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Streamlined and automated processes not only help save time and effort but also money. For patients, this means having to save and avoid the unnecessary costs caused by errors and overcharging. Pranov Duggasani and Zoe Holderness founded Slingshot Bills, a company that automates the patient advocacy process and saves individuals and their employers’ money. In this episode, they join Louis Bernardi to tell us what led them to start their company along with the problems and solutions they found in the healthcare system. In particular, they take a deep dive into the value of leveraging technology to help manage healthcare spend. Pranov and Zoe discuss the many issues they encountered while auditing, from bundling issues to EOB errors and more. As consumers, we have the right to information that is so often not given to us. Follow along to this great conversation and learn important insights that could help you pay less for your health care without more work.

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How Employers Can Leverage Technology To Manage Healthcare Spend

With My Guests Zoe Holderness And Pranov Duggasani

We have a great episode in store for you. Two brilliant yellow jackets, Pranov Duggasani and Zoe Holderness from Slingshot Bills are with me. We met in person at YOU Powered in Miami. Zoe and I connected. I swore I wouldn’t take any inbound calls anymore but I saw her coming to Georgia Tech. That’s where my son went. I know that they’re bright if they went there and made it through that grueling academia stuff. Welcome. How are you guys doing?

Good. Thanks for having us, Lou.

Where are you guys joining from?

We’re joining from San Francisco.

For our loyal readers, Dale, if you’re out there, hopefully, Slingshot Bills, when I did get on the call with Zoe and she explained what they were doing, I was blown away like I am a lot of times when I meet new technology solutions that are trying to help the American healthcare consumer navigate and eliminate as much of the waste, fraud and confusion out of the healthcare system. This one stood out in my mind. I will turn it over to whoever wants to go first, if you want to introduce yourself, a little bit about your background and Slingshot Bills and then we’ll get into a conversation.


BWF 10 | Manage Healthcare Spend


I’m Pranov as Lou said and you got the pronunciation perfectly so congrats. I’m the CEO of Slingshot. Zoe is the CTO. We met back in college at Georgia Tech and connected back when we were in California. I was a software engineer at Google. Zoe was a software engineer at Lyft and Tesla. We started working on this problem after Zoe felt it herself so I’ll let her talk about that.

I got overcharged for a gynecologist bill and thought that the bill was a little too expensive. I requested an itemized bill. I started digging into CPT codes and what those meant. I realized I had a case where it was a misuse of a modifier 25 and so I requested coding audits. Ultimately, I got my bill reduced but was frustrated by how long I spent researching what CPT codes were and how things should be billed correctly. Pranov and I started taking on cases for friends and we were lowering our friend’s bill by about 30%, which was wild to us because it was a population of 25 to 35-year-olds who were all insured by their employers and generally pretty healthy.

If it was a problem for them, we couldn’t imagine what it would be like for the greater population. It also seemed like a perfect application for software because there are all these rules in how you should bill something so that you don’t unbundle something or charge for a higher severity than happened. It’s the perfect application to implement software and have a decision tree rules engine and then machine learning models to figure out what is the correct way to bill something.

Technology is the solution to most things. This is a scenario when we’re talking about healthcare and health insurance and we talk about it all the time on this show, all of the misaligned incentives. It’s business and capitalism. You have to think, “Do doctors earn more when they charge more?” The answer is yes. A few years ago, there was some legislation that expanded the CPT codes, the standard codes for inpatient and outpatient care. Everything has a code. What the consumer has to understand is that when you go to the doctor, it’s not a flat rate or an office visit. There are a lot of different codes that go into it.

The complexity of the visit entitles the providers to more money. When you go to the emergency room, you can go for a stubbed toe that you thought might have been broken or something where your toe is about to fall off and you need surgery to reattach it. You would think hopefully that medical providers would be billing appropriately and would be maybe required to do that or subject to a penalty but they’re not. No one’s looking at this until Zoe Holderness gets a bill. Maybe it was the first bill you’ve ever gotten, I don’t know.

