We grew up in immigrant families, and for both of us, our parents would honestly tell us to not trust doctors because of unexpected medical bills. They really believed that doctors were adding on unnecessary things that didn’t help in order to make more money. As adults, we’ve both had first-hand experiences receiving surprise bills even with good insurance while working at tech companies, so solving this problem is personal to us.
It turns out 38% of Americans delay medical care for fear of the bill while prices vary 2-10x across health providers, even when using insurance. This led us to believe that creating a marketplace with transparent out-of-pocket costs could be a solution.
However, it wasn’t until the July 2022 Transparency in Coverage Rule (https://www.cms.gov/healthplan-price-transparency) that we had the payer pricing data (that’s actually high quality compared to hospital data) to create this marketplace. Certainly is the first company to use this data to predict and guarantee prices for consumers to book doctors.
We know the HN community has been interested in applications of healthcare price transparency data (https://news.ycombinator.com/item?id=32738783), so we’re excited to share how we’re using this data to predict and guarantee prices for a consumer application.
With Certainly, patients can enter their insurance, compare guaranteed out-of-pocket costs across doctors, and book an appointment with price transparency. For providers, we guarantee any patient we send them will always pay. Partner providers pay us any time we send them a new patient. Eventually, we’ll convert providers to using our SaaS platform to guarantee payments from existing patients.
We are currently focused on shoppable services - anything that can be scheduled in advance. Our solution falls between two ends of the spectrum for consumer shopping experiences. At one end is healthcare, where the status quo is you go to a doctor and you have no idea what will happen and you have no idea how much it will cost. At the other end is going to a restaurant, having a menu of items with corresponding prices, and deciding which items you want to order.
Certainly Health lets you see what services could happen during your visit and how much they will cost. We guarantee that if those services happen, you will not pay more than the out-of-pocket costs you saw upfront for each of those services. But it is ultimately the doctor who decides which services you end up getting (like a chef deciding which dishes you will be served). As a result, you can compare upfront out-of-pocket costs specific to your insurance and book a provider without worrying about surprise bills.
A common misconception is that patient out-of-pocket costs are set by doctors. Prices of healthcare services are actually the result of negotiations between providers and insurance companies. Groups with more negotiating power, like large hospital systems, are able to command higher rates than private practice physicians. This variance in cost is enormous across almost all procedures we've looked at, even between providers a few blocks from each other. It might cost $105 to get an orthopedic consultation with one doctor, and $550 to get a consultation with another doctor across the street, for example. This price variance means the out-of-pocket cost also varies for patients with high deductible plans or plans where the copay does not cover all services (which we’ve encountered very often).
We do not use hospital price data which is inconsistent and messy (https://www.kff.org/health-costs/press-release/analysis-inco...). Instead, our guaranteed prices are based on three things: (1) health insurance published rates for procedures, as required by regulation; (2) patient eligibility/benefits information (e.g. deductible, copay, coinsurance); and (3) an online learning model to account for variance across thousands of plans and patient conditions.
As we process payments and claims, we create an accurate platform for predicting out-of-pocket costs by accounting for variations such as whether certain procedures are covered by an insurance plan/copay, and how the rate changes based on diagnosis code (we discovered V97.33XD is for "Sucked into jet engine, subsequent encounter”), number of units, medical coding modifiers, and other factors.
Certainly is currently available in NYC where you can choose from over 5k doctors to book without surprise bills for free at https://certainlyhealth.com/. We plan to expand to other cities once we prove that we can establish a low CAC on both the supply and demand sides in NYC.
Although we’re early, we’re starting to see intended results. One patient saved $850 on a podiatrist visit booked through us compared to a previous visit with a different doctor for the exact same services. Another was charged for an annual physical, but we identified the mistake and got a refund issued to him. Most of our customers have had surprise bills in the past and are happy to have peace of mind with our upfront, guaranteed prices.
We’d love to hear your ideas, experiences, feedback and any feature requests!
I'm probably your ICP -- I live in NYC and have been burned by a surprise bill that was frustrating enough that I'd try a service like this. But after I entered some details to try it out, you hit me with an email wall, so I bounced immediately.
