PVerify

So today we’re chatting about pVerify and how it’s used at your company. Before we jump into that, could you give a brief overview of the company and your role there?

We are a benefits platform selling to Fortune 500 and major payors. Members get access to our network of virtual care providers. We also offer a financial assistance tool where employers can set aside funds to support members on their journeys of starting a family. I’m involved with the financial assistance product, focusing on creating the best member experience.

What drove the need to look for a product like pVerify?

We needed a way to get members’ year-to-date spend information with their insurance, to build out a price transparency tool within our product. Prior to getting pVerify, our workaround was to ask members to export their EOB forms from their insurance portal and submit it to us, and then we would read through the file and pull the required data. Obviously, that was not the most idea process, both for our members and for us.

What requirements did you use to evaluate these products?

The most important one was payor coverage, making sure the platform could connect to a lot of different payors. Second was how “fresh” the data was, whether they were making real-time calls to payors or getting a database dump at a certain time, and whether there was a lag in the data collection. Third was price. And fourth was whether they were a tech-enabled company that we could work with easily.

What competing products did you consider?

We looked at Availity, Change Healthcare, TriZetto, and Experian. Experian and Availity were at the bottom. Availity was very slow to respond, so we didn’t move forward with them. Experian was the most expensive and also didn’t have as much payor coverage as the others. A friend of mine works at another virtual health care company that uses Change, and he said they do have the most coverage, but their data was often out of date, so that dissuaded us. Out of all the vendors, pVerify seemed to be the most tech enabled vendor and also happened to be the easiest team to work with.

How was the implementation process with pVerify?

Very great. With some of their other competitors, it felt like we were too small for them to consider us as a client. pVerify was very responsive: our account exec responded the same day or the next day the entire time and helped us promptly if we had any technical issues. The implementation process was very smooth.

Onboarding and setup was great. pVerify has Postman already available with the most updated API specs, so we had everything we needed and just had to input member information to test the system. They also use REST API, whereas most other clearing house competitors use SOAP API. This also made it very easy to onboard and get set up with them.

What specific features or use cases do you use?

We need to figure out what the member responsibility is when a healthcare service is rendered. We use pVerify to pull members’ health plan information to correctly calculate that amount. To do this, we use pVerify’s real-time eligibility check.

How well do these features meet your needs?

It works pretty well. Our one complaint, and I don’t think this is pVerify’s problem directly, is that when the different insurance companies provide data to pVerify, each one is formatted differently. As a result, the API responses we get can be different from payor to payor. They standardize it as much as possible, but we still found some issues during production testing and had to put in additional business logic to account for them. I would expect that to happen with any clearing house, though.

What are the relative strengths and weaknesses for pVerify?

They’re very easy to work with, across their sales, engineering, and support teams. The API is solid and we’ve never had any issues with it not working. It doesn’t have as much coverage as TriZetto or Change, who have been there longer or have more direct relationships — Change is owned by UnitedHealth Group, which is the biggest payor in the States. The difference wasn’t too great for us to not work with pVerify. pVerify maybe has 90% coverage, whereas the competitors have closer to 95%.

What do you do when a specific payor isn’t covered?

We don’t have many cases like that: they have all the major payors, and usually the employers we work with don’t use smaller payors. But when it does happen, we have two options. We can reach out to pVerify and ask them to connect to a new payor, and they will figure it out. But if that is going to take too long, we would reach out directly to the payor through the employer and work out a bi-directional feed to get the information we need.

How has pVerify been from a reliability and stability standpoint?

It’s been very reliable, we haven’t had any issues.

Could you talk about the experience of working with the API and the quality of the documentation?

The documentation is all available online. Not a lot of health care companies do that; it’s typically always gated. pVerify has open API docs, and they have Postman set up so we can just download it and start using it right away.

Are there any additional features, APIs, or integrations you expect to use in the future?

We currently only use the eligibility API. We might use their claim status feature in the future, if we start getting claims data from payors and want to calculate member responsibility as accurately as possible and in real time. We don’t use any other integrations currently.

How has the account management support experience been?

They’re very responsive, within a business day.

Do you think you made the right choice going with pVerify?

Yes. pVerify’s other benefits outweigh the less-complete payor coverage. If I think about it logically, the only companies with enough funds to provide this benefit to members are likely to be with the top ten payors anyway. So I don’t think we’ll run into coverage issues for a while, unless there’s a small-to-medium business that deems this a very important benefit to offer and happens to use a local payor. And from a technical perspective, they’ve been way ahead of the other competitors.

Are there any areas for growth?

I think they can improve the quality of the API responses from different payors more, either by working with payors and requiring those necessary fields or by putting in business logic so that the API responses are more standard.

Do you have any advice for other companies looking for an eligibility verification product?

A lot of virtual care platforms have some sort of cost estimator or price transparency tool for members to see how much it will cost up front, so I assume they’re all using pVerify or one of its competitors. My advice would be to think about your target customer and figure out who the must-have payors are. You need to be able to support your specific members who will be on certain health plans, so you need to find the right vendor who can support all those payors. After that, you have to look at what implementation looks like. How flexible will they be in cases where they don’t have a payor connection you need? Are they willing to work with you on adding that connection to their network? Price is obviously a concern, but I feel like it’s fairly similar across the board at this point, it’s reached a level of market maturity.