Health Industry Leaders Leverage from Partnering with Software Solutions Advisors to Tackle Cost Reduction

The United States spent about $3.5 trillion in 2018 or 18 % of the GDP  on health expenditures, of which $1.5 trillion or 43% was directly financed by the federal government. National health expenditure growth is expected to average 5.5 percent annually over 2017-2026 according to a research study done by Centers for Medicare and Medicaid Services


In today’s healthcare system, streams of data are continuously passing between stakeholders involved in the care of patients.  However, these streams are disconnected and fragmented. This disconnection not only causes a waste of resources, higher healthcare costs and administrative inefficiencies.  It also prevents beneficiaries to receive the best quality of care available.


With the expected increase in the cost of federal healthcare spending in the coming years and to resolve these issues, major industry leaders are turning to the implementation of technological solutions that connect all stakeholders through an interoperable database to allow real-time point-of-care communication, claim management and care delivery.



Quintessential Software Solutions to improve ROI and grant better health outcomes

The ideal model is the one that allows instant eligibility and grants the provider immediate access to the patient’s record which includes such information as diagnosed risk factors, current medications and results from recent tests or scans.


While the patient is at the provider’s office, the provider enters a code for diagnosis and procedure. A central database captures the information and the treatment request is processed via an interface that uses business rules to adjudicate the transaction based on evidence-based medical guidelines and other relevant factors such as past patient utilization. This permits payers to positively and prospectively impact the care of the patient as well as the cost and promotes adherence to the medical standards.


In this sense, industry leaders learned that the best way to obtain top results and create a positive experience for all stakeholders is to partner with companies that bring a holistic approach to finding the right technological solutions for each case whether it be healthcare, workers compensation, managed care organizations or hospitals.



Benefits of the ideal software solution model


  1. Care Coordination: providers and payers are able to communicate in real-time.
  2. Claims Processing: in Workers Compensation up to 80% of medical transactions can be adjudicated in real-time.
  3. Medical Management / Utilization Review: Providers have certainty of payment made easier.
  4. Patient Satisfaction: Patients can be made aware of their financial responsibility before entering a treatment avoiding surprise billing.
  5. Provider Billing: Payment becomes prompt and simple because activities related to traditional billing (fee schedule application, utilization review, coding validation, reconciliation with pre-authorization) have been completed. Billing mistakes are reduced significantly due to the automation preventing most common errors.
  6. Population Health: Track member health in real-time and design automated interventions.
  7. Fraud, Waste and Abuse (FWA) Deterrence: Business rules to detect potentially abusive activity in real-time.



While software solutions can deploy multiple strategies to positively impact revenue and volume, a more complete service with the benefits of the model previously mentioned needs to be taken into account as well. If software companies do not offer this comprehensive solution, their clients will not be able to downsize medical costs and provide better health outcomes. This overall population health goal can be accelerated by building a partnership that fosters fluid and transparent communication between the payers and the Healthcare providers.

Within this group of companies is Conexia, a global leader with more than 20 years of experience. Their service is focused on the healthcare industry that integrates knowledge, technology and human resources to improve the efficiency of its payer clients. This integration ensures effective administrative workflow to optimize the use of resources in order to achieve better healthcare outcomes.

The company was founded in 1996 and since then it has grown to cover more than 20 million patients with more than 20,000 integrated providers in the United States and around the world.



Company Mission

Specializing in leading-edge technologies that bring innovation in the design and development of customized healthcare software solutions capable of connecting all industry stakeholders, they differentiate from competitors due to their singular mission “To promote health through information management as leaders in innovative solutions for the healthcare ecosystem.”

In accordance with their objective, they strive to be a better company for the world and to achieve this goal they have met and maintained the requirements needed to be a B Corp-Certified company for social and environmental accountability, transparency and performance.   