It's not just that I don't want to give my email until I've seen more of a product; the fact that you string me along until I get to the payoff is destructive of user trust. There was an article about this phenomenon on the front page just yesterday: https://news.ycombinator.com/item?id=36962502
When you say you entered some details, are you saying after you searched, saw results, and tried to book someone? If so, we are not collecting email, but actually are collecting your insurance information. We need that to get your specific out-of-pocket cost (e.g. copay, deductible, out-of-pocket max, etc.)
Do you mind trying again or emailing us at support@certainlyhealth.com with some more details?
2. I've been to medical appointments where doctors have clearly ordered tests to pad the bill. E.g. a lung capacity test to prescribe stimulant medication. Or doing many blood panels "just in case" (conveniently when they have an in-house blood scanner and phlebotomist). Some practices offer dozens of such tests and procedures. They are judgment calls but doctors are perversely incentivized to order them. What is the patient/doctor experience in these situations? Having the menu of services+prices readily visible and available and the doctor walking through the options and risk/reward?
3. Will you publish the pricing information over time? Perhaps comparing the transparency/hospital-published data versus your experiential and predicted data?
In terms of padding the bill, we think that doctors tend to pad it in order to get reimbursed more by insurance, but they're pretty soft on holding patients liable to these padded things, and also they will get in trouble if they do it too much. We do need to figure out the patient experience though, our goal is that patients know the cost of procedures a doctor is recommending (for ex if my doctor says I should get an arthroscopy and an x ray, I want to know ahead of time how much it costs), and can make an educated decision on whether they want to get the procedure done or want to see a different doctor.
The pricing information, we're likely to publish broad analytics level information, but from a business perspective we're thinking that the discrepancies between the published data and our experiential data are really our 'data moat' for the business, so that's likely to be our IP (as it's what prevents someone from easily copying us by scraping our site). We want consumers to have to go through our site in order to get the pricing info, otherwise if it's just an informational site and people use us to look up pricing then end up going to competitors, we wouldn't be able to financially support the site existing long term.
Studies show that physicians who own/part-own a DI facility tend to refer their patients for imaging substantially more than their peers who do not.
I'm curious about how you solved a couple of problems because it's becoming clearer to me that healthcare operates in a probabilistic way, which makes price prediction hard. Here's a simple timeline of how an average person interacts with the healthcare system.
1. A patient has a symptom
At this point, the patient can see a primary care doctor, or see a specialist themselves.
2. Patient sees a doctor and receives a diagnosis
Depending on the symptoms and the doctor, they'll receive a set of diagnoses with some probability.
3. Patient receives a treatment
The patient, based on their symptoms and doctor, will get some set of treatments with some probability.
I guess here's the rub with outpatient data. Even if you completely figure out the pricing problem, it's not obvious (at least not to me) that when a patient goes in for an outpatient procedure that they're going to be billed for exactly the shoppable service they think they're getting, because it's based on probabilities. I think your tool alludes to this actually -- more below.
A meniscus repair is an outpatient procedure, and part of CMS's shoppable services list*. But I'm not sure that it's the case that when you see an orthopedic surgeon for a meniscus repair that you'll be billed for CPT code 29880, or 29881, or something else. It might depend on the surgeon and what they see when they dig into your knee. They also might X-ray your knee, which may or may not be covered.
(I'm not actually sure of the possibilities here, but I think David Gaines at CareIgnition (https://www.careignition.com/) might know, if you want to discuss with him.)
Anyway, to test how you solved this, I searched "meniscus tear" in my area (zip 11377). What I saw was the rates for first consultations with orthopedic surgeons. I did not see rates for the procedure itself, so I couldn't easily see what you do in the case that a person is shopping for a 29880/29881. However, I did notice that the price variation for a consultation can vary up to a factor of 3, depending on whether the consultation is graded as low or high complexity. You do a good job of explaining this in the drop-down, and noting that most visits are low-complexity, but I suspect that as you expand to more outpatient procedures, the probabilistic parts will become nontrivial and more important...
