EP 549 Building A Better Provider Network - with Jarred Pierce

What happens when someone who spent decades inside the healthcare network machine decides the entire model's broken and sets out to rebuild it from the ground up without investors, without shortcuts, and without playing by the old rules? We'll find out on this episode of Shift Shapers. This is the Shift Shaper Podcast, connecting benefits advisors with thought leaders and entrepreneurs who are shaping the shifts in the industry. And now, here's your host, David Saltzman.

And to help us understand all of this, we've invited Jared Pierce, CEO and co-founder of United Preferred Network. Jared's been building provider networks, believe it or not, since he was 17 years old, with experience spanning network development, medical billing, and payer-provider contracting. And after decades inside the traditional system and seeing firsthand where it fails both providers and patients, he launched Unity to create a more customized, transparent, and provider-aligned network model that's gaining traction on the self-funded market.

Hey Jared, thanks for being here. Hey, thanks for having me. So let's start with the part that most people will find incredulous. You started building networks at age 17.

That's like unheard of. How did that happen and how did that early start shape the way you see the system today? So I was uh in high school and uh started dating a girl whose father was uh owner of a PPO network. I had no clue what that was.

Living in San Diego, we always had Kaiser, which is an HMO. Um, thought I had a really good job at uh Harper Freight Tools and was pretty happy and satisfied there. And luckily uh was offered a job after meeting her father and um yeah, fell in love with the industry. My first job actually was uh calling hospitals and asking for the physician roster, where we would then get that roster and hand um, you know, stuff envelopes and mail out contracts directly to the providers individually.

So it was a very interesting job. Um, again, I fell in love with the industry and um of course was uh, you know, here I am now. So I guess I'm living my my childhood dream still. When back going away back machine, when you were 17 and you were looking at this stuff, were you already savvy enough to know, hey, something doesn't seem right here, or did that take a while?

Yeah, it it was kind of curious as to why our little company that grew to be a massive network um was involved. You know, how weren't the insurance carriers handling this? How wasn't everybody already participating or having a set reimbursement rate? So it was uh confusing.

Um and again, especially just understanding the Kaiser HMO model, um, you know, why would a network or a PPO even exist? So it was very, very unique to me, but I learned very quickly um, you know, the good, the bad, and the ugly of our industry, I guess you could say. So let's fast forward. After decades in the industry, what specifically made you decide that's it, I'm done with the traditional model, I'm building something new and better.

Yeah, so I uh was building this this is the third network I built, um, second that I've owned, and I took a little hiatus right in the beginning of the pandemic. And so I was a partner in a medical billing company. I also started working for a surgery education program that was um uh eventually sold to Paradigm. And so I was still selling in the TPA market and still had, of course, the insight on the provider side being that I was a partner in a medical billing company.

And I felt like it was just the perfect timing to launch a primary network. Um, you know, nothing against some of the other older traditional networks or reference-based pricing, but I felt that RBP had ran its course a little bit when it comes to um, you know, the value it was bringing as well as just the noise that it was going to start causing. And I felt like in this was in 22, I felt, you know, the urge to do it, but I didn't wait, I waited until um, you know, 23 to kind of start building, I guess you could say, uh, the whole process and and format of what I wanted to to build for the network and just the whole industry.

So it was uh kind of that aha moment was I was at SIA and a couple TPAs were reaching out to me and saying, Hey, you know, we can you build us a network? We want to do this directly. And I said, Well, you guys already have a hard enough time as a TPA. You guys want to also build a network?

I said, Well, you know, good luck. Uh and so nothing against the folks that do it. I think a lot of people are able to do it in a regional or a um, you know, some kind of independent providers they can secure, maybe a couple of health systems. But I wanted to build a national network.

And so it was uh that time where I just said it's it's this is has to be done. RBP is gonna eventually have to shift and change. Let's get ahead of the curve. And let's also try to um, you know, promote some of that noise that's gonna happen to the provider community and be that savior, I guess you could say, because again, you know, the older networks, they've been living off older paper.

