Beacon Healthcare Systems is working to apply data science and analytics to appeals and grievances technology and information in the payer space.
Why? Because CEO Ken Stockman envisions gleaning insights from appeals and grievances data to create unique industry KPIs that inform payers about what they should be striving to accomplish. Stockman, in fact, says the resulting information will constitute “a report card for payers.”
Health Evolution interviewed Stockman about moving out of startup mode and into the growth phase, how the company is also advancing its compliance technology as part of an overall platform strategy and not backing down from the manner of business “body blows” startup founders often feel.
What is the inspiration fueling Beacon Healthcare Systems or its origin story?
Stockman: The origin is that I started another company in 2004 before Medicare Advantage had even begun. That was one of the initial players in Medicare Advantage working on risk adjustment and enrollment. I thought of that company on a set of PowerPoint slides, founded it, spent five years building it, then I decided to sell my stake and left. I started this company and initially hired people to run it for me for the first couple of years because I had an opportunity to go work in the payment integrity space with iHealth Technologies, which was bought by Connolly and has since become Cotiviti. After doing that for a couple of years I came back here, and I have been building the company ever since. I have a long track record in the payer space in understanding payers and how they operate, what their needs are and in building relationships.
One thing that makes my team so passionate is that some appeals and grievances include a 65-year-old member having a problem with their provider or the provider having a problem getting certain care approved. And that all runs through our platform. So, we are passionate about the fact that we are part of the health care delivery system and that we have client relationships that I’ve just never seen before.
Building on what you said about moving into growth mode, what should current and prospective clients expect in the next 18-24 months?
Stockman: We have two core products today: our compliance platform and our appeals and grievances platform. Our compliance platform is in complete investment mode. We’re expanding it, we’re extending it. For example, we have a new universe scrubber which has already been very well received. From my perspective, if we do not have the best product in the industry then we are not showing up to work. Our compliance tool is really evolving right now, and it is going to continue to see a tremendous amount of investment. We hired a Chief Compliance Officer last March, John Tanner, who was the Medicare Compliance Officer at Molina. We also added a Senior Vice President of IT Development and Infrastructure last year, Manish Nautiyal, who joined us from Molina as well. On the compliance side, you are going to see the functionality and overall focus on assisting in audit preparation and audit risk reduction.
Also, in the next 18 months, we have a member services strategy that includes certain areas of the delivery process that today are antiquated or manual. Some of the platforms that are in place are extremely expensive and unwieldy. So, we have been partnering with some of our clients to look at different ways we can help them automate parts of their member service processes in a cost-effective way, which ties right into our overall product.
What will that enable Beacon to do that it otherwise could not?
Stockman: The most exciting aspect is that we have done some initial proofs of concept and believe we have so much data now that we can create industry insights and KPIs that no one else is producing, and we have hired a data scientist. For health plans, we can basically shed light on appeals and grievances, we can start on social determinants of health issues, and we can create KPIs for both prospects and clients, so they know what they really should be striving to do. Across the next six months if you’re an appeals and grievances client, you’re going to see the insights and the data analytics science to help the industry understand that appeals and grievances are the report card for health plans. Health plans have historically taken appeals and grievances as “People are complaining, I don’t want to address this, but we have to.” What I used to tell people when I was in risk adjustment back in 2007 was “Don’t just do risk scores to raise your revenue. Use the risk scores to determine who should be in which programs.” No one ever did it because they were too focused on revenue.
What we want to be saying to our clients is “Hey look, we know that you have cases that are going to become untimely next week that you need to deal with, we know that you’re going to have an audit risk you need to deal with it, here’s how we can help.” We’re going to be leveraging analytics to guide the way health plans think about appeals and grievances to “Wow, I can get in front of this and therefore I’m reducing the number of calls to customer service. I’m improving my member retention rate and improving my provider relationships and I’m really making a significant improvement in our members health over time.”