I suppose one approach is to limit procedures in your search engine to ones where 1) the patient _knows_ exactly the procedure they're getting and 2) there's a low probability that they patient expects to pay for anything but that procedure. Or maybe you could say something about this? I'm genuinely curious.
Finally, one more comment on guaranteed pricing, which I'm sure you've thought about. My alarm bells go off when I see "guaranteed" because I know, for sure, that some of these rates are wrong. Not all, but some decent fraction of them, and it depends on the carrier -- Aetna's rates tend to be more reliable than United's for example. I know this because I compared them to internal contracts, and know other people who have done the same. You might be able to pressure the carrier to honor the rate that they published (and I know this has been done on the hospital side) but that's a different story, and I'm not sure how that process shakes out. I also know that sometimes the carrier published multiple rates for the same service, without disambiguating information. I'm not sure how common this is with the subset of codes/plans you've pulled.
* "Explanation of Benefits", i.e. the bill. The insurance company would tell you, before your procedure, the patient's portion of the bill, which parts would be denied, etc.
* https://www.cms.gov/healthplan-price-transparency/resources/...
We are taking the approach, as you suggested, of limiting procedures in the search engine to ones that patients know what they're getting. Our initial focus is actually Dermatology for this reason, from a combination of popular demand and us seeing that the procedures billed are often very simple and easy for us to model / predict.
For us, our goal is to guarantee the rates that we show on the site, and we're building a model that figures out what the correct rates are as claims get adjudicated. At scale, internally we will have the most accurate model of what costs will be, figuring out which of the carrier rates is real. This part is definitely challenging as well and we expect to lose money on the guarantee (paying out to patients) for some time until we figure it out, but we're limiting the losses by not listing the more complex high variance stuff.
RE in advance EOBs, we think that we can help providers comply if/when that regulation goes into effect!
We did hear from some dentists that their insurance company forbids them from sharing their rates, which makes it tough to add dentists to our platform.
If you have any other questions about working dentist, feel free to email me and we can setup a call. My wife is a dentist and we've learned a thing or two over the years.
It’s been nearly 10 years since I was involved in that practice so I have pretty stale info
Finding consumers is going to be difficult. You guys are also going up against an entrenched multi billion dollar health care industry. We found that the providers were all required by their contracts with the health insurance companies to ask for an insurance card. If a patient had disclosed that they have health insurance, the provider was not allowed to offer a cash price (which is often cheaper).
Since you are building a marketplace I would strongly recommend reading The Coldstart Problem by Andrew Chen. I wish this book were available back when we launched our marketplace.
Good luck. I hope it works out.
I didn't know that they weren't allowed to offer cash rates to insured patients! Definitely a bummer from the patient's perspective (why pay for insurance if it will just cost you more...).
Have heard a lot about the book, will check it out!
https://help.practicefusion.com/s/article/CPT-License-FAQ#:~....
This is the real startup gap. There are thousands of CPT codes. When a medical provider is trying to give an estimate, it should be easy for Medical providers to have packaged, template CPT codes for template procedures. Then, they should be able to add/remove CPT codes from the package (like drag and drop), and the prices should change automatically.
The template packages could even be put on a social marketplace for doctors so that the information is shared.
One of the difficulties is that in many systems medical billing is done by coding specialists based off the provider's note. They may recommend CPT codes, but that may not be what's actually billed. In addition, most providers are too swamped to do things like put together an estimate or drag and drop CPT codes. Hell, many providers will literally count the clicks they have to make in an EHR and will LOUDLY let you know if your proposal will increase their number of clicks by even one.
I don't mean to be a downer on this, and I do think there are solutions... but I think 90% of the problems in healthcare aren't technological ones but are navigating large, entrenched systems that have very little incentive to change.
Are patients required to disclose this? Or can I simply decline to provide insurance?
curious what you do now?
Sums up the problem with our Health Industry in America. The middle-man Health Insurance mafia is too powerful to let anything else happen.
"Physicians in the United States are among the best paid in the world (Bodenheimer, 2005). The average U.S. specialist physician earns $230,000 annually—78 percent above the average in other countries, as shown in Table 2. Primary care physicians earn less (they earn $161,000 on average), but the same percentage more than their peers in other countries." - sauce https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/
How would it work if the insurance company’s vendors charged the insurance company more than they charged random people off the street?
