Candid Health

So we’re chatting about Candid Health and how it’s used at your company. Before we jump to that, can you give us a brief overview of the company and your role there?

We’re a tech-enabled digital health provider. We connect individuals with our clinicians and we get the services covered by their health insurance. I am one of the co-founders and the CTO. I run the product, design, and engineering teams.

How long have you been using Candid?

We’ve been using Candid since the end of August 2022.

What caused you to bring in Candid in the first place?

We needed a more proficient system to handle claims as we were growing. We used to submit claims manually and had an in-house biller. We wanted to transition to a more tech-enabled approach, which is why we started looking into purchasing an RCM solution for tech-enabled companies.

I’m really curious about the work that Candid is doing for you. Are they just providing a tech platform, or do they also handle services? Can you walk me through the whole process?

Candid offers a smoother process compared to Change Healthcare when it comes to submitting claims. They take care of EFT/ERA enrollments and EDI enrollments, which we didn’t want to handle ourselves. They’ve also developed a nice internal workflow tool that they’ve improved based on our feedback. Additionally, they perform a preliminary check on many claims, like automatic eligibility checks before submission. They’ve got a pre-submission rules engine that handles specific denial cases automatically. So yes, they do provide some services, but not everything. We still need an internal team for certain tasks, but I do think they handle more than some of the other competitors out there. They also have checks in place for procedural matters, like catching incorrectly paid amounts, flagging stale claims, EDI enrollments, and flagging when an EFT/ERA enrollment is needed.

Let’s go back to the initial procurement decision. There are quite a few players in the RCM space. I imagine you went through a thorough evaluation process. How did you approach it, and what criteria did you use to assess Candid and its competitors?

Pricing was a big factor, and it led to the elimination of many options right off the bat. Secondly, we looked at the quality of the team behind the company. We were highly impressed with Candid in this regard. We knew we’d have to iterate and work with them as we grew. For example, we knew we needed a custom integration with them. Finally, we considered our trust in their future roadmap. While there was one company attempting to undercut Candid by around 10 basis points, we ultimately chose Candid because of their team.

Great, let’s dive deeper into some of the other vendors. Can you share who else you considered and give us an idea of how they compared to Candid, and what ultimately made you choose Candid over the others?

We looked at Gentem, and if I remember correctly, their pricing was pretty crazy. It felt more like they were tailored for small businesses, and it didn’t seem like their pricing would scale with us. We also looked at Enter Health, and they had slightly lower prices, but I wasn’t too impressed with their team. It felt like they were more geared towards a self-service approach, and at the time, we needed a bit more hand-holding. There was another one called Apero, but we didn’t delve too deep into them. It seemed like they were less hands-on. We didn’t look at them as closely because it felt like they had roughly the same service, and Candid was growing faster and had a more robust offering.

Were all the pricing models pretty much the same, like based on gross billings or net revenue, or did they have different structures?

Well, I’d say Candid’s pricing felt the most straightforward at the time, although I think they’ve changed it recently. Gentem’s pricing was a bit confusing. It was like a monthly minimum of $2,000, or 4% plus 30 cents per claim, whichever is higher, and it required a one-year agreement. They also had these additional services like credentialing and enrollments that you could add, but it would affect the pricing, and honestly, it felt like there were too many variables to keep track of. Enter had a similar structure. Candid just had a flat percentage fee. I think they’ve updated it to be 30 cents plus a fee now. I believe they did this to simplify their cost structure: the 30 cents is a fixed cost on their end for submissions. Luckily, we got in early with Candid, so we were grandfathered into the better pricing model.

Let’s circle back to the sales process. I’m curious about the level of transparency, the amount of information available, their ability to move quickly, and their flexibility with terms.

They were quite accommodating. It felt like we were getting the white-glove treatment, and we had confidence in their team’s capabilities. To give you some context, I had a similar conversation with a Gentem account executive, and it felt like I couldn’t get her to communicate clearly. Enter was somewhere in between. We were still treated well, but it was evident they had been in the business longer and were geared toward different customers. When we looked into customer references, it became clear that they were dealing with larger hospital systems like Intermountain, as opposed to tech-enabled healthcare companies. It’s not that we didn’t think Enter could handle it, but it seemed like they had a different focus. We knew that many tech-enabled healthcare companies were choosing Candid. Overall, the sales process with Candid was very accommodating, and they showed flexibility. Even now, as we’re renegotiating the contract, they’ve been willing to work with us to find a solution that benefits both parties.

Can you tell me about the onboarding and setup process? Did they maintain that efficiency and continue to work well with you?

Yeah, our onboarding and setup process was quite unique, to be honest. Due to some factors out of our control, we had to switch over in just a day, which we hadn’t really anticipated. But the team was incredibly flexible. Due to the speed of the transition, we had some manual data needs, and Candid stepped up and assigned some manual help to reconcile those issues during our onboarding process, which helped provide transparency into our accounts receivable. Their willingness to go the extra mile during that initial setup made a big difference. Once we got the EFT/ERAs sorted out, things went a lot smoother.

