AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze

What actually happens after you hand your insurance card to the front desk at a doctor's office? On the pharmacy side, a claim clears in milliseconds. On the medical side, the same visit can trigger a weeks- or months-long odyssey of coding, clearinghouses, carve-outs, and paper claims before anyone knows what's owed. On this episode of Astonishing Healthcare, host Justin Venneri revisits the "story of a claim," this time following the far more complicated journey of a medical claim.Joining him are two guests who've been working to improve medical claims processing for years: Kevin Sundquist (VP, Product) and Liya Lomsadze (Senior Director, Product). Together, they trace why medical claims lag, why the system got carved into so many disconnected pieces, and how unifying medical and pharmacy benefits on a single platform - Judi® - changes the experience for plan sponsors, members, and providers.HighlightsWhile pharmacy claims are adjudicated in real time, medical claims often can't even be created on the spot. The clinical record and billing system are frequently separate, and each handoff adds lag and introduces new chances for error – a single mislabeled insurance record can delay a simple lab claim by six months.In the medical world, it's common to split a single claim's journey across multiple vendors: in-network pricing to one entity, out-of-network pricing to another, prior authorization to a third, and benefit application to yet another. Plan sponsors, brokers, and consultants need one system and the flexibility to carve out any piece to a preferred partner if they’d like.Rigid legacy systems force unnecessary compromises and workarounds. Manual tracking of visits to a chiropractor or physical therapist and hacking deductibles for plan members are all too common.Judi’s capabilities are expanding. Payments, care navigation and management, case management, and much more are brought into a more connected experience for members, sponsors, and providers.Related ContentAH037 - The Story of a Claim: Redefining the Benefit Experience, with Kevin SundquistTop 10 New Judi® Updates Improving Health Benefits AdministrationAH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating EfficiencyFor more information about this episode and its transcript, please visit Judi Health Insights.