A lot of times, when people are out of school, they’re adults and their parents throw them on their own. You’re on your insurance after you’re 26. In most cases, people age off the plan and they get this EOB that might as well be in Latin. What is this? I have one in here, $1,200 for 15 minutes with the doctor. It was silly. What you have to understand is that what Slingshot is doing is they’re using technology to look at that invoice. You’re connecting to the underlying health insurance plan or the TPA if it’s a self-insured employer. You’re determining if the billing and codes are appropriate for the procedure and the diagnosis.

What we found too is that people didn’t know how to read this EOB. You don’t understand the code. People don’t realize there’s even a possibility that there could be an error in it. We’re used to getting a receipt for whatever we received and knowing that it would be correct. At these large hospital systems, you’ll have your doctor providing care, writing down notes on your EHR and then somebody else translating those notes into billable codes and filing a claim with your insurance. There’s that disjointedness, which also creates more opportunity for an error to sneak into your bill.

It’s not the doctor. I make it a point on this show not blasting doctors but it’s the business side of healthcare. A lot of healthcare facilities and practices are privately equity owned and they make big investments to get big returns. There’s an opportunity for a huge return in healthcare. When they made it so much more complex, the coding became so much more complex. Maybe the attention of the law was to pay less for lower-level services.

What they did was create an opportunity to be able to bill for higher-level services that insurance companies and even TPAs typically don’t have the resources to dig that far into. The whole healthcare system knows no one’s getting an itemized bill or even looking at it unless it’s $5,000, $10,000, $20,000 or more. What percentage of the claims that you guys have taken a look at so far have upcoding or bundling mistakes in them?

For some of these initial audits that we’ve been doing, it’s interesting. We’ll find anywhere ranging from 5% to even 10% of this claim spend go into errors or overcharges, things that shouldn’t have been billed for. They can take all shapes and forms. It is that feeling like, “Unless it’s a large bill, we’re not going to take a look at it.” Therefore, it goes under the rug.

Errors and overcharges can take all shapes and forms. It is that feeling of “Unless it's a large bill, we're not going to take a look at it.” Therefore, it goes under the rug. Click To Tweet

It takes a lot of manpower hours or human power. With technology and two brilliant software engineers, you can make it easy. You can take the hard work out of it and automate it so that the member doesn’t have to do anything. The TPAs are not doing it so they don’t need more people doing manual labor to look for things. You said 10% of the spend. That’s very different from the percentage of claims if you had 1,000 claims. $1 million spent could be $50,000 to $100,000 worth of errors. If you had, $1 million spent and 1,000 claims, what percentage of the claims have errors in them?

I was looking at this for one of the audits we were doing. It was 200-something claims that we were auditing and we had around 25.

25 of the 200? It’s about 12.5% of the claims. It’s a high number. I’m shocked that it’s not 90%, to be honest with you.

You have to keep in mind that we get claims for primary care orthopedics and hospitals. It’s higher in these large hospital system bills but across the board.

They’re more sophisticated billing, where they’re outsourcing it. They’re paying a lot of money for an outsourcing company that specializes in this to maximize their revenue. There’s no nice way. At the end of the day, it’s the members. It’s the people that are insured under a plan that pays the price for this. Many people think the insurance pays my healthcare costs and they disconnect the premium that you’re paying from the claims. You have to understand that if you’re overpaying by 10%, your premiums the next year are going to take that overpayment and they’re going to trend that out.

That becomes more money every single year. $100,000 in an overpayment on a relatively small group could easily have $1 million worth of claims. You could have a 50-person company have $1 million in claims easily and even more than that. That is a tremendous amount of premium over time. You identify coding errors. We call it upcoding. What if you find a down-coded one? If you find one that they accidentally coded lower, do you leave that alone?

We don’t do anything about that. I don’t think we found one. We’re not looking for them.

Explain what the bundling issue is. A lot of people probably don’t understand that when you get certain procedures, especially maybe inpatient and outpatient care surgeries, there’s a bundling aspect to it. If you want to spend some time explaining what that is.

What that means in very simplistic terms is you’re paying for line items that should be grouped in one charge but they’ve separated them to be more expensive. If you think about the restaurant analogy, it’s like going to a restaurant and ordering a cheeseburger and then instead of getting a $15 charge for a cheeseburger, you’re getting a charge for a burger, bun, cheese, lettuce, tomato and suddenly you’re paying $25. The issue with this is you’re a regular consumer and you look at your itemized bill, even if you get an itemized bill.

