AH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating Efficiency

Transcript

Lightly edited for clarity.

[00:22] Justin Venneri: Hello and thank you for listening to another episode of the Astonishing Healthcare Podcast. This is Justin Venneri, your host and senior director of communications here at Judi Health. And for this episode we've got two members of our product team in the studio with me, Liya Lomsadze, who is a Senior Director, and Jake Mulkey, a Director, and they've both been heavily involved in the development of our unified claims processing capabilities and the development of Judi Health.  

Liya joined us for Episode 58 earlier this year, which was such a fun discussion about actually building Judi Health. And Jake was on for episode 39, which we mentioned recently with his counterpart for that episode, Samantha Custer, and that was on how he worked closely with the comms team to ensure that we could provide a compliant transition benefits solution.  

Thank you both for joining me today.

[01:06] Jake Mulkey: Thanks for having us.

[01:07] Liya Lomsadze: Good to be here, Justin.

[01:08] Justin Venneri: All right, quickly, I know we have a lot to get through here in a short amount of time and you guys are buried. So Liya, can you go first, share a little bit about your background path to Capital Rx and now Judi Health?

[01:18] Liya Lomsadze: Yeah, thanks, Justin. So prior to Judi Health, I worked at a handful of different healthcare systems in New York, primarily doing some data analysis and figuring out how we can make healthcare delivery a little more efficient. And since joining Capital Rx, I've worked on our operations teams and then moved over to product to help support the build of pharmacy claim adjudication and now unified claims processing.

[01:40] Justin Venneri: Got it, Jake, same to you, please.

[01:41] Jake Mulkey: Yeah, for sure. I've been at Capital Rx about four years. Prior to Capital Rx, I was working for a few years in the prior authorization space and specialty drug hub programs. Since joining Capital Rx, Judi Health, I've been kind of on two main areas of focus: State exchange, claims accumulations, and eligibility exchanges, and the vendors associated with those.  

But then the last few years have really moved more toward overseeing our pharmacy adjudication product teams for all of our lines of business.

[02:07] Justin Venneri: Awesome. Well, I love working with both of you guys and seeing all the product updates and everything else that comes out of your “shop” and building medical.  

That's what the discussion is about today. After building out a new pharmacy benefit administration platform several years ago; I can't believe how fast time flies. And I think, well, pretty sure all the survey data out there show this, everybody out there - plan sponsors, health plans, you name it, they want better care for their members, lower costs, and improved transparency.  

So how has our experience in pharmacy claim adjudication and administration helped us, or helped you, to tackle building out medical? And does that extend into dental and vision?

From Pharmacy to Medical Benefits: Building and Scaling Healthcare's First Unified Claims Processing System

[02:44] Liya Lomsadze: Yeah. So there's this joke in health tech that I think about often, where everybody who joins healthcare trying to figure out how we can fix healthcare in America, their first thought is, “Hey, all I need to do is build my own electronic medical record and that'll fix everything.” And as a result, the healthcare landscape is full of people who tried to tackle that, learned a bunch of lessons the hard way and kind of pivoted away. And the same thing is pretty much true on the administration side.  

So we've heard AJ talk a lot about how there's this huge misalignment between the sort of investment and focus that's been put into tackling the care delivery, so tackling the electronic medical record, side of things, but really not as much on the administration side with claims processing, eligibility accumulators, everything else.

[03:30] Justin Venneri: Yeah, it was just a bunch of band aids and acquisitions and roll-ups, and you have all these different systems that don't talk to each other as a result, right?

[03:38] Liya Lomsadze: Exactly. But people are trying to solve our side of it too, of course. So when we set out to say we're going to build the first unified claims processing system this country has seen, there was a lot of very rational skepticism because lots of folks have tried building their own claims processing platforms, and it took them a lot of years and a lot of investment and sometimes it didn't work at all.  

But we were able to make it happen in one year.

And I think it's precisely because of our background in pharmacy benefits and everything we learned along the way building out Judi to process pharmacy claims.

[04:08] Justin Venneri: And Jake, you have, you know, as you were describing with your background, an interesting mix of experience in product development along these lines. How did building out the pharmacy claims processing platform really help in terms of preparing us to execute on building out medical claim adjudication alongside of it?

[04:25] Jake Mulkey: Yeah. So I think there's this kind of large and potentially incorrect perception that pharmacy is really easy thing, or it's the easy side of the business to get correct or to scale because it does touch so many members, touches so much of our clients, and directly impacts behavior at point of sale. But pharmacy is hard. It is not an easy kind of shoe-in thing to do. And I think because it is so often behind the scenes and it's not something that is necessarily the flashiest of all of our products or all the things that Judi Health has to offer. We have a lot of very creative plan designs, a lot of high level of configurability within our tool. And we've built the tool in a way that allows Judi to handle those very unique situations at scale.  

