AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze

The timeline between pharmacy and medical claims processing could not be starker. Pharmacy claims resolve in milliseconds; medical claims can take months. In this episode of the Astonishing Healthcare podcast, host Justin Venneri welcomes back Kevin Sundquist and Liya Lomsadze from Judi Health to trace what happens after you hand your insurance card to the front desk, and why that journey is so much messier than it should be.

Together, Kevin and Liya explain why medical claims move so slowly, how legacy systems create needless friction, and what a Unified Claims Processing™ can do to fix it.

Why Is Pharmacy Claim Processing So Different From Medical?

The contrast between these two processes starts at the point of care. In pharmacy, a member stands at the counter, the pharmacist enters a combination of numbers, and the system returns exactly what to charge. As a result, each member’s claim gets near-instant certainty.

Medical does not work anything like that. As Kevin explains:

"Once you give your insurance card to the front office, you don't really know what happens. You might get a copay, and that copay might be right or it might not be right."

In other words, some systems are so opaque that charging the member the correct amount is nearly impossible. A single hospital event, like having a baby, generates numerous services that must be aggregated and billed to the right insurer, whether that’s a primary plan, a secondary plan, or a marketplace option.

What Makes Medical Claims So Slow?

Liya walked through the first medical claims Judi Health processed for its own population, which launched on January 1, 2025. Waiting for that first claim revealed exactly why the system lags. She points to two core problems.

Medical Claims Can't Be Created On the Spot

The claim representing your visit often can’t be built right there in the room. The clinical notes and billing software are often separate systems.

"As you can imagine that the electronic health record and the billing system could be two completely different systems."  

Some encounters, like the birth of a baby, require human intervention to code correctly. Every handoff between systems introduces lag, and every integration introduces a chance for errors.

Getting Medical Claims to the Right Payer Is Complicated

On the pharmacy side, the switch routes claims from pharmacies to the right pharmacy benefits manager (PBM) quickly and reliably. Medical routine is far more variable. Several different clearinghouse providers connect the EMR and the payers, some payers want claims sent directly, and some claims still arrive on paper.

What Happens After the Claim Arrives?

Once a claim reaches Judi Health, usually in a standardized format once a day, the real work begins. Kevin notes it’s common to receive the pharmacy claim well in advance of the medical claim that generated it.

From there, the claim runs through the benefit. Our proprietary enterprise health platform, Judi®, prices it, assigns a copay, applies coverage, and counts thinks like the number of visits used, so the member stays covered. The member then receives communication through both digital tools and a physical letter, which remains a regulatory requirement.

Then comes what Kevin calls “delays on delays.” The provider needs to be paid. The member needs to pay their copay. The doctor’s office often has to chase that payment, sometimes handing collections to outside agencies.

As Kevin puts it, “It's more about the odyssey of a medical claim, I would like to call it, not just the story from that side.”

Why Are Medical Claims Split Across So Many Vendors?

Liya highlights another complication that compounds the delays: the tendency to carve up the claim journey and share the pieces among different platforms and vendors. It’s common to split out:

• Determining whether a provider is in network and what they should be paid.
• Pricing out-of-network claims to a separate entity.
• Handling prior authorization requests and decisions.
• Applying the benefit itself, including deductibles, copays, and cost sharing.

Each carve-out means another integration and another slowdown.

"One of the things that we are hoping to solve with Judi is bring all of those capabilities into a single system so you don't have to carve this entire long journey up into five more pieces,” Liya said.

How Does a Unified Claims Processing Platform Help Plan Sponsors?

For plan sponsors, brokers, and consultants, this unified architecture offers flexibility without rigidity. Judi isn’t prescriptive: if a client wants to carve out part of the process to a preferred vendor, they can. But when the pieces remain together, plan designs become far more creative.

Liya shared two revealing examples of how legacy claims processing systems fall short:

• ‍Frequency Limits: One client’s existing system only lets them set up a single frequency limit. So, if they cap physical therapy visits, they’d have to manually adjudicate every chiropractic claim to count visits correctly.
• ‍Deductible Math: Another plan sponsor couldn’t configure a compliant deductible because their software required it to be a multiple of something else. They had to raise it a couple hundred dollars for “completely unnecessary reasons.”