BWF 10 | Manage Healthcare Spend
Manage Healthcare Spend: A bundling issue is when you’re paying for line items that should be grouped in one charge, but they’ve separated them to be more expensive.


You’re probably not getting that anyway.

If you do the extra step, you request an itemized bill and you get something, you’re going to see, “I did get an incision. They did give me pain management. I did have this procedure.” You’re not going to realize that pain management, those sutures at the end of your surgery, should all be included in the global surgery code. Even one thing I think is interesting and I didn’t know that we started working on this is when you have a major surgery, if you go have a follow-up visit for pain management related to that surgery to check in with the surgeon, that’s under the global surgery code. That’s also included in the initial payment for that major surgery.

Does that differ from network to network? Are those bundles universal or different for Aetna, Cigna, Anthem or UnitedHealthcare?

There are slight differences in what different networks accept and how they choose to categorize things. CMS, Center for Medicare & Medicaid Services has overarching guidelines for how things should be bundled together and not unbundled.

Is that the source of where you’re building your rules out?

That’s our starting point. You look at these first.

You challenge the claim based on that criteria. You’re appealing the claim on behalf of the member?

We appeal the claim on behalf of the plan. The nice thing about that is we can reach out to the provider without having to contact the member first. We’re not getting someone’s hopes up that there is an error in their bill and that we can save money. The first time we reach out to them is after we know that the bill has been changed and we know that they overpaid and that there is money coming back to them. It helps us challenge more items without disrupting that member experience.

That’s important. I’m thinking there’s an HR director out there reading and thinking, “This sounds like so much work. I don’t want to create more work or disruption for my employees.” Are you getting authorization from the plan sponsor in writing and then calling the provider and the provider will talk to you because you’re calling on behalf of their employer, not the carrier? You’re not calling on behalf of the network. You’re calling on behalf of their self-insured health plan. They don’t push back saying that it is private information under HIPAA. They can’t do that. It’s almost like you’re the TPA, which has the same authorization. That’s very interesting. I hadn’t thought about that.

We’re presenting the information. We’re saying, “This is how you coded it. This is how we think it should be coded. Here’s the reference.” We’re not just saying, “You should have done it this way.” We’re citing the National Correct Coding Initiative and the CPT guidelines. We’re backing up our claim with, “This is the reference that supports that.”

Is this happening before or after the claim is paid?

We do it after payment. The great thing is if you’re a TPA reading, we don’t slow down your process at all. We come in post-adjudication so you can get your payments out on time and then we’ll look at it after the fact. Another thing for the HR people reading is because we’re post-payment, you’re not going to have members get balanced billed.

That’s pretty disruptive when you’re negotiating how much should be paid out prepayment because the provider might send the bill to the employee while they work it out with the plan, whereas the provider’s already been paid in our situation so they’re not going to bill an employee anymore. If we come to an agreement and the provider says, “I see that this was an error. I’m going to adjust the claim,” then we get the money sent back to the plan and/or the employee.

Behind the scenes, you’re connecting with some data exchange with the TPA. It’s running through your program and you guys can get to work on all of it. Compared to the amount of time it took you guys manually when you first started helping your friends, is it a little bit quicker? Is it a little bit more efficient than all of those phone calls and confused friends like, “What are you even talking about?” I can’t even imagine.

It’s significantly faster than when we first started. One of the things when we first started was getting that bill in the first place from a lot of friends and consumers. There are a lot of things that you don’t think about until you have to go through that process. One, does the consumer know what that bill is? Is it a bill? Is it an EOB? Is it the amount of detail that we need to see if there are errors in it? There are all these kinds of questions that need to be answered before we can even start looking at whether there are errors in this bill. That whole piece is pretty much solved because we get that claims feed.

