PODCAST

|

Apr 13, 2021

Healthleaders revenue cycle editor interviews OODA Health's co-founders

Episode #13 - Published 04/13/21

Alexandra Pecci:

Welcome to the health leaders revenue cycle podcast. I'm Alexandra Pecci, revenue cycle editor for healthleaders. Today, I'm so excited to welcome Seth Cohen, co-CEO, and co-founder at OODA health and Midori Uehara co-founder and head of provider partnerships at OODA health. OODA is a healthcare technology company providing a payment platform that aligns payers and providers to make healthcare more affordable and accessible. Seth and Midori thank you so much for being here.

Midori Uehara:

I don't need to tell anyone in this audience that the relationship between payers and providers can sometimes be difficult to manage. One of the things that keeps revenue cycle leaders awake at night is dealing with payers, whether that's denials, DRG, downgrades, keeping up with changes out of network billing, and the list goes on and on. Instead of continuing that adversarial back and forth relationship between payers and providers, OODA Health has completely re-imagined it and also how the revenue cycle fundamentally works. OODA Health's partners include Anthem, Common Spirit Health, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, Hill Physicians Medical Group, Blue Cross Blue Shield of Arizona and many others. So of course the big question for you guys right away is what is OODA health? What do you do and how to do it?

Seth Cohen:

Great. Yeah, I'm happy to take that one. So OODA Health is a healthcare technology company. And as you mentioned, we are re-imagining the revenue cycle. So what does that really mean? We are looking at the revenue cycle from the start to the finish from pre-service all the way through denials management and we're rethinking, where could the payer and provider relationship be different? Right? Because what we see is the revenue cycle, which has historically been a provider set of activities to seek reimbursement often involves a very broken relationship with their payer partners. And so what we've done is we've identified a couple areas within the revenue cycle where we see that relationship to be most broken and we're focusing on solutions there. And so in our view, two of the most broken parts of the revenue cycle from a payer provider relationship perspective is prior authorization and patient billing. Prior authorization is not a surprise to most.

Seth Cohen:

It is a, is a process that has a lot of friction to it. Payers and providers often are faced with a very antagonistic set of interactions to approve services that providers deemed necessary. Usually not much debate there. What I'd love to spend a little bit more time on is explaining the patient billing one, because that's often one that folks are a little bit surprised to hear patient billing is historically been a provider centric set of activities, right? It's then the provider's burden to chase patients for bills. What we see though, is that the payer should have a very different role here because ultimately it is the payer that has designed and created a product. It is the payer that has created that deductible, but it's often now the provider that's spending the time educating patients on stuff they never created. We see an opportunity to actually introduce the payer into the equation and to help them take back some responsibility for the products they make.

Alexandra Pecci:

So walk us through that process from start to finish from everyone’s perspective who is involved, the patient, the provider, and the payer. What do they each see, do, and experience. And then what is OODA's role in kind of facilitating that and bringing it all together?

Midori Uehara:

I'm happy to speak to this question. So focusing on OODA Pay, our patient billing solution. From the patient's standpoint, when they're using OODA Pay for their financial experience, after having a healthcare visit, they will see a streamlined and intuitive bill that they can, they can be informed of what they owe either through paper, if that's truly their preference, but more often digital channels. The typical patient financial experience is pretty bare bones. Patients will see a sum that they owe. Maybe there's confusing language about what the services were that resulted in that charge. There's a befuddling charged amount, some kind of adjustment. What OODA Pay does is we make all of that intuitive for the patient. We communicate what they owe very clearly.

Midori Uehara:

We make it really easy for them to make a payment. And then most critically we tell them why they owe what they owe by infusing benefits context into the entire billing experience in a seamless way. So that includes benefits, information, accumulator status, any tax advantaged accounts they may have. So for example, HSA FSA HRA are within that billing experience embedded. And so it's really a one-stop shop when a patient is looking at what they owe instead of having to go to different portals, to understand what they owe, they can see it all within OODA Pay. So that's from the patient standpoint. From the provider point of view, when they work with OODA and bring OODA Pay to their patients, we are lifting the burden and complexity of having to bill patients off of their plates and every activity from start to finish.

