you scan a check, for example. That type of innovation was a second generation.
We’ve always focused on predictive analytics way beyond just the data capture, how that can streamline the billing process and ultimately make that experience good for both the consumer as well the healthcare provider.
As patients become a significant source of revenue for provider because of health plans with high deductibles, there’s a real pain around collecting patient responsible dollars in a streamlined, easy manner that both educates the consumer as well as makes it easy for that transaction to occur. It’s not just about replacing the electronic clipboard. That is now table stakes. It’s enabling that workflow to occur any time well in advance, on any device, with the right kind of smarts embedded into it.
The third generation is to take it one more level in solving the key issue in healthcare, which is that the consumer doesn’t know what things cost and the merchant — the healthcare provider — literally has no guarantee that they’ll ever get paid. Solving that in a way that educates the consumer and enables price transparency so that there are no surprises later is a big part of the transformation that we as Health IPass and Sphere have brought to healthcare consumer engagement.
Does that inability to tell patients what they will owe upfront limit their willingness to leave their credit card information on file as they do in almost every other industry?
I’ll answer that from two standpoints. One is the regulatory implications. The No Surprises Act is the next evolution of regulatory intervention by both state and federal government to avoid surprise billing and to make sure there is advanced notice for the consumer in terms of what their out-of-pocket is going to be. From a technology standpoint, providers have often struggled to have the right type of technology that enables them — as they become in-network with various insurance companies — what that contracted rate is.
The first part of a triangulation that we do within our platform is to know what the contracted fee schedule is with a particular provider across the different insurance companies. The second is to be able to set up the right kind of rules to say, for example, that if you had a surgery and multiple procedures were done, how does that affect the reimbursement in terms of what the provider would get paid? These were rules that were here before in a black box, where nobody quite knew except the super specialist in billing. Technology now has been able to bring in and codify all of that information.
On top of that, we need to know how that affects a particular patient at a particular point in time. Luckily, through the Affordable Care Act and the administrative simplification that was put forth many years ago, the black box of where a particular patient is in meeting their deductible, the balance remaining, their max out-of-pocket, and the plan design data are easier for companies like us to access.
We built a robust solution around being able to, for regular office visits all the way to surgical interventions, compute, based on all three of these factors, what the patient’s out-of-pocket is. We present it to the patient so that there is no surprise. Then it becomes easier for the patient to opt in and leave a credit card on file because they know it’s not going to be hit for just any amount, that payment assurance is being procured or secured in conjunction with the estimate that has been provided. We get incredible adoption rates across millions of patients every month and every year.
If a patient checks in through Health IPass, the healthcare provider typically gets paid almost 97.5 cents on the dollar, which is unheard of when most healthcare providers get 50 to 60 cents on the dollar with paper-based practices and the surprises it yields. An educated consumer is definitely a better payer, and our data and our history has proven that for the healthcare provider, that is absolutely the case.
How do you tune the various factors that impact the likelihood of being paid, such as insurance history, provider specialty, the emergent nature of the encounter, and the level of co-pay and deductible involved?
There’s definitely multiple layers of complexity to your point. The first is to take the payer-specific rules and create a library of rules that can be set up across providers. I mentioned the example of multiple procedures, where perhaps the first cohort is paid at 100%, but is the second cohort paid at 50% or is it 33%? Those are typical rules that you could layer a global set of rules. On top of it, we need to always be able to model the individual contract. If you are at Northwestern here in Chicago, for example, who’s a client of Sphere, you have a special contract with Blue Cross Blue Shield of Illinois that enables you for a different reimbursement model on that multiple procedure example. We have to be able to overlay that with a provider-payer specific set of rules within our platform.
On top of all of that is the variability of where an insured patient is at that particular point in time. We have real-time connectivity with 926 insurance companies across the country. In real time, we know that the patient has this much money remaining on his deductible and this much money on his out-of-pocket maximum, both at an individual level as well as a family level. There’s a lot of computation and artificial intelligence / machine learning that is in play here in terms of making it simple at the end of the day to educate the patient that for a suggested procedure, here’s your out-of-pocket.
Ultimately, the card-on-file mechanism enables the consumer to have peace of mind. The provider is still filing a claim with their insurance company and letting the insurance company adjudicate the claim. Only when you have it down to the penny, the exact amount that is truly the patient out-of-pocket, does an electronic bill get presented. Patients get a text message or email, whatever they prefer as a consumer, and they still have the opportunity to ask for payment assistance or things like that before their card is auto-debited for the exact, down-to-the-penny amount as adjudicated by their insurance company.
Dentist offices make sure that outstanding balances are addressed before they schedule the next appointment. Is it hard on the medical side for practices or clinics to discuss the balance owed, a low propensity-to-pay, or a possible financial hit for patients who are early in their benefit year when they haven’t met their deductibles?
The big difference between dental and medical is typically when you go to a dentist, the dentist knows exactly what is going to be done. A treatment plan has been pre-established. That’s not always the case in the medical world. That’s part of the reason, along with lack of the right tools, that we have surprise billing. There’s a lot more complexity to in-network and out-of-network. The best practice is to embrace this notion that transparency creates better patients and better patient engagement. Obviously that has to be assisted with the right technology.
We’ve taken pride in helping clients remove this paper and these black boxes, whether it’s on the front end of the process or post-visit engagement. We talk about how can we streamline the entire appointment to payment journey as part of our patient engagement process. It’s about allowing the patient to schedule themselves, answer the appropriate screening questions, get on the schedule with the right provider as most convenient for the patient, and take the journey all the way through in terms of setting the expectation based on the type of visit, how the patient has answered a certain set of pre-screening questions, the expected out-of-pocket, and educating them on what the insurance company will and will not cover and where they stand on their benefits early in the process.
Certainly if the patient has outstanding balance — regardless of whether that bill came from a specialist visit like a dermatologist, an orthopedic surgeon who is part of the group, diagnostics, surgeries, or labs — being able to present a consolidated single bill at that moment of engagement by the patient. Eliminate getting 16 different bills that all come at different times. It’s too confusing for someone who may have a household with a few more interactions with the system. Transparency into what their outstanding balance is and presenting payment assistance or payment plans that may be available for that particular patient, as determined and customized by that healthcare provider, is an important step of what we do.
As I mentioned before, the more you educate folks in advance for future care, the more you are able to secure their payment assurance through a card-on-file and streamline the electronic billing process. It works out well for all parties involved. The patient is happy. They don’t get surprised. They don’t have to go look for a stamp. They don’t have to go look for a paper checkbook. It’s very, very good for the health system that was getting 50 or 60 cents on the dollar to suddenly realize that moving to 97.5 cents also creates better patient engagement and better patient satisfaction.
What factors will have the most impact on patient payments and healthcare in general in the next few years?
Number one is increased transparency into patient out-of-pocket expense. We welcome this and are certainly glad to see regulatory intervention, including the No Surprises Act, that will put more impetus behind creating that level of transparency. The second is owning more of the patient journey. We now do everything from upfront patient self-scheduling all the way to, after you’ve had your surgery and you’ve gone home, what are called patient-reported outcomes. What’s your range of motion? How is that improving over time? Being able to leverage technology to provide that type of clinical insight to the surgeon, in this case, to be able to intervene properly with the particular patient.
That’s the range of capabilities that are important, so you don’t have a hodgepodge of vendors that are doing different things and you can create a more streamlined experience for the consumer. Those two big trends is what we are excited about. We feel that we are in a great spot to be able to service the needs of consumers.
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