This Small Business Innovation Research Phase I project will investigate the potential of creating a free consumer medical financial management portal. The portal will pull in health care financial data and organize it in a fashion that allows consumers to understand and act on their health care data. The research will also explore the possibility of funding the product by providing value-added solutions to the healthcare industry through innovative software engineering algorithms. The rising costs of health care, the growing popularity of Consumer-driven Health Care plans, and the aging of America?s population have all increased the need for more consumer control over health care finances. Consumers currently have no easy way to reconcile paper statements from payers and providers and are forced to manage it with spreadsheets, notebooks, and sticky notes. Although data for managing medical finances is starting to become available, consumers do not yet have the tools to do it.
The 250 million Americans with health insurance are known to be frustrated by the overwhelming volume and complexity of health care financial paperwork. They don't understand if they are being charged correctly, if doctors are filing claims correctly, or if their insurance company is correctly passing costs to them. This confusion causes extra cost to the health care system. Consumers pay bills they do not owe and delay paying bills they do owe. Health Insurance and provider call centers are inundated with customer calls about arcane billing and coding messages on Explanation of Benefits letters. Criminals exploit consumer confusion to defraud payers for hundreds of billions of dollars annually. These frictions all increase health care costs and ultimately result in lower care. The proposed solution will allow use of data mining, analytic rules engines, pattern matching, and other tools to provide consumers with a free health care financial management engine and a fraud detection system for health care payers. If successful, the proposed solution will help consumers become healthier, save money, and help reduce the drag fraud creates on our national competitiveness.
We researched the challenges American consumers have managing the data associated with healthcare finances. Consumers are faced with fragmented, disconnected data sources that ultimately impact their ability to obtain healthcare services. We had 4 major pivots through the course of this project based on what we learned from the market. We investigated a Fraud Detection Service, services offered directly to consumers, consumer claim filing services, and campaign platforms for organizing benefits for parents of children with special needs. Through the course of this research we discovered the following: Data is still too fragmented to solve these problems with infrastructure software. Insurance companies are unwilling to engage with 3rd parties for fraud detection unless they completely control the technology. Consumers will only pay for a service where they get refunds from filed claims. Consumers are not currently self-organizing around groups that make a scalable service offering possible. Parents of children with special needs face exceptional challenges dealing with insurance coverage for their children. Other Key findings: Consumers care about their medical Bills – not Insurance. We had initially assumed that getting and understanding the complex consumer insurance information would be the biggest problem for consumers. This was the most frequently articulated problem in the interviews we had with consumers. However, consumers had no call to action until they received a bill from their doctor or hospital. Billing data is almost impossible to obtain. The state of our healthcare billing systems is worse than we had anticipated. Consumers access a wide variety of provider networks that use different, disconnected billing systems. There was simply no scalable way to billing data without using manual labor and paper. Claims filing is a major challenge and tied directly to transactions. Consumers ask for help filing claims directly. In some cases they had thousands of dollars of outstanding claims that we could recover for them from insurance companies.