“That kind of manual inefficiency is just beyond unnecessary and something that Judi does not artificially create.” - Liya Lomsadze

What New Tools Is the Judi Health Team Building?

Kevin outlined several areas of active investment, starting with payments. At the beginning of 2025, Judi Health started using its own product to pay providers.  

"We collect the dollars first before we pay the providers from the plan sponsor, and then we send those out,” he explained.

Owning payments lets the company control fees, limit plan sponsor exposure, and support real-time reversals and readjudication.  

Beyond payments, Kevin pointed to three priorities.  

• ‍Integrated Care Management: Tracking members approaching stop-loss thresholds or checking whether members on diabetes medications have seen a doctor recently. ‍
• Payment Integrity: Extending pharmacy expertise into medical claims, using AI to build the next generation model for confirming appropriate rates. ‍
• Member tools: Following the 2025 acquisition of care navigation provider Amino, Judi Health launched what Kevin calls "the member experience revolution."

Reimagining the Member Experience

The member tools relaunch aims to create the first unified member experience module, tracking every piece of the benefit and integrating it with care navigation.

Kevin describes the vision of helping members choose the right in-network doctor, avoid surprise billing, and see an accurate cost estimate based on their accumulators, the network, and the visit date. Further ahead sits an AI virtual advocate product, pulling in lab values, allergies, and chart notes from the EHR.‍

How Does Unified Data Change Customer Care?

Liya dove into the reason why it’s difficult to simply answer how much a procedure will cost.

“If you think about it, a single medical claim has really hundreds of data points on it. But fundamentally, I think you would need at least 20 of those to really confidently answer that question. And nobody has 20 data elements available when they are just trying to figure out what is this procedure going to cost me if I get it here?” - Liya Lomsadze

In other words, without unified data, care teams can’t confidently provide an accurate estimate.

To close that gap, Judi Health released a tool letting the customer care team plug in a single procedure code and get back a best estimate of coverage, given the plan structure and mappings. It flags when a procedure might count as preventative or when it’s affected by plan limits.

"Bringing together pharmacy and medical, bringing together all of the attributes that we know about a member, gives our customer care team an additional insight into, frankly, everything that could possibly be going on,” Liya noted.

How Does Judi Health Reduce Friction for Providers?

Kevin framed the provider relationship as a partnership. Judi Heath works to reimburse pharmacies appropriately using its NADAC model with a higher dispensing fee and stays flexible on networks and claims pricing.

The team recently added CLEAR verification to its provider portal, removing extra MFA steps so providers can handle everything in one place. Kevin also stressed a bigger ambition:  

"How do we build the best software to change the industry and democratize that so that anyone that wants to work with us can use the products to make the experience for the provider and the member better?" - Kevin Sundquist

Where Is AI Making a Real Difference in Claims Processing?

Kevin returned to a well-known pain point in healthcare: faxes. Judi Health built a generalized AI model to extract key information from faxes, creating prior authorization cases and even medical claims from them. On the pharmacy side, AI reads chart notes submitted by doctors or ported from the EHR to answer clinical questions, so pharmacists spend more time evaluating cases than hunting for answers.

He also cautioned against a common trap. "A lot of these systems that are out there are trying to bolt on AI to these old software systems.” But with old infrastructure comes inherent friction and challenges.  

Liya echoed the value of intelligent document processing, sharing a memorable moment from when she visited the dentist.

“I love my dentist. My dentist is the best. He, I thought, was extremely tech forward. And then my first dental appointment after starting this work, I watched him print off my dental claim and put it into an envelope right in front of me. And I was sad because, like, oh my God, I'm part of the problem. Somebody's gonna have to, you know, go transcribe this paper claim into some piece of software.” - Liya Lomsadze

Why the Medical Claim Journey Matters

A medical claim’s odyssey is, in effect, a chain of handoffs, integrations, and vendor carve-outs that delays payments, confuses members, and frustrates providers. Judi Health’s answer is unification: bringing adjudication, payments, care management, and member tools into a single platform with thoughtful AI integrations built within modern electronic infrastructure, rather than bolted onto aging technology.

When everything is unified under one system, the result is greater transparency, less waste, lower costs, and a better experience for everyone in the healthcare system.

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Click here you want to learn more about how Judi unifies medical, pharmacy, dental, and vision workflows on one system.