I’m thinking about a recent prospect that I was looking at and they had about $6 million in medical claims and $1 million in pharmacy. We’re not talking about pharmacy now. You guys are focused on the medical but that can include very expensive specialty and injectable medications. If you’re getting an injection at a doctor’s office and you have a specialty medication that you’re being billed $20,000 for and they’re trying to bundle in the office, the physician fee, the nurse practitioner that’s standing there watching, maybe the syringe and maybe the cotton swab that’s probably $100. There have been some crazy things that we’ve seen and some of the TPAs that we’ve talked to. A $250 box of tissues in a hospital is insane.

Think about that $6 million claim spent. $600,000 goes back into the employer’s pocket or their employee’s pocket. What could they do with that? That particular prospect was about 250 covered employees plus another 150 dependents. We’re not talking about large companies. When you get into the thousands and you think that your Aetnas, Meritains and UMRs, those large carrier-owned self-insurance arms are doing this, you’re greatly mistaken because they make more money when they pay more claims, even on a self-insured account, stop-loss, premiums, all of these things, where there are so many people with their hands in the cookie jar. Getting it right and shifting some leverage and control back to the consumer is everything that we’re talking about.

A lot of the conversations that we have on the show are a little bit advanced and it’s confusing. The consumer needs to understand they’re deliberately holding information back. You mentioned the Explanation of Benefits. Explanation of Benefits doesn’t even usually have any codes on them. You need to get the itemized bill to see what you were even charged. My EOB here says diagnostic services at $600, $150 and $450. When I called the doctors to tell them that I thought that they may have billed it under my son, Lewis, instead of me, I made the mistake of saying I had radiology done.

He said, “You didn’t have radiology and diagnostic services.” I’m in the business. I don’t think there’s a huge difference between the two. If I got the itemized bill and I haven’t gone the step yet to see what the cash price is, one of our next guests on the show is going to be, paying cash for benefits or healthcare. I would challenge people out there to ask for your EOB, make sure you don’t pay a doctor before seeing that and get the itemized bill.

Something that shocks me when I was first learning about all this was the limit of information that you can get as a consumer. You can go to all this trouble and get your itemized bill but you’re still not getting your diagnosis codes. Sometimes, you’re not getting the NPI specifically. That’s something where plugging into a claimed speed is important because you’re getting all of the level of detail that you can get for less work too. It’s a one-time setup.

BWF 10 | Manage Healthcare Spend
Manage Healthcare Spend: Plugging into a claimed speed is important because you’re getting all the level of detail that you can get for less work too.


There’s another aspect of what you’re looking for when you work with a client on this. You’re looking for coding and bundling but you’re also looking for something that’s a hot topic, which is members that maybe are entitled to care at no cost. If you want to talk about that for a second.

When we were going through this process, we noticed that these non-profit hospitals have financial assistance policies and oftentimes, they’re pretty high. They can be up to 400% of the federal poverty level. To put that in numbers for a family of 4, the federal poverty level is at $30,000. 400% of that would be $120,000 for a family of 4, that household income. You have these non-profit hospitals that are required to do this by law to provide financial assistance. They have to create a community well. They’re getting these tax write-offs essentially because they’re a non-profit. People don’t know that financial assistance is available. They don’t know that they qualify.

In the application process, you have to print out the application, excluding your W-2. It’s extensive and then you have to do it every single time you visit a hospital. It’s unnecessarily complicated. What we’re striving to do is to simplify and streamline that process. We already have claims information for people through that stream so we can see when they’re getting billed from a non-profit hospital.

We can get their income and use that as an indicator of would they qualify for financial assistance because we work with employers. If they do, we can ask them a couple of questions, fill out that application for them and then continue to follow up with the hospital because unfortunately, you can’t just send the application. You have to call and see where it is in the process and help push it along.

I want to elaborate on that a little bit so that people out there are clear on what we’re talking about, the not-for-profit hospitals especially. With the huge tax incentives and advantages they have, for me, hospitals are just real estate companies but that’s a separate story. They do a lot of good but they have to provide free care whether you have insurance or not. You can refuse to give them your insurance information. If you fall below that threshold so you use the example of $120,000, that’s not universal. It’s going to be different maybe in different parts of the country, family-sized and the exact type of income. It might not just be your W-2. It might also be investment income.