The next major challenge was dealing with the sheer number of tasks we were generating. They were really helpful in iterating with us on their rules engine, even though it wasn’t a self-service tool. We had to make changes by making spreadsheets and sending them these complex “if-else-and” logic puzzles! But they were super responsive in updating the rules as we refined them.

Overall, it went as smoothly as it could have considering the circumstances. We really appreciated their flexibility in working with us throughout the whole journey.

I’m curious, did you have to go through a manual process back then because there were so many tasks to handle, and you didn’t have direct access to the backend rules engine? Has that situation changed now?

Yeah, the rules engine is editable now. There was a bit of mutual learning going on back then. For instance, we had some specific payor routing rules that they hadn’t come across before, and they worked with us to support that. And since then, they’ve encountered more clients with similar use cases where there’s an additional layer of logic before it’s fully processed on Candid’s end. They’ve been flexible in working with us on those intermediary steps we needed to fix.

We’ve talked a bit about EFT/ERA enrollment. Are they also involved in anything related to other use cases? For instance, are you using them for provider credentialing?

We actually don’t use their provider credentialing feature. That’s mainly because by the time they rolled it out, we had already developed our own internal system. It’s not too complicated for us to verify whether a provider is credentialed before allowing a patient to book and submitting claims. So we handle that on our end. Similarly, we don’t heavily rely on their Contract Management feature right now. Our contracts and codes are pretty straightforward. I can imagine that others might have a wider range of complexities, but that’s not the case for us. However, we do make use of their tasks feature, and they recently introduced work queues, which has been quite helpful.

And the API is a big deal for us. We programmatically submit claims to Candid every day, and it’s been working smoothly. We’re also heavy users of their data export capability. Additionally, we’ve set up Candid’s native Stripe integration, where we configure our Stripe invoices in a way that they automatically sync with Candid. Candid has its own data pipeline that pulls from Stripe, making it easy for us to reconcile copay, coinsurances, and deductibles paid through Stripe, which gets reflected in Candid.

One big pain point is that they had a relatively long outage with their exports from the end of July into the beginning of August, lasting a few weeks. Their exports have also been a bit buggy, causing some problems for us with our data pipelines. So, I’d say the CSV export feature has been a bit less reliable and somewhat buggy. However, it doesn’t seem to be the primary workflow for everyone.

How would you describe the extent to which Candid has put your RCM on autopilot versus how much manual work you still have to do?

We’ve definitely automated a lot ourselves, and Candid plays a role in facilitating that automation. But, for transparency’s sake, we’re actually considering transitioning away from relying on Candid’s services and toward bringing everything in-house. We might use them more as a SaaS platform, which it seems like they’re starting to offer now. When you’re dealing with billing hundreds of millions of dollars, you typically have in-house teams to handle unusual situations that arise. Sometimes those quirks are better dealt with in-house because you have all the information and context. So, while they did help automate accuracy checks and boost our confidence in the claims going out the door, they haven’t significantly reduced claim denials or similar issues.

How do you assess the strengths and weaknesses of Candid?

I think they’re a really sharp team, super responsive, and they’ve accomplished a lot. I believe their focus on digital health companies and their flexibility with the rules engine and tools they provide are great strengths. In terms of weaknesses, I’d say there’s been a bit of ambiguity at times, particularly around defining their service scope. It was a bit tricky to pin down where their responsibility ends and ours begins when we initially came onboard. Initially, it was like, “You guys handle all the denials, right?” But then it turned out that for certain denials, we still needed to handle it. We’ve since ironed out these kinks and reached a more steady state together. However, looking ahead, I wonder how much they benefit from handling denials across the board in terms of economies of scale. If it’s the same kind of issue with the same payor, that’s efficient for them, but when you’re dealing with the long tail of random niche payors, it might not be so much. So, I wouldn’t exactly call it a weakness, but inevitably, as our company grows, the idea of bringing that service component in-house becomes more appealing. It makes sense both from a margin perspective and in terms of having complete control over the experience.

How do you assess the overall developer experience and the quality of their documentation?

I’d say it’s pretty solid, and makes a lot of sense intuitively. But for someone new to the healthcare field, there’s a bit of a learning curve. For instance, the Change Healthcare payor ID is different from the one you submit to Candid, which might also be different from what’s on the back of the card, and it’s not the same as what Healthie sometimes shows. So there’s a bit of nomenclature confusion when you’re trying to understand the API.

But apart from that, it’s very user-friendly. For most of our eligibility tasks, Candid is basically a wrapper around Change, and that works for us. They just charge us five cents per query and we prefer having everything in one place.