Midori Uehara:

And so what we do is we integrate with their systems and we integrate across the EHRs. We assume responsibility for all of the activities of billing. And then we take on the communication with the patient under, under the provider's brand. We also provide high touch customer support in addition to all of the technology assets. And then another key lever that we enable through OODA Pay is real engagement with patients. We know that providers are trying to get different messages to patients, not just about their bills, but about other programs that might be available. And so we fold those types of communications into the patient billing experience, so that it's a much more strategic touch point. And then finally, I'll go through the payer and then I'll, I'll take a breath. But from the payer standpoint, as Seth mentioned, we are activating the payers resources to contribute to this problem of a terrible patient financial experience. We are connecting with payers directly to get that benefits and accumulator information to facilitate integration with those tax advantaged accounts, and also to have an open conversation and dialogue. And this is a little bit more qualitative, but to have a dialogue with their key provider partners about how they can work together in service of their mutual patients or members.

Alexandra Pecci:

So bottom line for providers is they're getting paid up front and they're not billing the patient.

Midori Uehara:

There are a couple of different economic models available to providers. And so a more common one actually is a contingency fee model where the provider is receiving everything that OODA is able to collect from patients, net a fee. And so they've actually you know, some, some history there is that because we've demonstrated that strong results when it comes to the financial side of increasing collections, most of our provider partners would actually like to share in that financial upside and so opt for an economic model that is a contingency fee rather than an upfront guaranteed payment.

Alexandra Pecci:

The next question that pops into my mind is why would a payer want to enter into this kind of partnership?

Midori Uehara:

We get that question quite a bit, as you can imagine, right? So payers could say, well, patient billing is not our problem, so why do we want to make it our problem? Right. We hear that all the time. And I think that it's important to first start with that question, right? Is it really not the payer's problem today? Right. when a payer designs, an insurance product and there's cost share, but that cost share does not get collected in full that cost share does not just disappear. You know, it actually is written off as bad debt and accounted for on a provider's books. And the more, the bad debt accumulates, the higher the rates, the provider must negotiate in order to compensate for that bad debt. So the first thing we have to remember is that when a patient does not pay their bill, it's not a provider problem.

Seth Cohen:

It's a system problem and the system includes the payer, right? And if there are opportunities to reduce bad debt, then therefore there are opportunities to reduce the overall rate increases in healthcare. So that's kind of starting point one is to remind everyone, at least the payer that bad debt is not just a provider issue. It comes right back into the managed care negotiations with the payer. The second thing is around member experience, right? We know that billing is the single worst part of a patient's experience with healthcare. And it is the single biggest detractor from an NPS score. And when a member has a bad experience, they don't just blame the provider. Inevitably, we've all gone to a provider with a question on the bill and the response is almost inevitably while your coverage isn't great or call your insurance company, or if they've denied this or they wouldn't pay for this.

Seth Cohen:

So again, it's not just a provider problem, that member experience is absolutely impacting the payer. And so what we tell the payer is you have two choices. You can continue to suffer the impacts of this without having any control or influence, or you can actually take some responsibility and a more active role to improve it. And I will be honest. We have been really pleasantly surprised to see just how many payers immediately get this now. Uh we thought, frankly, it would be much harder to convince payers to take a role in this. And it frankly has not been, I think that it's been you know, maybe because of competitive dynamics, maybe because of calls for Medicare for all, maybe just because member experience is seen as a more critical way to maintain loyalty and retention, we've seen a lot of interest from the payer community.

Alexandra Pecci:

On the other side, what are some questions that you get from revenue cycle leaders, both as they're hearing about this for the first time, you know, before they joined the partnerships and then after, while they're working with you?

Midori Uehara:

Yeah, we get a lot of great, super thoughtful questions from our provider partners. Upfront, we hear very often what makes you OODA different from every other patient billing vendor that is knocking down my door right now. And our answer is quite simple, which is our orientation is more holistic. And we bring in that payer context and resources, and the result is better outcomes in the form of higher collections performance and unparalleled patient satisfaction. We also hear, and this is more around the trust issue between payer and provider. You know, why should I trust the payer to help with my revenue cycle? I, I negotiate I'm across the table from them every year, every couple of years negotiating a contract. I'm not so sure I want them involved in something as sensitive as my relationship with my patient. And so we've developed a number of approaches to patient billing that ensure that both payers and providers are comfortable with the roles that they're playing and in collaborating.

