Oscar Health’s New Claims System

Why we’re focusing on the infrastructure of health care

Late this spring, Oscar raised a new round of funding. We did so to accelerate our investment in technology, to make health care a more positive experience for our members. And one of the largest areas of focus for 2018 is completing the Oscar Health Claims System.

Right now, the health care industry’s most profound limitations can be directly attributed to the fact that health care’s foundational infrastructure — especially the claims system — hasn’t been updated in decades. Even amidst amazing developments, like AI that can detect diabetes and sophisticated algorithms that predict health conditions, most insurers’ core operations rely on technology built in the 70’s and 80’s, at a time when fifty-pound desktop computers were considered flashy.

But claims systems are the payments infrastructure for the entire industry, and innovation in health care will continue to be hampered until we repair our pipes. There’s no reason for our claims systems to remain in stasis, acting as processors that take in indecipherable codes and spit out reams of medical bills. And it’s up to the healthcare industry to build flexible and configurable systems that facilitate better, more affordable care.

At Oscar, we view the current limitations in technology as an opportunity. As a tech-driven insurer, we often get questions like: Why can’t I see and pay my bill right at the doctor’s office? Why aren’t there any discounts or flexible payments options depending on when I see the doctor? Why aren’t doctors financially incentivized to follow up with patients after an ER visit? Why can’t a fertility app be incorporated into my care options and benefits?

That’s how Oscar’s claims system was born. We knew that if we wanted to change the status quo, we’d have to rethink the foundational infrastructure of health care. And last year, we kicked off the long and complex process of building a configurable claims system from the ground up, starting with the foundational data models, followed by access and data flow services, working up through the configuration language that enables us to flexibly configure plans, benefits, and contracts. Almost midway into 2018, we’re thrilled to report that our development on Oscar’s claims system is well on its way to completion. It’s currently pricing a subset of claims and feeding them back into our current system, and will continue to run in parallel until its wider release.

While it’s very early, and the use cases will be contingent on varying state and federal regulatory frameworks, the claims system will allow Oscar to significantly improve the consumer experience. Because we’ve constructed a configurable system that ties into all of Oscar’s datasets and services, we’ll be able to power features that were previously impossible. We’ll be able to pay doctors on the spot through real-time claims adjudication, provide doctors with real-time prior-authorizations for their patients (a major problem that most EHR systems have tried — and failed — to tackle), create flexible pricing for doctor’s visits, and make healthcare more transparent for consumers through sophisticated cost estimates. Accessing health care through Oscar will soon begin to feel more like every other modern, consumer-driven industry.

Oscar’s claims system isn’t just a high-functioning piece of technology; it’s also a new data model for health care. The claims system will provide a comprehensive, real-time single-source-of-truth view of our members and providers. It will enable us to link claims, members, plans, benefits, and payments, providers, and networks seamlessly and instantaneously, and cut out time-intensive manual processes that are prone to errors. We even created our own simple programming language, which will enable Oscar employees — including non-engineers — to dynamically configure our claims system.

Oscar’s claims system was built with the next stage of the healthcare industry in mind. It will support future product iterations and business lines and enable faster, easier, and more efficient product and feature development. This year, in 2018, we plan to nearly double our technical operations. And we hope talented engineers, designers, operational experts, and others will join us in this mission to fix healthcare’s foundation. It’s too critical not to.