And doing that has really made it a lot easier for us to transition into medical, right? There's a lot of this pressure in pharmacy to get things right from a claim adjudication standpoint, obviously in real time with members at point of sale. And because we've had to work in that environment, thinking ahead of go live dates for clients or partners that we have, where pharmacy has to be basically perfect and spot on day one, we've worked in an environment where those configurations have to be readily intelligible, not only to the users but to clients themselves. And then obviously that flows down to members’ experiences in filling claims.  

And so just one example really of how we built Judi and kind of are using the tools that we have to not start from scratch and reinvent the wheel when we move into medical claims processing.

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A New Year’s Eve Tradition & Real-Time Pharmacy vs. Lagging Medical Claims

[05:48] Liya Lomsadze: And I'll give you an example because we have this New Year's Eve tradition on the pharmacy benefits side of the world where you know, since the launch of Judi In 2021, we stay up until midnight on December 31^st, and midnight precisely on the dot, the new claims, the new pharmacy claims start rolling in and we like to, you know, bet on what the first drug is going to be and what state is it going to come from and things like that.  

And let me tell you, it was such a hard left turn launching medical claim processing this year because we did not get a single claim until I want to say January 8th. So you can imagine, with my background in pharmacy, I was losing it every single day, that first week of January. Where are these claims? Where are they? Why aren’t they here? What’s happening? Is this working? Is this on? Is this machine on?  

And it was on. It's just that, again, medical is not set up to live in this real time world.

[06:41] Justin Venneri: I remember you saying you wanted to be the first claim, right?

[06:43] Liya Lomsadze: Exactly. So we launched this for Capital Rx, now Judi Health, employees, January 1st. And I was so -- I really, really wanted to be claim number 1 in the door. I got my appointment with my doctor, you know, so I got the earliest slot on January 2nd. I showed up and then my claim didn't actually arrive until three weeks later. So somebody else got, you know, the coveted claim number one slot and mine was like 400 something, I want to say.  

And like, yeah, that part of it is just, you know, whatever, who cares if you're claim number 1 or claim number 1,000 ? That's not the important part. The important part is that I had to wait for three weeks to figure out how much I owe for that encounter that I already had. My doctor had to wait for three weeks to see if the care they provided would get covered. And that delay is something again, that we're so not used to in pharmacy because we're used to making these decisions immediately and everyone at the point of sale having that clarity all at once.

Designing for Flexibility: Complex Plans & Automation

[07:32] Justin Venneri: So where do we go from here?

[07:36] Jake Mulkey: Great question - I was just going to say, I think one thing that's, kind of to retouch on or maybe just elaborate on some of the points Liya's made, with pharmacy claims being real time, there is that human standing at point of sale. And because of that, and I mentioned this too, right, we have to focus so much on making sure things are accurate.  

And I think the interesting thing, and Liya can obviously speak to this more, but in shifting to medical, because we have more time to ensure accuracy, we also probably have more time to think through, well, what are the things that we want to do differently that maybe aren't standard on a medical claim processing, right? So not only is it accurate and is it timely but are there changes to the ways - just net new changes in the industry - with how medical claims benefits are figured, are set up, how we interact with networks, how we interact with payments. And it really allows Judi to figure out and chart the course that we want to take in that kind of less of a pressure cooker environment and really start from square one.  

I don't know if that's something, Liya, that resonates with you, but I can imagine if I'm building off of building blocks that I've already had from pharmacy benefits and the lessons that I've learned from that, that in medical it gives you more power to say we got some of the basics like how is this going to work, things like vendor connectivity, networks, pricing, some of the actual intake of claims, those things get to be bread and butter after a certain point. And now we get to focus on more of the exciting things about medical benefits that maybe historically other folks may not have been able to.

Automation, Data, & Pushing Toward Real-Time Data in Health Benefits Administration

[08:59] Justin Venneri: You know, that's really interesting, Jake. Liya, what are one or two of the findings from your experience in rolling this out where, beyond the obvious of a plan sponsor, or we can see that, you know, customer care representative can see the medical and pharmacy claim next to each other for that member that's calling in at that moment in time, or has a question.  

Beyond putting things next to each other in the system, what are one or two things that you've been able to take from the experience with building out pharmacy claim adjudication and apply to the medical side that are helpful in taking care of plan members or processing things more efficiently?

[09:32] Liya Lomsadze: That's a great point. So Jake alluded earlier to the creative plan designs that we've seen on the pharmacy side, all the different complexities that go into getting those claims to adjudicate properly. We, in building out medical, benefited so much from that experience because a lot of people who come into claims administration, maybe with a different background, they don't know yet that, you know, it's possible to have one deductible, or maybe two deductibles, or maybe 10 deductibles on any given plan. And those deductibles can have all kinds of fascinating interactions with each other. But we already knew that.  