Midori Uehara:

And so I think we've been able to open a dialogue that mitigates that concern. And it's also relationship specific. Another common question of course, is do you integrate with my particular system or systems? You know, I have this legacy EHR with this imperfect connection to a soon to be retired practice management system. Can you consolidate my fragmented systems? And we're really proud of the solution architecture that we've developed, which is system agnostic and relies on standard feeds, standard transactions leveraging the EDI 835, 837 flows to communicate information so that we can truly be system agnostic and consolidate across a providers disjointed systems, even if they have some that are new and have modern architecture, others that may be on the way out, but we can work across them all. So those are a couple of the key questions that we are very happy to, to answer from our provider partners.

Alexandra Pecci:

Why is this arrangement good for everyone involved and how does each party benefit?

Seth Cohen:

I'm happy to take that. Let's think about the different parties and break them down. First, let's start with the most important, which is the patient. The patient suffers a pretty miserable billing experience today. I think that, you know, one thing I've learned from working in this space now for a couple of years is anytime I tell family or friends that I'm doing something in patient billing, inevitably, I get cornered and told about some awful experiences. You know, about this one time where I got this hospital bill and it was total surprise, or everyone has an experience like this, which is really unfortunate. We don't feel the same way about other consumer experiences we have when we purchase things on Amazon, or we go to hotels or we travel. We don't typically come away with a horrible billing experience with nearly the kind of frequency we do in healthcare.

Seth Cohen:

And unfortunately it's only getting worse because patient deductibles are going up, not down. In fact, increasing increasingly going higher, even more so after COVID because there's a lot of folks who are in the gig economy, or maybe rolling off of a large group plan, going into an exchange where deductibles can be quite high. So the patient billing experience has been miserable. It's only getting worse. And frankly, it's not working because half of all patient balances do not get paid. So not only is it a miserable experience, it's just not effective either. So starting there, I think there's ample opportunity to improve. And frankly it's a very low bar. From the provider side, I think Midori captured it well, that provider frankly, is at a ceiling, so to speak of how much they can collect, right? And part of that ceiling is driven by the fragmentation of the current model.

Seth Cohen:

The providers can do a ton and they do a ton today to make the bills look nice to offer an online portal where you can pay maybe payment plans where applicable all that's great. But at the end of the day, if a patient is staring at a bill that they do not understand, if they are staring at a bill, they did not expect, or if they're looking at a bill and cannot match it to an EOB from their payer, they will not pay it. And so no provider can solve this problem alone and by bringing the payer in, we can break that ceiling that they're stuck at and actually get them much closer to what they're contractually owed. So getting them that yield as well as a better patient experience is the key for the provider. And not least the payer, as I mentioned earlier, yes, payers initially wonder why they should get involved. But when we explain that this is not just a provider problem, it is a system problem. They quickly get it. And they have a huge opportunity to support their patient community and also support their provider community and make sure that the contracts they're setting up are actually getting realized

Alexandra Pecci:

Let's talk about specific outcomes for providers. How does this partnership improve revenue cycle KPIs?

Midori Uehara:

Yeah, we, we improve a couple of really important outcomes for providers. One that most of our partners are laser focused on is their yield or their net collections. And what we've been able to show with our, our partners and relationships to date is a 20% improvement on the baseline of collections. We are also able to accelerate collections and reduce that bad debt expense as a result. One thing that we've been able to do that drives the reduce bad debt expenses, enroll more patients into payment plans who otherwise would not have been able to pay. We make it very easy for patients to match their payment schedule to their budget, which has enabled patients who previously would simply not pay get onto a plan that works for them. And then another really important metric that our partners are focused on is patient satisfaction.

Midori Uehara:

And there are a couple of different ways that we measure that in different health systems, as I'm sure you know, and appreciate use different metrics to measure patient satisfaction. But the ones that we use are just a simple satisfaction score after the patient completes a payment. And then we also use NPS and it's important for us to get good baseline data. But as I mentioned, I think in just earlier, we've been able to achieve a 96% patient satisfaction rating which is often, you know, an order of magnitude above what our partners have been able to achieve on their own. So those are a few of the metrics that we've seen in our relationships to date that we've really been able to move the needle on.

Alexandra Pecci:

And how does it affect denials or are denials not even a thing anymore?