I’m sure it’s a pretty complicated formula but by setting a threshold within your system, you can identify the employees who are likely to be eligible for financial assistance, educate them in advance so that they know this is what happens when you go to the hospital, get and fill out the paperwork. Not only are you saving that person the exposure of their out-of-pocket costs, which unfortunately for way too many people can be in the thousands of dollars or even more than $14,000 but you’re also saving the plan and especially if you’re a self-insured employer.

We’ll have them use their insurance because you can have these financial assistance policies apply even if you have insurance so it covers the member portion. We’re saving the member money but the plan does still have to pay their part.

Some laws say you don’t have to use your insurance but that’s maybe for a separate conversation. I got to look a little bit further into that.

You’re right. It is a matter of whether some of these financial assistance policies will require you to. If you have insurance, use that first.

It’s going to differ from the hospital. There’s no big sign when you walk through the door to say, “Come over here for free healthcare and avoid your out-of-pocket cost.” The most extreme example I’ve ever seen or heard of was a town in the Midwest that had 30,000 people in the whole town and 20,000 of them were in collections from the local hospital. There was 1 hospital within 50 miles of this town so everybody was forced to go there. They had over 60% of the residents of that town in the collection, which is despicable.

There are a lot of people out there, Marshall Allen and other people who are attacking medical debt head-on because it’s horrendous when we’re talking about a lot of the other things that hospitals do, which is getting medications at cost and then selling them to members of group health insurance plan where they’re supposed to be using those medications for the more needy people. We don’t feel bad for the hospitals. The hospital executives are doing well. I do feel bad for the doctors. The doctors and nurses that work there are amazing people. Unfortunately, they’re not getting a lot of the financial benefit of some of the underhanded business tactics of these hospital systems.

The thing to remind people too is that with these financial assistance policies, you’ve already paid them. Citizens paying taxes are paying for these financial assistance policies because we are paying for the government and the government is giving tax breaks to these non-profit hospitals for them to provide community goods. The community good is this financial assistance policy. We’re paying for it one way or another. If you qualify, you should use it. We’re going to have it as easy as possible for you to use it.

BWF 10 | Manage Healthcare Spend
Manage Healthcare Spend: The community good is this financial assistance policy. We’re paying for it one way or another. If you qualify, you should use it.


It’s amazing that there are no stronger regulations that mandate heavy penalties and not sharing this with their communities. It’s mind-boggling. In New York, there’s a popular chain of hardware stores. I won’t mention their name. I was speaking with them a couple of years ago. We were talking about healthcare, transparency and a lack of it when it comes to healthcare. They told me that on their shelves, everything has to be clearly priced and marked for the consumer to see. Even if it’s marked but it’s marked wrong, you go through every store, at least here in New York and I’m sure probably most states have this, you have the people with the little pricing machines and they’re clicking everything.

If you get caught with the wrong price on that shelf for a can of soup in the grocery store or a screwdriver on the shelf, if it’s supposed to be $9.99 but it says $12.99 and you have a customer that complains, they can get $10,000, $15,000, $20,000 fines. Some of these fines are huge. The healthcare system, which is the number one cause of bankruptcy in this country, has no requirement. Restaurants don’t even have to put prices. They have to put the calories. That’s important.

No one’s going bankrupt because they had a Big Mac. Maybe I’m wrong. I don’t eat Big Macs anymore. I did, which is why I’m working out with a bio coach. I’ll plug them in. Did you meet Darrell in YOU Powered? You can’t miss him. He is about 6’5 and chiseled. He’s my trainer and a good guy. I have a big day. My oldest son’s getting married and I want to look good for that event. Did you meet Chris Fisher?

We’ve done a 3x3x3 Challenge. We like Chris Fisher.

Chris is a good guy. He’s on the show. Hopefully, still. I don’t know. I can’t say who else is there. I’m sure that you guys aren’t just stopping here. I’m sure already because you’re brilliant that you’ve identified maybe another problem. Am I guessing wrong? I’m assuming that your wheels are spinning and saying, “We can help people with something else.” Is there something that you can share on that or do you want to keep it secret because it’s proprietary and I didn’t sign a non-disclosure agreement with you?