And again, other folks who come into this kind of from scratch might imagine, hey, you know, it's normal to have an in-network benefit and out of network benefit, but that's pretty much it. But we already knew that wasn't true. We already knew that it's possible to have tiers on tiers on tiers of networks.  Some might be preferred for this, some might be preferred for that.  

And understanding that complexity helped us build a system that is going to be flexible and is going to support any kind of plan design that plan sponsors may want to enable without locking ourselves into any kind of weird corners and then having to work out of them later, which a lot of folks who unfortunately have come to this without that kind of background do have to traverse.  

The other unusual thing coming into the medical space was realizing how much of it still runs on human beings. So in pharmacy, right, as Jake explained, we have to get that claim adjudicated in milliseconds and has to be back at the pharmacy almost immediately. And there's no way for a human being to insert themselves into that timeline. In medical, it's very normal and actually very intentional to have human beings manually adjudicating certain medical claims by hand. So not the computer, not the system. A human being is going in and making some decisions. And there's great reasons for that. And there's also, you know, frankly, some not great reasons for that. But I think coming from pharmacy, where we understand that the world can look like something with 100% automation, has been, I think, a helpful pressure to make sure that the way we're building out our platform is going to get us there, right? Or is at least going to let people control which claims require that manual review and which don't in a really fine-tuned way and to make sure that the system is not what's preventing claims from adjudicating.

[11:39] Jake Mulkey: I think that's a really good example. I also find that interesting too because obviously we have a lot of context across the product team, Liya, and we know about pharmacy and medical, but there are so many other teams as well that I think probably have a similar finding, right? I'm thinking about PA, how so much of PA workflows historically have been manual. And over the last, you know, 5 to 10 years, really, especially over the last few years with some of the AI stuff too, has really become a lot more automated. And there's that decision, I think that mimics medical in the same way to try and find like what is the balance between automation and the balance between manual review when necessary.

And I think Judi as a whole, irrespective of just claims processing for pharmacy, medical, I think you really underpin just the core of Judi, that we take that approach first, right? We take the approach of finding the right balance, doing what's necessary when necessary, but also trying to build a sustainable scalable platform that we're setting ourselves up for success and doing things sometimes against the grain of what maybe the norm is in order to do that. And I think that medical example is a perfect display of that.

[12:37] Justin Venneri: So one thing that comes up often is the gap, the delay. It's like pharmacy claims, real time medical claims. I've heard 60, 90, longer, days to see those flow through the system. What have we learned from that? Is there a need or is there a possibility of materially closing that gap? Like, what have you seen so far with Judi Health, with our population, and then what are the implications of that for the future?

[13:02] Liya Lomsadze: So I will say you're right. In medical, there are so many different leaps that that claim has to make in order to get its way to us. You go to your doctor, your visit gets documented in the EMR, then it has to flow through to their billing system, then it has to flow through to a clearinghouse, then possibly to a network, and finally to your TPA who processes it. And we don't have very much control or visibility into all of those upstream processes from where we stand at Judi Health right now.  

So we can't make real time claims processing in medical happen all on our own. And that is a dream that a lot of people would love to see occur for a variety of reasons. But I think what we've learned through pharmacy is that that future is possible if you construct your systems, if you construct your contracts, appropriately to support it, you can get there. And pharmacy is already living that future.  

So, yeah, you have to get a lot of parties aligned. You have to get a lot of things figured out before that can be made possible. But I think coming from pharmacy, we have seen the future and the future is bright. So we believe and we want to see that brought to medical because it really does make everything so much easier. The kind of price transparency that we talk about in pharmacy, that's possible in pharmacy, is really just not currently possible in medical with the way things work. Real times claim processing would help with that immensely.

Unified Data, Clinical Coordination, and the Next Evolution

[14:16] Justin Venneri: You know, it's funny, Susanna Villegas Spillman talked about this our last episode - AH093 - Health Benefits that Work for Everyone: Aligning Incentives & Focusing on Members’ Needs - where making decisions is harder for the plan sponsor in her seat and her peers, everybody, because you're looking at data that's three months old, four months old, five months old, six months old, and it's siloed. So, you know, pulling all that together should help with several different aspects of the equation here.  

Another question that just came up relates to clinical processes. I'm curious if we've seen any examples where having everything adjudicated in one system helps with the coordination of care, because that's a big thing that comes up a lot. How would members benefit from this?

[14:50] Jake Mulkey: Yeah, I can go ahead and take this from a pharmacy standpoint then, if you want to build off of it, Liya.  