As for the documentation, it’s pretty solid overall. The documentation of CSVs isn’t great, but otherwise it’s what you would expect.

How much work do you need to put in for a solid Candid integration?

Well, it actually depends on which EMR system you’re using when transitioning to Candid. With Healthie, we’re essentially pulling information from Healthie, doing our own processing, and then sending it over to Candid. There’s no direct pipeline between the two. We managed to set up a basic version in just a couple of days, so it’s quite doable.

Is it something you need prior knowledge for, or does Candid help you grasp the necessary context to write all that code and do a good job?

Before we started using Candid, we were pretty much figuring things out on our own. So I can’t say for sure how it would have been if we didn’t have that knowledge already. Candid has been helpful, especially when we’ve been experimenting with billing pilots. For example, if we want to test new code or bill a different payor for a specific type of claim, they’re pretty accommodating in their rules engine. You might need to come up with a workaround at times, but overall, they’re quite flexible. I believe they’re very willing to collaborate with you, helping analyze denial reasons and such. However, I don’t think they can replace someone in-house who truly understands what’s happening, comprehends the data, and can dive in for internal analysis.

Do you have any tactical advice for organizations that might be building with their API?

Honestly, just don’t assume the CSVs generated are going to work immediately. You might get more errors than you think. But aside from that, no, what you see is what you get, and it’s pretty straightforward.

Can you talk a bit about the integration with Healthie?

Yeah, it’s not really a standard integration at the moment. They haven’t built it yet but it’s on the roadmap for Q4’23. What we do is we check for Healthie appointments that have taken place. After that, we run it through all our scripts, which includes performing credentialing checks and applying other business logic. Finally, we send all that data over to Candid. So, it’s not a tight integration right now. There’s a lot that passes through us. However, there is one automatic integration feature with Stripe. When you create an invoice, you include two identifiers in both the invoice and the payment. When you charge the payment method, they’ll automatically sync up, which is really convenient.

I’d love to discuss account management and support. How do you feel about these teams?

I think this is Candid’s shining star. All our other vendors, I have some issues with their support teams and account management. But everyone at Candid with whom we’ve interacted has been so quick to grasp our pain points. They’re always seeking feedback and promptly addressing issues. They’re also great at explaining when they can’t solve something or pinpointing the root cause of problems. Honestly, they rank among our top vendors in the healthcare space, especially when compared to some others that can be a bit frustrating at times.

Looking back, do you feel like you made the right call with Candid?

Yeah, I think we did. We’re very happy with them. I think Candid is the kind of vendor that will work well with us into the future. Especially the fact that they’re supporting larger accounts and offering an off-ramp into bringing some services in-house for just a few basis points or a better margin is pretty impressive. I’m not sure if other companies do that, but it seems like they genuinely care about growing with their customer base, which is great to hear.

Do you see any potential areas for growth with Candid?

I do think they’re in a bit of a tough spot because there are dependencies on our team. For instance, they can’t handle certain EFT/ERA enrollments on our behalf, and it’s also a bit of a hassle for us to deal with. Sometimes we run into issues when we hire someone new to healthcare, like, “What’s this Novitas portal I have to log into?” So, the education aspect can get a bit messy. However, they’ve started building support docs and such to help people who need to work with them.

In terms of the product itself, I think they’ve been improving, but there are still some issues. For instance, for some of their dashboards, we’re still exporting all the data to do our own analysis, and we’re at a point where we’re thinking that maybe what we need is just too custom. But when it comes to the workbench, I do appreciate the work they’ve done on work queues. It used to be all task-based, which made it tricky to specialize people. We have a team of virtual assistants, and ideally, one person should focus on things like inactive coverage, while someone else handles incorrectly paid claims. Previously, there weren’t many tools for that, but they’ve been building them out, which is a positive change. So, right now, I’d say those are the two key areas to look at.

Do you have any advice for buyers who are currently trying to figure out their RCM solution?

Honestly, the most important advice I’d offer is to determine the level of commitment you’re willing to make. Decide how much effort and engineering resources you want to allocate to a solution like this, and don’t overestimate the challenges of integration. It seems to me that many healthcare companies hesitate when it comes to a one-time integration, but I don’t understand how they can effectively support custom workflows if they don’t have custom integrations. Eventually, you’ll have to face the integration challenge, so don’t be afraid to view it as a worthwhile one-time investment. Consider it an opportunity to build your own mini rules engine and implement various checks before passing data to a tool that can significantly improve your operations.

However, if you lack engineering resources and you’re currently using Healthie, it’s worth noting that the Healthie-Candid integration isn’t well-supported right now. In such a case, choosing a solution that integrates more seamlessly with your current setup might be a smart move. Ultimately, your decision should align with your honest assessment of the level of technical investment you’re willing to undertake, and that should guide you in selecting the right provider.