Feedback from the staff demonstrates this organic alignment that occurs both inside and outside the company.   On this matter, Sid Scarborough, Client´s Solution Engineer at Conexia stated:

Our mission is to promote health through information technology.The reason I joined Conexia was to have a positive impact on people’s lives.  We all had friends and family that have gone through some serious illnesses or medical conditions.   The two bigger stressors in life are dealing with money and dealing with Healthcare. I feel the company can make the biggest impact here.


Scarborough highlighted another patient chief concern regarding finances.  “Not knowing how much the patient responsibility portion of the bill is going to be when a member receives the service is very disheartening for patients so it’s important that we implement some solutions that can resolve those issues.”

Advisors such as Conexia’s provide products and services solve those problems and make the administrative workflow in healthcare and workers compensation more effective, faster and more economical.

Additionally, the solutions offered are easily overlayed with existing systems and are applicable to all those organizations that aim to provide healthcare service to the population, whether they are public entities, private medical companies, providers, workers compensation carriers, trade unions or insurance companies.



Company Values

Respect is a fundamental pillar of the company culture that is shared with internal peers and externally with the communities plus organizations with which they partner. This consideration is not only based on individual differences but also on the search for new paths, learning from mistakes or successes, and promoting equality within the organization.

Strategic win-win innovative partnerships are created to provide value to its clients, ultimately improving health and quality of life for people in the communities it serves. In this way, the company contributes to the success of its clients emphasizing the pursuit of excellence with continuous practice through teamwork.


In examining their values and methodology, Thompson Warren, MIT (Massachusetts Institute of Technology) MBA, who has worked with them, stated:

Conexia means innovation, bringing something new and better to a healthcare insurance ecosystem that just is not working well right now. It means that the spirit of entrepreneurship and doing things faster, better, and more accurately.


In the same line of thought, J.R. Long, Vice President of U.S. Sales Operations expressed that the company represents an opportunity to improve all actors in the ecosystem for healthcare delivery. He stated that it is not very often that one can work with an organization that has a dedicated focus on the outcome to the patient as social responsibility to their clients and to their employees as well.


When you find that kind of organization that has that care in culture you want to deliver that day-in and day-out not only with your co-workers, but for your clients and for the providers, and ultimately the injured workers and patients that we serve. It is a very meaningful purpose and it provides opportunity and value to your life that you not always find in any organization.

 J.R. Long, Vice President of U.S. Operations


Arthur Balagula, an MBA graduate also from the MIT who worked with the Marketing Department, commented that the solutions and software products are really good and unique and that having the personal aspect on top of that, a team of people who clients can feel comfortable with and working with is really important as well.



Commitment to Excellence

Corporate values are aligned with their customers’ which ensures the improvement of the customer’s day-to-day operations enabling an enhanced service to the people the latter serve.


Advisors and holistic IT healthcare solutions should encompass values that align with healthcare industry leaders core values, innovation,  excellence, accuracy, speed, and respect. For example, Conexia was recognized by Great Place To Work® and is constantly making efforts to improve and to demonstrate the company’s commitment and corporate culture to achieve excellence through the constant improvement of their intellectual capital and through innovation.


Conexia Inc Great place to work



Furthermore, it was designated a High Impact Global company by Endeavor for their economic and social positive influence around the globe and they sponsor and are supported by the MIT G-Lab for global business innovation.


Against this background, Hunter Dray, who had the opportunity to fulfill an internship, said that the atmosphere is very collaborative and that he liked the fluidity of the working day and how “folks can pop-in and out and everything is done very pragmatically”.


Additionally, they partner with Official Disability Guidelines (ODG) to provide evidence-based guidelines that unite payers, providers and employers ensuring responsible delivery of healthcare based on the best medical evidence.


ODG contains independent, evidence-based, nationally recognized treatment guidelines for the most common work-related conditions. ODG also includes evidence-based return-to-work guidelines as well as predictive modeling and medical management tools and is the most complete set of integrated evidence-based medical treatment and return-to-work guidelines.    


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