Love to see innovation in this space!
The challenge of not knowing what other services might end up being done seems daunting from a UX perspective. Hopefully you guys can find a solution.
(I was early on the Data team at Oscar Health, so have more than my fair share of experience with thorny health care pricing data.)
Definitely a challenge timing wise if a patient does other services with other doctors off platform between when we quote them and they see the doctor though.
Would love to trade notes on the pricing data!
Happy to connect if it would be helpful for you!
Once they agree to take your insurance you are liable for out of pocket or copays as per your agreement with your insurance company.
Unless you deliberately go to a doctor who doesn’t take insurance, which is generally only something very wealthy people do.
What situation is this attempting to address?
Edit: I’ve read the explanation in more detail above and I still don’t get it.
A simple example for me is I had a high deductible health plan (while working as a software engineer at Uber) where I went to see a dermatologist to remove a wart, but I had no idea how much it would cost until weeks or months after the visit. It turns out that cost of seeing a dermatologist and getting liquid nitrogen treatment can vary by hundreds of dollars depending on where you go, even if you use your insurance.
So Certainly shows you the upfront price that is specific to your insurance and lets you compare prices across providers. And if you book through us, you don't need to worry about surprise bills since we guarantee that you won't owe more than the prices we show upfront.
The majority of surprise bills are errors and stuff that verges in fraud. And even though the patient doesn’t legally owe it, they may not understand this and even if they do it is super stressful.
At minimum it is a time consuming nuisance to respond to all the random BS bills.
I feel like you could accomplish that with a tiny fraction of the infrastructure.
This is the problem though. 9/10 when I get a surprise bill, it's because the hospital tacked on billing codes. So unless your model can spit out a likelihood that a clinic is going to classify an ear cleaning as a surgery, it will not prevent the worst surprise bills.
You should also include cash-price options. Since switching to an HSA, I have saved tons of money. Some hospitals even have across the board 60% discounts for cash. Pretty often the cash price can be lower than the out-of-pocket expenses when going through insurance! And I have never yet gotten a surprise bill when I settle the bills immediately.
This is an amazing hack.
Also, it's harder for them to include it, because those aren't available like insurance rates are.
They have been SUPER awesome. I have had to play 0 games with their billing department and I think everyone should demand the same for all clinics.
Would this mean the app is less useful once you are already admitted to a hospital in NYC that I know has a lot of care in my network? How does it help in such situations if we assume the law may not always do so?
Is there a catch-all bucket that "other things" go into?
https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int...
There's a lot of "other specified" or "unspecified" categories in the ICD-11
Medical tourism is definitely something we'd want to eventually add, though that pricing data is not accessible in one place like the insurance company data, so it seems to be a bit harder starting place.
With that said, you are absolutely correct that CAC is probably the biggest challenge with this marketplace. Healthcare is generally infrequent and unpredictable (unlike travel or groceries). But the market is huge (probably biggest in the US), and there's only been one company that's made any kind of dent in becoming a consumer marketplace (Zocdoc). Our hope/belief is that being the first place to allow consumers to see prices creates the product-market fit to lower that CAC and gain traction over time, but time will tell!
[0] https://termbrowser.nhs.uk/?perspective=full&conceptId1=7410...
SCTID 23791009
We trawled SNOMED extensively for fun, er, I mean, data model research in my last company. But we didn't spot that one.
1. I tried searching colonoscopy in the UES and the experience is a bit confusing.
Although it says "showing price for colonoscopy" I had to expand the price breakdown to see that some of the quotes (the cheaper ones) don't include the procedure and are just for a consult.
2. If the provider performs any services not listed in your Certainly Price Protection package, you will be liable and have to directly pay the provider for those services.
This is going to be challenging as you scale up. What you're doing/saying works for predictable encounters like derm as you state in comments but thinking of my own procedural days I often don't know what I'll be billing (or doing) until I'm starting the case. I'd imagine it's worse for my surgical colleagues.
It's a good idea, it'll be interesting to see how you tackle the bigger problem in surprise billing/price transparency which is the more complex work and encounters rather than the easy stuff like a consult, makes sense to start there though.
