Hacker News Reader

Comment by blastbking | Hacker News Reader

When patients enter their insurance, we have an API we use to retrieve their deductible remaining info, and then we use that to calculate their out of pocket cost that we show. And yes, we guarantee the patient responsibility!

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!

View on HN

Getting timely, accurate data from the insurance companies on this intuitively feels hard. What are the guarantees around those APIs? There are so many path-dependent factors, like outstanding claims, readjudication of old claims, or "revenue optimization" games on the backend.

Happy to connect if it would be helpful for you!

> outstanding claims, readjudication of old claims

I was going to ask about these in particular. I am very curious how you can assign an accurate number to these so that you can guarantee an out-of-pocket number.

Sure! This is something we're still figuring out as we're quire early. Would say that the APIs don't guarantee a lot, so it's up to us to piece together the story for a patient and figure out these edge cases.

I say this not to discourage you, but what's being described here is far from an edge case. Providers have often up to ~90 days (when in network with the plan) to submit a claim. Then payers have time to process the claim and adjudicate it. If the claim is denied, providers have more time to appeal the claim, etc.

Again, this isn't intended to be discouraging at all. Just don't operate on the assumption that eligibility APIs showing out-of-date deductibles is normal and not an edge case!

I am an industry veteran and can assure you this fact alone kills your guarantee. Pivot immediately.

Reply on news.ycombinator.com