The US health care system is notoriously labyrinthine, with a lengthy claims process that frequently results in errors and high administrative costs. Based in Bangalore, CloudSelf is building a cloud-native platform that is more transparent and customizable than legacy systems to improve payment integrity (or the process of ensuring healthcare claims are paid correctly). The startup announced today that it has raised $4.8 million in seed funding led by BEENEXT Capital and 3one4 Capital.
Legacy systems pose a significant barrier to payment integrity because many are black boxes or lack transparency into their inner workings or systems, CoverSelf co-founder Rajasekar Madrid told TechCrush.
Claims and payment platforms identify errors in claims and payment contracts, including non-compliance with current policies and guidelines. This means these platforms must constantly update policy and policy information, Madrid explained. But since legacy systems are a black box, it is difficult to exchange information between different parties in the process of payment integrity. It also slows innovation and causes potential leakage of intellectual property, making payers reluctant to share use cases with each other.
In the year Founded in 2021, CoverSelf wants to provide an open and customizable system that makes it easy for payers, providers and suppliers to share real-time data while protecting IP. The startup is currently a pre-launch, but has already partnered with major healthcare companies.
Cover self group
Madrid said the platform could take different deployment approaches depending on what customers. For example, it tested its payment and accuracy platform in partnership with a top private health insurance provider. The CoverSelf provider was able to detect 9% of invalid claims without otherwise being noticed.
Before Coverhead, Madrid and co-founder Raghavendra Pawar were the first employees at US healthcare startup Healseed (Madrid was the first employee). Pawar has also worked in healthcare organizations such as Cotiviti and Prime Healthcare, spending a total of 16 years in the industry.
While at Healthlucid, Blue Cross Blue Shield (BCBS) asked them to build a self-managed platform for claims and payment integrity. The Fortune 500 company contacted Pawar to ask if he is self-managed and aware of claims and payment integrity. The two saw a need for a platform like CoverSelf.
“Current vendors are a black box and don’t enable collaboration,” Madrid said. “As a result, people are reinventing the wheel over and over again and increasing the cost of health care.”
They added that the use of black box platforms by vendors obscures the root causes of erroneous claims and forces payers to rely on them. This means they can’t tell hospitals and doctors what caused the error, which can lead to long and expensive denial and appeal cycles.
The CoverSelf platform is designed to adapt to increasingly complex payment models and changes to compliance requirements, code sets and regulations.
Users can build on CoverSelf’s domain-specific platform with pre-built code sets and industry libraries, allowing them to quickly scale while staying on top of the latest code sets and policies. The CoverSelf platform also includes claim verification APIs for payers and providers.
CoverSelf’s competitors include startups such as Rialtic and HealthEdge and legacy systems Cotiviti, Change Health, Optum and Multiplan.
Madrid says CoverSelf’s key differentiators include its customization capabilities and API-first/cloud-native approach, IP protection, data mining platform and a feature that automatically corrects errors on what-if and payer-specific claims. And he runs them.
“It’s a very rare and often difficult place to get into this industry because it’s such a great place to work,” Madrid said. However, this only serves to highlight the same potential, with companies like Realtyc recently raising $43 million in funding, creating a strong motive for companies like ours to develop decisive solutions to address business challenges. in this industry.”
“The cost of waste in the US health care system is estimated to be about 25% of total health care costs,” said BEENEXT Managing Partner Dirk van Koukbeke in a statement. Claims and payments integrity, i.e. incorrect billing or fraud, alone accounts for more than $100 billion of the problem. Now, anyone who has worked in the American health care system understands its enormous complexity. We believe Team CoverSelf has assembled a uniquely qualified team to encapsulate this and improve healthcare outcomes for patients in the US at a reduced cost.