What concerns me however is the guarantee part of it. It’s a bold move that is fraught with risk, especially as you get into higher ticket items, such as various surgical procedures. It’s not clear to me how you spread this risk out (you take the downside risk, but what’s the upside - just the referral fees?)
A thought: I wonder if this also mean that large hospitals will have doctors that earn more and somehow correlated with better care in certain cases? For example, In NYC I have found better care with Beth Israel and NYU Langone for Preventative and Diagnostic Health care than private practices.
I have *not* had experience for injury treatment/surgery at hospitals, but WSJ has reported extensively on wacky Hospital billing practices for such patients.
No, usually lower. Especially academic hospitals.
Better care because it's academic which draws the type who want to the best and are willing to forego higher pay for prestige. Also because billing matters a lot less and generally doesn't go into physician pockets at these hospitals so you can see more complexity and spend more time.
>For example, In NYC I have found better care with Beth Israel and NYU Langone for Preventative and Diagnostic Health care than private practices.
Mount Sinai and especially Langone are amongst the best academic hospitals and health systems in the US right now.
After moving back to the US, I had a huge amount of culture clash after an ER visit. I was leaving the hospital and asked the front desk where I could pay, and they looked at me like I was a lunatic.
I'd be really curious if you have plans to tackle these types of visits if you get enough bargaining power.
So we can predict what the cost of the visit is. However, emergency care is much more difficult to predict the total cost of in terms of what gets done during the visit. For my visit, I also had x-ray imaging done, but it can be more difficult to predict the full scope of services that could be done during an ER visit.
So it is something we plan to address later. But it should be a tractable problem that we plan to solve.
Went to leave hospital after days of being there (and tests, and whatnot), and was told "well... you'll have to submit this to your insurance - we can't deal with it. It's going to be expensive(!)". They were sort of visibly ... agitated (possibly just because they don't deal with many overseas US people?). His total they were making him pay was around $200 USD.
Additionally, the visit actually solved the problem, which is something that rarely happens when I go to the doctor in the US.
How are you retrieving this? Typically eligibility is only available through clearinghouses to providers - not directly to consumers.
You are selling health insurance.
I work at a big tech company and have theoretically very good insurance, but I have heard stories where the insurance gets declined even though they say they take it… or some lab specialist is using a different insurance network and you have no control over using them. If I don’t have coverage then there is nothing stopping them from billing me like $1m as far as I can tell, after the fact, when I can’t just decline the service. It’s insane that they can’t say what it will cost up front.
My company switched insurance name but not network and doctors didn’t understand it and started denying the claims… even though they were technically in the network! That’s when I gave up, after reading other employees’ reports of that.
I mean this kindly, but your concerns are not rational. Every middle class person I know goes to the doctor from time to time and has somehow avoided $1m dollar bills for providers listed as covered by their insurance.
While our system is bad, you are greatly overestimating the probability of something very bad happening to you.
A checkup will not end up with thousands of dollars of bills, schedule a routine health-check, you can also call your insurance first to check what is covered.
https://www.npr.org/sections/health-shots/2018/02/16/5855481...
> After Elizabeth Moreno had back surgery in late 2015, her surgeon prescribed an opioid painkiller and a follow-up drug test that seemed routine — until the lab slapped her with a bill for $17,850.
https://www.npr.org/sections/health-shots/2019/12/23/7874035...
> The visit was quick. Kasdan got her throat swabbed, gave a tube of blood and was sent out the door with a prescription for antibiotics. She soon felt better, and the trip went off without a hitch. Then the bill came. Total bill: $28,395.50 for an out-of-network throat swab. Her insurer cut a check for $25,865.24.
Highly recommend not going through middle adulthood without at least having annual physicals.
There are a lot of things that happen to bodies that are easy to treat if you know about them soon enough.
It sounds like you may need help using your insurance; call the insurer from the physicals office if the office won't call the insurer. Healthcare in the US is a tremendous administrative burden on us all, but overall it is still necessary.
Federally, this practice was ended January of 2022 [2].