I think for medical, so you're exactly right. Like, I think the nice thing about pharmacy claims processing being real time is that our clinical teams that build support some of those more complex clinical programs that we offer in Judi happen just in that moment. A member at point of sale is getting alerted to patient safety or opioid edits or if there are other clinical drug utilization reviews that need to be done, those things happen kind of simultaneously with claims processing and are able to be built and configured directly within Judi for pharmacy benefits.  

I can imagine that there are similar processes for medical and I think the other thing to note there as well, for pharmacy that often means, you know, specific to some of our programs, like low cost alternatives, that we do have interconnectivity with Judi's member portal and member app and are able to pass things not only to the pharmacist, but kind of secondarily relay that message to members directly. And especially now with Judi Care and the expansion of some of our member experience tools, we're really starting to see the full picture of maybe what a clinical experience would look like for a member. And I can only imagine that medical adds onto that nicely and is a nice counterpart to the other data inputs we have from pharmacy adjudication.

[16:01] Liya Lomsadze: Yeah, Jake touched earlier, right, on the idea of the balance between automation and manual workflows and particularly in the pharmacy prior authorization space. We're often needing some sort of clinical documentation in order to better make a decision as to the appropriate coverage of a particular drug.  

Medical claims data is a much richer source of that kind of clinical information than pharmacy is. So some immediate ways in which I'm hoping that we can take advantage of unified claims processing, right, is using that medical claims data to understand what diagnosis somebody might have. And then maybe knowing that immediately helps us pass them through an easier PA approval process rather than having to reach out to the clinician and ask for documentation. Because we already have the documentation. We already know they saw their endocrinologist; we already know they have diabetes. It's already all there on the medical claim.  

So the more of that when we talk about, again, the unified claims processing also brings us that richer unified data set that we can leverage to make all of the decisions that are currently siloed easier and quicker to make.

Building Toward a Frictionless Health Benefits Member Experience

[17:02] Justin Venneri: Okay, that's awesome. And I love the richness of this discussion and the examples and the description you're providing of how this can work. We're at the top of the hour here, so we kind of have to go right to the last question.  

I'll start with you, Jake. What would you say is the most astonishing thing you've seen? Can't give away any secrets, don't want to take any risk, keep your compliance hat on. But as we've gone through this journey to launch this and as we look at adding vision and dental to kind of round out the picture, what's the most astonishing thing you've seen or realized or think is just worth sharing a good story on to close us out.

[17:32] Jake Mulkey: I think for me the most astonishing thing has really been seeing the potential that comes with some of our member facing tools in light of all of the now unified claims experience that we have, and we talk about also including dental and vision in there.  

And I get really, really excited and really jazzed about what the future is going to look like a few years from now where we have all of these different components and different kind of pieces to the puzzle for member experience, and what types of workflows that's fueling, what type of special programs, maybe, we can offer for members to either lessen cost share burdens or better coordinate clinical workflows. Things we've all touched on today, right?  

But I think really getting excited about what is coming down the pipeline that's going to be most impactful to patients. And kind of tying back to the beginning of the discussion we were having, so often people jump right into the healthcare space and think they're going to have a really large impact on members directly because they've found the solution. And I think we're really putting in the man hours to come to the solution that's right in regards to how we're actually going to have an impact long term on not only our clients and plan design and lowering costs for them, but ultimately the healthcare ecosystem and a member's ultimate position at the top of that ecosystem as the most important thing that we focus on.

[18:48] Justin Venneri: Liya, how about you?

[18:49] Liya Lomsadze: Jake mentioned earlier how one of the double-edged swords of pharmacy, right, is that so much of it happens kind of behind the scenes and it's invisible to you as a patient that all of this is happening - your claim is actually getting adjudicated when you're picking up your drugs at the pharmacy.  

To me that's a feature, not a bug. I want every other part of my healthcare to be that effortless or just to work so that I don't have to feel like I'm the one coordinating all my own care, which is what pretty much every American is doing, right? We know that when it comes to medical.  

So the thing that really excites me and it is going to take time, but I think all of this experience with pharmacy has really put this wind in our sails to aim for some of these things that are big, that are going to be hard, that we can't do on our own, but they are the right thing to aim for and they are the future.

[19:34] Justin Venneri: Well, it certainly seems like we have the right building blocks in place to stack everything up on top of this.  

So thank you both for spending the time with us in the studio today and explaining what you've been working on and what you've learned and how it's going. Hope you have a great rest of your day and I look forward to staying in touch.

[19:49] Jake Mulkey: Yeah, thank you, Justin. It was great to get to chat.

[19:51] Liya Lomsadze: Thanks Justin. Until next time.

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