Midori Uehara:

For OODA Pay. And then actually I'll, I'll speak to our prior auth solution briefly. OODA Pay on the patient billing side is for the most part downstream of the denial interaction between a payer and provider. But what we're able to do is we're able to insulate the patient from the messy back and forth and serve as a single source of truth on what's going on. So let's say a bill is being disputed or a claim is being disputed between the payer and the provider. Very often today provider systems will automatically bill the patient for full charges because the claim hasn't been paid by the payer yet. And sometimes their systems simply just send out a bill and that's really alarming. And in fact, that has happened to some of our OODA employees before where they've received a bill for $20,000 plus, and it says in fine print at the very bottom, we're sorting this out with your payer. So it's basically an interim bill. We get rid of that heartache and headache for patients by coordinating across the two. And so denials may still occur, but we're insulating the patient from the noise that they create by better coordinating the payer and the provider in those instances.

Alexandra Pecci:

And I would imagine that will be really important next year when the No Surprises Act goes into effect.

Midori Uehara:

Yes, absolutely. When there will be perhaps even a longer timeframe of sorting things out between payer and provider. You know, I mentioned before, I want to speak to our prior auth solution as well, just briefly because we know that a missing authorization or a mismatched authorization, those are also frequent reasons for denials and our prior auth solution is automating and streamlining the authorization request process within the payer and then feeding those results back to the provider. And what we're able to do is create a more reliable prior authorization process within the payer so that there are fewer of those mistaken denials for no authorization found, even though the provider did submit an authorization. I know that that's a huge pain point for many providers who are pulling out their hair saying I'm submitting an authorization for everything I possibly could. And yet I'm still getting denied, even though I'm certain I submitted that. So we're helping to normalize that process, automate it and then make it more consistent and reliable. So we don't get those unnecessary, noisy denials due to some kind of breakdown in the process upstream on the payer side.

Alexandra Pecci:

Finally, let's talk about the future even more. What are you working on to improve the program and what might it look like in five years, 10 years down the road?

Seth Cohen:

Yeah. I could talk about that question all day long. Cause there's so much opportunity here. Well first let's talk about the two specific products that we mentioned in this podcast. So first is around patient billing. I think there's so much that we can do to to more deeply personalize the experience using claims information from the payer or prior auth information from the payer. We can really model a very clear projection of what that patient is likely going to encounter from a billing perspective and be much more customized in how we present that. So for example, if we see a prenatal claim come through and we can anticipate that the patient is expecting a pregnancy and then we can forecast what those costs likely might be perhaps set up a longer term payment plan that would cover the upcoming care as well.

Seth Cohen:

Right? So again, moving away from this episodic transactional view of a patient and saying more holistically, what do we think that this patient's going to encounter? I also think on that personalization standpoint, we can think more about discounts and offers and incentives for patients. As we all know, when we interact with billing sites online, you might get offers or discounts on a credit card statement in exchange, signing up with a promotion. Once again here, why do we treat patients as they're just a receivable to be chased? Why not treat them as a member to be engaged? And so in that spirit, you could imagine a world in which you get $10 or $20 off your bill, or maybe your bill completely goes away if you sign up for a care management program that we know is in your best interest long-term. And so I think one really exciting area again, is moving away from this episodic view of a patient and thinking more longitudinally about what that patient really could benefit from long-term.

Seth Cohen:

On the prior authorization side, there's so much there, we didn't spend as much time explaining that product in depth, but just building on what Midori was sharing. We think there's a lot that we can do to automate that process end to end and leverage connectivity to EMRs so that the provider is able to passively submit requests for prior authorization versus having to sit in front of a fax machine. So a lot more coming there. And then beyond both of those solutions, we continue to look across the revenue cycle, right? Prior authorization and patient billing are just two areas. We're looking a lot into denials management as well. And how do we support more efficient review of denials or even prevent them upstream? We're looking at managed care contracting and some of the ambiguity and labor intensivity of contracting between payer and provider and what can we do to create smarter contracts there. So there are so many areas in revenue cycle where we see an opportunity to improve the payer provider relationship. And we're going to continue to invest in those areas, as we build out our roadmap.

Alexandra Pecci:

Seth, and Midori, it has been so wonderful talking with you. This is such a fascinating topic. Thank you for being here and sharing your expertise with us.

Seth Cohen:

Thank you so much. This is a lot of fun.

Midori Uehara:

Yeah. Thank you, Alex. This is great.

Alexandra Pecci:

And thank you listeners for joining us on the health leaders revenue cycle podcast until next time keep taking care of patients and each other.

Learn about how you can partner with OODA Health to improve your members’ experience and your revenue management.