MetaDigital

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Summary

MetaDigital is a prepayment verification solution for healthcare claims. We use verifiable digital signatures that authenticate providers, patients and the services provided at the point-of-service. We add value to insurance companies and health plans (payers) in the following ways:

  • Reduce healthcare expenditures up to 10% by preventing fraudulent claims going through undetected
  • Create a new standard for claims verification that allows for reduction in the revenue billing cycle

Problem

Healthcare fraud, waste and abuse accounts for 5-10% of all healthcare expenditure in North America. Current detection and recovery methods are only able to reclaim 1-5% of that fraud using outlier analysis and rules based solutions. These approaches fail to verify the type of service provided and point of contact confirmation between patient and provider. For example, if a physician submits a fraudulent claim without having met the patient (ghost billing), the current system cannot validate the point of contact confirmation between the patient and provider. Instead, the current model relies on historical data to identify suspicious activity which is prone to survivorship bias. This creates loopholes for fraud to be exploited.

Solution

We create and assign a unique signature for each patient and provider which can be attached to claims at points of service. The signatures on a claim are associated with individuals’ unique identification (e.g. insurance information, license number) which allows us to prevent fraud by verifying the following:

  • Identity of patient and provider
  • Point of contact confirmation between patient and provider
  • Types of service provided

Team

Anesu Machoko, CEO & Co-founder

Neil Suh, Managing Partner & Co-founder

Alexander Tam, CTO


Goals/Milestones

The major milestones are related to advancement in the sales cycle

  • Expected 2020/09 - MSA for a pilot with a health plan or payer
  • Expected 2021/06 - Completion of the first pilot with customer

Competition

The competition consists of a payer's internal payment integrity department, and other third party payment integrity companies. Some examples include:

  • Cotiviti
  • Zelis
  • Optum

The standard approach the competition uses is data analytics and rules based algorithms. This involves examining each healthcare claim and determining if it meets a list of criteria and if the claim looks significantly different than it's peers. This approach contrasts our solution which focuses on identity and the participation in the health service. It is important to note that insurers use multiple third party payment integrity companies to analyze their claims since compensation is based on the amount recovered. Therefore our solution would complement our competition rather than act as an alternative.

Strengths and Opportunities

  • Verification of healthcare claims is independent of historical data preventing large shifts in member and provider behavior from reducing it's efficacy
  • Verify every claim as opposed to only a small subset that are outliers
  • A change in regulation allowing providers in the US to operate across state lines eliminates/reduces one of the ways payers can detect fraud

Weaknesses and Threats

  • The target customers (insurance companies and health plans) have long sales cycles
  • COVID-19 has forced many payers in the North American markets to delay or drop any project that isn't directly related to handling the disease thereby lengthening the sales cycle
  • The solution requires more upfront capital to build the infrastructure compared to current data analytic or rules based solutions