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