Our wheels are always turning. The way we see it is we’re establishing trust with the members and employers of the plans to say when Slingshot comes, it’s to give you money back. Step two of that is we’ve established trust. Members trust us. They know that Slingshot is a good thing. They know that a notification from us means they might have $200, $300 or $1,000 more dollars than they expected to have. What can we do when we have that trust? For us, member navigation is exciting and interesting. It has a lot of potentials to save members money and plan money. That’s an exciting place to go. We’re focused on establishing that trust in the first place, getting that money back to people and the plan.

The other thing that we’re always excited about is data. As we work with a plan, we get more of their data and then we can figure out with these insights, what we can do. For the care navigation example, I used to have a list at my old job of preferred providers. You can have a list of preferred providers but that doesn’t mean someone’s going to go and check that list before they schedule an appointment. I did not do that. If we can build something that we’re working on, we’ll predict where you’re going to get the care and for what.

Maybe we see you went to the physical therapist. We’re looking at your diagnosis and know you’re going to have to go to the physical therapist for the next six months. We can help you navigate to that preferred provider based on quality metrics and price, now that we have these price transparency laws. That’s something I’m excited to dig into. Using data to create solutions is super important, especially in the healthcare industry.

Using data to create solutions is super important, especially in the healthcare industry. Click To Tweet

I’ve forgotten about that component because when I did the demo with you, that was super exciting for me. I forget, is there a dashboard that the employer has access to be able to see the data that you’re talking about? You’re identifying the coding problems but you’re also collecting all of the codings. Even for the 90% of claims that are maybe appropriate, where something isn’t glaring, you can work with that data to say, “Where’s the person going to go next?” Get ahead of that next visit and recommend high-quality providers. Going to the best doctor should be the most important thing that everyone is looking for.

If you ask people, they would say, “Yes, I’d love to be able to do that but I can’t now. How do I know who’s the best doctor?” Data can identify the doctors who treat more appropriately and don’t over-prescribe opioids, overperform surgeries or have some financial incentive with radiologists on the next corner where they’re getting, I’ll call it a kickback but whatever they’re getting. We don’t want those providers to benefit from the consumer being under-informed. It’s not ignorance because they’ve been deliberately kept in the dark.

Even though there’s a lot of data, the data’s not super friendly where people even know it exists. It’s going to become much friendlier. Amazon didn’t happen overnight. There are going to be, in the next years, easy-to-understand websites. Doctors are going to be competing for patients. You’re not only going to see which doctors have high ratings because they have a clean waiting room, friendly staff or nice bedside manner but you’re also going to see the doctors that have the best results.

The orthopedic surgeon that’s going to work on my knee is going to be, hopefully, I won’t need that but I’m fearful in several years I might, he’s going to be the one with the best outcomes, with the highest and maybe quickest recovery rate, people that aren’t on crutches the rest of their life. There are a lot of doctors out there that shouldn’t be performing the type of care may be that they are and they’re allowed to continue to perform.

You make a great point about it having to be actionable because there’s so much data that exists out there but if it’s not in a consumable format and something that I as a consumer can go act on, then people don’t use it. Whether I have an error in my medical bill or which doctor I should go to, you have to create a solution that is easy for someone to use.

BWF 10 | Manage Healthcare Spend
Manage Healthcare Spend: There’s so much data that exists out there but if it’s not in a consumable format and something that consumers can go act on, then people won’t use it.


Not just easy but also the timeliness of it. Sometimes, these decisions are made instantaneously. I’m a skeptic of doctors because I understand under the fee-for-service model, they get paid the more they see people, treat people and prescribe all of these things. It’s not fair to him the way I feel. When I was there, he said, “Your EKG is perfect but it’s a little irregular,” which I’m like, “You can tell me anything you want. I have to believe you.” He said, “I would like to send you some tests.” I didn’t know at the moment that he meant to walk me to the next room where that doctor was waiting for probably most of the patients that came to that office.

