We grew up in immigrant families, and for both of us, our parents would honestly tell us to not trust doctors because of unexpected medical bills. They really believed that doctors were adding on unnecessary things that didn’t help in order to make more money. As adults, we’ve both had first-hand experiences receiving surprise bills even with good insurance while working at tech companies, so solving this problem is personal to us.
It turns out 38% of Americans delay medical care for fear of the bill while prices vary 2-10x across health providers, even when using insurance. This led us to believe that creating a marketplace with transparent out-of-pocket costs could be a solution.
However, it wasn’t until the July 2022 Transparency in Coverage Rule (https://www.cms.gov/healthplan-price-transparency) that we had the payer pricing data (that’s actually high quality compared to hospital data) to create this marketplace. Certainly is the first company to use this data to predict and guarantee prices for consumers to book doctors.
We know the HN community has been interested in applications of healthcare price transparency data (https://news.ycombinator.com/item?id=32738783), so we’re excited to share how we’re using this data to predict and guarantee prices for a consumer application.
With Certainly, patients can enter their insurance, compare guaranteed out-of-pocket costs across doctors, and book an appointment with price transparency. For providers, we guarantee any patient we send them will always pay. Partner providers pay us any time we send them a new patient. Eventually, we’ll convert providers to using our SaaS platform to guarantee payments from existing patients.
We are currently focused on shoppable services - anything that can be scheduled in advance. Our solution falls between two ends of the spectrum for consumer shopping experiences. At one end is healthcare, where the status quo is you go to a doctor and you have no idea what will happen and you have no idea how much it will cost. At the other end is going to a restaurant, having a menu of items with corresponding prices, and deciding which items you want to order.
Certainly Health lets you see what services could happen during your visit and how much they will cost. We guarantee that if those services happen, you will not pay more than the out-of-pocket costs you saw upfront for each of those services. But it is ultimately the doctor who decides which services you end up getting (like a chef deciding which dishes you will be served). As a result, you can compare upfront out-of-pocket costs specific to your insurance and book a provider without worrying about surprise bills.
A common misconception is that patient out-of-pocket costs are set by doctors. Prices of healthcare services are actually the result of negotiations between providers and insurance companies. Groups with more negotiating power, like large hospital systems, are able to command higher rates than private practice physicians. This variance in cost is enormous across almost all procedures we've looked at, even between providers a few blocks from each other. It might cost $105 to get an orthopedic consultation with one doctor, and $550 to get a consultation with another doctor across the street, for example. This price variance means the out-of-pocket cost also varies for patients with high deductible plans or plans where the copay does not cover all services (which we’ve encountered very often).
We do not use hospital price data which is inconsistent and messy (https://www.kff.org/health-costs/press-release/analysis-inco...). Instead, our guaranteed prices are based on three things: (1) health insurance published rates for procedures, as required by regulation; (2) patient eligibility/benefits information (e.g. deductible, copay, coinsurance); and (3) an online learning model to account for variance across thousands of plans and patient conditions.
As we process payments and claims, we create an accurate platform for predicting out-of-pocket costs by accounting for variations such as whether certain procedures are covered by an insurance plan/copay, and how the rate changes based on diagnosis code (we discovered V97.33XD is for "Sucked into jet engine, subsequent encounter”), number of units, medical coding modifiers, and other factors.
Certainly is currently available in NYC where you can choose from over 5k doctors to book without surprise bills for free at https://certainlyhealth.com/. We plan to expand to other cities once we prove that we can establish a low CAC on both the supply and demand sides in NYC.
Although we’re early, we’re starting to see intended results. One patient saved $850 on a podiatrist visit booked through us compared to a previous visit with a different doctor for the exact same services. Another was charged for an annual physical, but we identified the mistake and got a refund issued to him. Most of our customers have had surprise bills in the past and are happy to have peace of mind with our upfront, guaranteed prices.
We’d love to hear your ideas, experiences, feedback and any feature requests!
by Andrey
Azimov