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Outsourcing: Jason Beans, Founder and CEO of Rising Medical Solutions (Part 2)

Posted on Thursday, Oct 27th 2011

SM: Tell me more about how you deliver that service. What do you need in terms of your workforce? What do you tackle in technology? What do you tackle in human resources?

JB: It’s a very hybrid model. It’s a half technology, half service model. We have a team of, say, 40 or 50 technology people in our Chicago office. We’ve recruited people from Orbitz and the Accenture consulting side and some very senior people. We’ve built out the ability to take out electronic billing from doctors, run it through an engine, route medical data to our clients or to patients to approve, route payment data electronically back to the doctor or to a check printing center if the doctor can’t take ACH.

We have, just to give you an example, over three million electronic messages going in and out of our system every month, just exchanging data, running claims updates or policy updates and routing them back and forth so that both the doctors and the insurance carriers are communicating. Doctors are signing up for PPO networks or canceling PPO networks, so it’s a massive amount of data management on that side. We also take, because we run a million medical treatment payments per year, we’re gathering a very large database of what should or should not occur. So, we have a pretty large data analytics team that is trying to build out tools to help our clients make more effective decisions.

For example, if it’s this type of injury, what should it cost, on average, so they can reserve properly. Which treatment path is the most effective? Which doctors have the best outcomes? That’s an ongoing process to try to allow them these technologies to determine the most effective treatment path – and the patients, too – but we’re building it out for our payer clients. The thought is to bring it directly to the consumer market once it’s refined … if that makes sense.

SM: Let me parse what you said. Maybe it would be easier for our audience to go through some use cases.

JB: Okay. It’s very complicated. I’m sorry.

SM: Well, that business is quite complicated. It’s no surprise that your [part of it] is quite complicated. So, let’s say a doctor prescribes an MRI for a patient. What happens in that transaction?

JB: It varies everywhere, but I’m going to give you the most detailed version. In some situations, they have to get approval from the client. So, they can go online, put in a request for that MRI on our client’s website. We can build out the technology so that it’s actually our form; they’re actually typing into our technology but it looks like our client’s site. That will run through our technology and it may be auto-approved, if it meets criteria. If it can’t, then we will allow them to submit electronic medical records. Our nurses, as a service, will go through and review them and see if they meet protocols or route them to a doctor for a decision. It’s called pre-certification. Once the service is approved, the doctor can bill. He can bill electronically, through a clearinghouse, to us. We’ll accept that electronic payment. We’ll know if the service has been approved. We’ll run it through – if he’s in our PPO network – we’ll run it through and find out what the rate is. And we will drop that to the carrier so that [the carrier] can approve it in its claim system and issue the money. And then the carrier can transfer the money to us, and we – if the doctor signed up with us – will electronically transfer the payment back to the doctor.

SM: The doctor has to sign up with you or is it the insurance companies?

JB: If he wants an electronic payment, yes, I have to have a record of where to transfer the money. If he wants a check, if he has not registered his bank, we can print a check and mail it with a detailed explanation of which services we’re paying for and how much. So, every step of the way is configurable and every step is different with each carrier and with each doctor and each state.

This segment is part 2 in the series : Outsourcing: Jason Beans, Founder and CEO of Rising Medical Solutions
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