Patients are often surprised to learn that their doctor doesn’t know the cost of a procedure or test that they ordered. A Salt Lake City-based startup, Rivet, is looking to change that by tracking down billing information and creating estimates.
The company closed an $8.25 million series A funding round led by technology venture capital firm Menlo Ventures. Lux Capital and Pelion Venture Partners also participated in the round. Croom Beatty, a principal at Menlo Ventures, will join Rivet’s board as part of the funding round.
Behavioral Health, Interoperability and eConsent: Meeting the Demands of CMS Final Rule Compliance
In a webinar on April 16 at 1pm ET, Aneesh Chopra will moderate a discussion with executives from DocuSign, Velatura, and behavioral health providers on eConsent, health information exchange and compliance with the CMS Final Rule on interoperability.
“This is a massive breakthrough in an industry that loses 30% to 60% in patient revenue by being unable to collect debt. With Rivet, not only do patients know exactly how much they’ll be paying for care and have an easier way to pay, but healthcare providers have better insight into their billing processes to make sure they are being compensated appropriately for their services,” Beatty said in a news release.
The startup has two software solutions: One that helps midsized practices negotiate in-network rates with insurance companies, and another that lets patients receive cost estimates for a procedure and pay a portion of their bill upfront.
Rivet plans to use the new funding to build out its platform into an end-to-end billing suite, and grow its team.
Co-founder and CEO Ted Ferrin started the company as a system to help middle-market physician groups manage their contracts with payers.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
“Providers don’t know what’s in their reimbursement contracts. Those reimbursement contracts literally dictate what the insurance companies pay them and what the patient is subject to pay them,” he said. “They’re as much in the dark about price transparency as patients are.”
Rivet pulls in information from providers’ reimbursement contracts. Once they manage to get in network with an insurer, there’s usually a negotiation process. Ferrin likened it to an employee asking for a raise.
Rivet helps providers prepare for that negotiation by giving them a benchmark analysis of their contracts, so they can have a better understanding of what a good reimbursement rate looks like. They can point to those numbers, as well as other features that might be appealing to insurers, such as extended hours for patients.
“You don’t always succeed. You may negotiate with 4 or 5 payers and you may be successful with half of them. And that’s ok,” Ferrin said.
Bringing prices to patients
Rivet began building out its billing software after noticing some provider groups were using its technology to give their patients out-of-pocket price estimates.
“It puts us in this really interesting position,” Ferrin said. “We saw our customers trying to solve this acute pricing transparency problem.”
Negotiation rates between healthcare groups and insurers are closely guarded secrets. But since Rivet has access to providers’ contracts, it could generate a spreadsheet of all of the codes they can bill for and their reimbursement rates. Those codes often get adjusted; for example, if an insurer determines two codes are redundant, they may only pay for half of the second code. So, Rivet created a logic engine that processes some of these rules, and also runs machine learning algorithms on past claims to reach a final estimate.
The idea is, Rivet could easily generate an estimate ahead of a routine physical or an MRI. Patients would receive a cost estimate via email or text before they go in for their appointment, and could pay for it upfront in some cases.
For more complicated estimates, such as planned surgeries, a provider could request a portion of the estimated cost upfront. Ferrin said Rivet is commonly used in specialty practices, such as orthopedics, gastroenterology and ophthalmology.
“Our goal is we can at least get the financial conversation started with real actual data driving that conversation,” he said.
Part of the reason why many practices have trouble billing patients, is because their technology is optimized to bill insurers. 20 years ago, when deductibles were lower, collecting from patients almost didn’t matter, Ferrin said. Now, with high-deductible plans, much of that cost has shifted to patients.
“Patients have become the payer,” he said. “They’re literally footing the bill.”
Photo credit: cat-scape, Getty Images