Go to a Doctor and get a checkup.
[1] https://www.insurance.ca.gov/01-consumers/110-health/60-reso...
[2] https://www.help.senate.gov/chair/newsroom/press/senator-mur...
Have you seen a dentist? The dental coverage from employers feels much more limited (except for preventative cleanings) and you can expect some not so fun problems if you miss so many cleanings.
Only do above with doctor you don’t plan to see again or anesthesia/lab company. Your insurance company will have a list of doctors in network, print it out and ask for front office staff to verify over email.
They absolutely will do so. https://www.reddit.com/r/CRedit/search/?q=ambulance&restrict...
That is the way. A couple of years back, a physician tried the out-of-network labs scam with me because they try it with everyone. It does like this: you piss in a jar at the intake visit, the physician sends it off to an out of network lab for high-complexity drug screening, and you get presented with a 4-digit bill.
Everyone is innocent, the physician said "you peed in the jar", the insurance says "out of network", and the scam lab says "services were rendered". When you make it clear that any bill will be disputed and attempts to collect will end up in court, they settle for 0 dollars.
They still tried the same on my wife, a few months later. All physicians are scum of the earth.
I usually commend anyone trying to fix our Healthcare system in America but every time I see a startup in this space, no one can dare to fight against the main culprit: the middle man Health Insurance Mafia. I wish someone could do something where Health Insurance mafia is no longer in picture except for catastrophic insurance. Watch how prices drop for everything when Doctors/Hospitals can bill patients directly in cash.
This is a surgery center in Oklahoma that offers pricing without insurance.
Btw you are forced as well because of Obamacare but even if you were not forced, you would still need it unless you are an excellent salesperson/negotiator where you go a Doctor's office and negotiate Cash Price.
Tell me what's the first question you are asked when you call a Doctor's office other than your name ? It is "What Insurance company do you have" ?
I think this is a good space for the government to step in with progressive policies, and there are a lot of supporters that aren't as easily influenced by lobbying and under the table bribery.
Our approach is to make something that makes the existing system easier to use for patients, under the assumption that that system continues to exist as-is. We do think there is bipartisan support for price transparency. Something like single payer healthcare is much less likely to get passed and health insurance companies would fight for their lives to prevent it from happening.
There is a ridiculous amount of overhead that the whole insurance dance adds to providers and I think it's unfortunate how much that inflates pricing for everyone.
This is not a technological/startup problem to be solved, but a regulatory one.
Managed care organizations (MCOs, aka health insurance companies) are the mechanism by which you can provide different groups of people with different levels of healthcare, while still having plausible deniability that you provided healthcare for political purposes.
Example: Medicare and Medicaid are both subsidized healthcare programs in the US. But the people who receive Medicare are more valuable to leaders, so Medicare pays more, and hence Medicare recipients get better healthcare. Medicaid recipients are less valuable to leaders, and so it pays less, so Medicaid recipients have to travel farther and wait longer for healthcare.
MCOs can even be used to implement different levels of healthcare for different groups of employees based on how well the coverage for that group of employees pays providers. You can delineate all the way from President and staff, to legislators, to military, to civilian employees, and private businesses can delineate between employees of low profit margin, low pay businesses, and high profit margin, high pay businesses.
On the provider side, poorer people will get seen by NP/PA, while richer people can be seen by MDs. Or richer people can skip the line or get access to MDs via concierge medicine or direct primary care.
The US pays more per capita for healthcare than most of europe. Why do you believe that lowering fertility rates—leading presumably to an increase in the proportion of the population needing access to healthcare due to age, and a similar decrease in the amount of tax payers—would lead to a shift towards a US-model that costs more overall?
First, other billionaires have tried and failed[0]. Billionaires don't stand a chance against a trillion dollar industry. Second, did you ever consider that a more realistic approach is to start with easily addressible problems like this one rather than trying to boil the ocean.
[0] https://www.cnbc.com/2021/01/04/haven-the-amazon-berkshire-j...
And the CMS 9915-F isn't going to fix this problem.
See the healthcare cartels among the top bribers of all time:
https://www.opensecrets.org/federal-lobbying/top-spenders?cy...