My skepticism is that almost everybody’s going to see this other doctor. I had a moment where I could have said and I probably should have, “What’s this going to cost me? Do you belong to my insurance plan? This is a routine physical. If you do this now, is my entire annual exam not going to be routine anymore? Is there going to be a diagnosis on the other services the doctor did? Is this going to get denied because your test can’t be performed on the same day as my routine physical?” All these things went through my brain but what I decided to go with is, “I hope this goes bad so I could talk about it.” When I got the EOB and it said, “Denied. You may owe $1,200,” I was getting ready to fight.

I then looked at it closer and said, “This is probably my son because it said my insurance had expired before the care was taken care of.” My older son aged off the policy a couple of years ago. I’m back to waiting. I’ll get every revised EOB. The average person who has no idea that any of these things are happening trusts their doctors. I want them to trust the doctors but the healthcare and health insurance ecosystem has to earn that trust back.

In my opinion, they’ve lost that trust. They’ve taken advantage. They’ve deliberately kept their consumers in the dark. They’ve had all the data. The data that you guys have access to didn’t just happen overnight. They’ve had it behind the scenes for many years. It’s what they chose to do with it that’s a little bit despicable.

The balance of power that you’re describing is how Slingshot got our name if we wanted to be a tool for the little guy. You have this David and Goliath situation. We’re like, “Let’s be a tool for the consumer so that they don’t get taken advantage of.”

It’s important that people feel like they can trust their doctor. That is something that people no longer feel in a lot of situations. Being able to reestablish that by directing people to quality providers means that they can trust their doctor when their doctor says, “Here are some other tests but I know as a consumer, this isn’t something you’re doing because it means a more fee for you or higher revenue and a fee for service type situation. It’s because this is what I need as a patient.” Being able to reestablish that trust is important. It’s not as if providers and healthcare as a whole is a monolith.

Some providers are 100% right there in their patient’s corner doing whatever they can to make that patient feel better. Some providers are on the other side of that and then some providers are within larger organizations where their main focus is making that patient feel better. There are then these other arms, their billing department and RCM, where their whole incentive is revenue. It’s this complex environment. Being able to get people to the right doctor for them where they can trust them and their decisions is important.

Being able to get people to the right doctor for them where they can trust them and their decisions is important. Click To Tweet

Using Zoe’s example of the burger earlier, the chef isn’t responsible for how you get billed at checkout. The chef could be amazing. It might have been an unbelievable burger. Maybe it was worth $25 but they advertised it for $15. The thing is that there are a lot of different problems with healthcare-managed care. I always mention the book that I’ll probably never finish that I’m working on. The last couple of years of managed care has evolved very slowly in some respects but the one thing that it did is it groomed the consumer because of the lack of data and brokers like myself.

We’ve filled in the narrative for the benefit of the health insurers in the healthcare systems. Northwell is the largest hospital system in New York State. It’s over 30 hospitals. The reason for that is that they needed leverage. In the early days, North Shore Hospital was 1 or 2 hospitals. Long Island Jewish Hospital where my wife was a neonatal intensive care nurse, was an independent hospital. They were all independent. The managed care discounts truly gave the employer and their members lower prices. You were paying 40% less than you were paying prior to managed care.

Those hospital systems were getting beat over the head and said, “We’re going to need to merge horizontally so that we can take some leverage back so these insurance companies will have to think twice about these discounts. We’ll have more leverage to negotiate higher prices because you’re not going to be able to sell a health insurance plan in Nassau County, New York without our 5 or 10 hospitals.” It grew to over 30. They were brilliant. They didn’t want to stop there. They merged vertically. They took over all the facilities, radiologists, urgent cares and specialists down to the primary care doctors. Those poor primary care doctors don’t typically get paid much more than Medicare anyway.

The only way they can get paid more is to join the healthcare system to get a little bit more money probably but the demand on them is so great that they have to see a patient every seven minutes. The deterioration of the healthcare and population health is because that relationship has gone. Our job, you guys on the technology side, mine as the benefit optimization officer, advisor, broker and the hundreds more like myself that are part of Health Rosetta and some other great organizations is we have to beat the consumer over the head and let them know there is a better way we can shift that leverage and give you the slingshot so that you can take Goliath down, because if you don’t, where does this go from here?

