Outsourcing: Jason Beans, Founder and CEO of Rising Medical Solutions (Part 3)

Sramana Mitra: What do you think is the core differentiated value in what you do? Is it more the rules engine that helps you determine what is to be approved and what is not to be approved?

Jason Beans: That is a differentiator. I wouldn’t say it was the number one, just because if people were as smart as we were, they could develop similar rules. What we’re trying to do, to own – and that takes technology – is we’re trying to own service in health care, take the pain out of the process. We’re trying to make everything easy, intuitive, and painless and even provide a high customer service model to the providers, patients and carriers that we don’t think has been seen in the industry.

We use our technology to the same end. We use the technology to automate things, but with the end game being to make the process easy for everyone. That’s what we’re trying to own as our differentiator, just a great user experience and great service.

SM: You said it’s a hybrid between technology and high-touch human service. What is the human piece of it? What needs to be done outside of technology?

JB: We, in technology, cannot make a determination. They are very complicated, the medical decisions. If we can’t determine if a surgery is appropriate based on the data, electronically, it will be routed to our medical staff, who will review the medical records, talk to the treating physician and make a determination. Does this person need a back surgery or right now, or should she be doing physical therapy instead of going into a surgery that could hurt her forever? There’s that human touch. When medical bills are submitted, there are thousands upon thousands of codes for treatment, and a small change in the coding will make a huge difference in the reimbursement. So, when we’ve found that people have used this code inappropriately in the past or it’s a large charge and we want to take a look at it, we’ll have certified coders and experts in medical billing look at it. We’ll have negotiators, if they’re not in our network, pick up the phone and try to negotiate a fair rate. Again, we can use our engine to determine a fair reimbursement or we don’t feel like we’re getting a fair reimbursement based on the automated rules, we route to people to try to work with the doctor and get something fair.

SM: I see.

JB: Does that make sense?

SM: Absolutely. Now, help me understand the business model around your business. Who pays, how much and how do you price it?

JB: Again, that’s something very simple. For a lot of the services, say, the utilization review, the service side is a time and expense model … or a flat rate per case. If we make a determination, say it’s $100, for easy math. The medical bill processing side can get complicated. A lot of our services are transaction based, so if it’s something that can be automated, maybe it’s $7 or $8 a transaction for all the electronic exchanges and running it through our engine. For saving over and above the automated things, for negotiating higher rates above what could easily be done by our competition, we sometimes get into a value-share model where we take $0.25 on what we can save so that we’re incentivized to try to get the treatment in the most cost-effective manner. It can vary dramatically depending on the service. I try to get, as often as possible, into a value-share model so that our incentives are aligned with our clients’ incentives.

SM: In this case, the value that you’re talking about is value for the insurance clients, not the physician clients?

JB: Right, right. We have some models where it’s based on pre-negotiating the rates with the provider and maybe we just Stub Hub or we just take a percentage of what the provider is paid. In that way, now, the Stub Hub charges 10% of the transaction or something along those lines. We do have models based on what the provider is paid, too. It depends on the product. I wish it were less complicated.

This segment is part 3 in the series : Outsourcing: Jason Beans, Founder and CEO of Rising Medical Solutions
1 2 3 4 5 6 7