The horrible part of this but maybe one of the opportunities is out-of-pocket costs can’t go any higher. The premiums can’t go any higher but they will. They’re going to take businesses down with them. They’re going to take a lot of wages and compensation that could otherwise be going to families away from them. It’s too important of a job. Thank goodness for people like you. Otherwise, without the data, I would be screaming and yelling nonsense at people. The data doesn’t lie. Any other thoughts? Anything you want to ask me and you want to share?

As you’re summing it up very nicely at the end, the other thing to think that’s at stake here is as these premiums go up, people are going to skip care and that’s what’s going to happen. They’re not going to be able to afford the cost of their healthcare so they’re not going to go get care when they need it. That’s a huge impact.

That’s been happening. When you were at YOU Powered, I don’t know if you sat through Wendell Potter’s presentation, the ex-Cigna executive. It was like a confession session of his. They invented and manufactured this idea of consumerism. It wasn’t a real thing. They weren’t giving the consumer any power. That’s where these high-deductible health plans came from.

The idea was they were coming to the rescue of the healthcare consumer. It was the consumer’s fault that prices were going up because utilization was so high. You’re going to the doctor too much because the out-of-pocket cost is too low. You don’t have enough skin in the game so we’re going to give you skin in the game and they did.

Ten years into the skin in the game, you have families with out-of-pocket costs that are $14,000 or more and they’re not getting the care that they need. They’re not taking their medications. They’re getting sicker, which ultimately ends up with more expensive care at the end of the day. Hospitalizations could have been avoided if people could afford to take all five of the medications that hopefully, they really need. They weren’t just prescribed by a doctor, over-prescribing again.

That’s a great point because care avoidance is a huge problem. It’s going to be a hard thing, on a high scale, to tackle in a short period. The type of programs and the health plans that Health Rosetta and advisors like me want to build are going to eliminate those out-of-pocket costs. We want to get them to the best doctor, eliminate the cost and save the plan money by getting them to the best doctors. With your technology, you know when people have a certain diagnosis. Let’s use diabetes because it’s so prevalent.

You could probably tell if they’re getting their care. Are they going for their visits? Are they taking their medications? Maybe they’re taking their medication and stretching it over 2 months where a 1-month dose or 1 month’s worth of usage but they’re stretching it to 2 months because they’re trying to cut their cost in half. Is that type of thing that we can also identify with the data that you’re collecting?

Yes, it’s in the data. That’s something we want to build out as we build into the care navigation aspect.

Anything additional you want to share?

Not from me. Pranov, you got anything?

No. This pretty much covered it. It was exciting to come on and chat.

Toughest question of the day. Do you see Georgia Tech beating Georgia in football anytime in the next century?

Yes. In the next century, for sure.

How about the next couple of years? That’s the last game on the schedule. I’ve been to a couple of games and I’ve seen them win one. It was exciting. There’s hope. It’s a new style of football. Thank you so much both of you. This was great. I will be in touch real soon. I’ll get you a copy of this so you guys can use it in any way you want. If you are out there and you want to get in touch with Zoe or Pranov, is the best place to go to website and request a demo? If you’re a TPA out there, look them up. If you’re an employer and you want to learn more and get your TPA to use them, look them up. This is the real deal. Thank you so much, guys.

Thanks, Lou.


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About Pranov Duggasani

BWF 10 | Manage Healthcare SpendA former software engineer at Google, Pranov is passionate about helping people pay less for medical care. He believes patients deserve transparent and equitable healthcare, especially when it comes to how much they owe. Pranov co-founded Slingshot Bills to automate the patient advocacy process to save individuals and employers money. Pranov is from Alpharetta, Georgia, graduated from Georgia Tech with a degree in Computer Science, and currently lives in San Francisco, California.


Zoe Holderness

BWF 10 | Manage Healthcare SpendA former engineer at Lyft and Tesla, Zoe is excited to bring automation to patient advocacy. Zoe co-founded Slingshot Bills after navigating the medical billing system to audit and reduce her own bills. Zoe is from Charlotte, North Carolina, graduated from Georgia Tech with a degree in Mechanical Engineering and minor in Computer Science, and now resides in San Francisco, California.