Maybe there's not as much value anymore. People don't want to just only be uh accessing a percentage of build charges discount. So this is where I wanted to build a RBP level of reimbursement, but with actual secured contracts with the providers agreed to and signed off on, eliminating any noise to the provider or to the member, um, and just making it so that providers can deliver care and not feel like they're a collection agency. So, from your vantage point, what were the biggest structural problems with how provider networks operate today?

So I think again, when you're talking about an older network, they're living off of old paper. And so some of those agreements, the former administration or the former billing company signed these contracts, and at times they can't be located, or there's just a you know outdated pricing methodology that does not serve where we're at when it comes to the savings that need to be uh shown, as well as how stop losses, you know, of course, involved. And so I think uh, you know, not to name any names, I could definitely name a lot, but uh some of these networks just live off of a methodology that does not bring any value anymore.

And so where we came into play was let's see how we can still secure a discount as a primary network. And the the world didn't need another rap network. And so I didn't come out and say, hey, I'm gonna build another rap solution. We've done it with some of the innovative brokers and health plans that are very anti-BUCA.

They don't want to rely on those uh health plans to either provide the network or overcharge or again cause the issues they do. You know, and and I said we need to have a network that can continue to grow, that listens to members, that can incentivize members to actually utilize their health benefits and not delay care they need because of cost. So, you know, some of our first clients were, I think, some of the most innovative brokers. Um, you know, we're really grateful for their business because they've stayed on with us since day one and now allowed us to catapult into these larger TPAs and plans and just other opportunities that are now, you know, going live after a couple years of really building this network out.

You've been pretty vocal about not being a fan of RBP. Why do you think it gets it wrong and both for providers and for members? I just think that, you know, you have a bunch of folks that came in, and yes, they're you know very profitable companies. They they have the financial backing, but they don't really care about the provider.

And, you know, ultimately, because I've been on the provider side, I've, you know, been an advocate for them on many levels as well as manage their own medical reimbursements and contracts and billing. So from my perspective, it's you know, you can have the type of discounts that they're securing, but do it the right way. And I'm not saying it's laziness. I just think that again, you know, you apply this algorithm or this methodology that, hey, a provider just accept this because we know this is what they make take, but you're not getting any sign-off.

And so that causes so many issues for the provider for the member. The provider's confused as to why or how am I getting this reimbursement rate? I didn't agree to this. And then now what we're seeing is access issues.

So members are being turned away at the door. Um, you know, they don't want to take on that card. And that's not just for RBP. I'm seeing that also for like a multi-plan or other, you know, uh larger legacy networks that again, there's no real value to the provider.

I'm happy that the providers are now understanding that they know how to fight this and are pushing back. And that's why I think a lot of RBP vendors are now trying to do it the right way. But it's kind of hard when you've now frustrated the provider community and now say, hey, we're ready to negotiate in good faith and actually do it the right way in the real way of how I've done it for the last 20 plus years. So um, again, I guess it's just that maybe I'm an old school mentality and I want to have that piece of paper and I want to do it the right way.

And again, I don't want my customer service and provider relations or appeals team working hard. I want them almost sitting back and being able to focus on other tasks that we need instead of you know being worried about what problems are coming our way, which I know a lot of networks, that's what they're dealing with now more than ever. Yeah, well, that that's true from both sides. So you talked about legacy networks.

Let's talk about Unity. How is your approach to building a network fundamentally different from traditional PPOs or what you call legacy networks? Mm-hmm. Well, some of the other networks I guess we can that we compete against or compared to, you know, they have their stack, they have their members, they have their providers, and they really try to push, you know, as much utilization without trying to grow.

And of course, we're trying to promote every single provider we sign up with and make sure that there is an incentive for them to join instead of just hopefully sit back and maybe we send you a member or two. So where we've grown differently is we're actually listening to the members, we're forecasting where members can will go, and we're using historical claims data. And that's really where the growth has been that we've customized a network exclusively to our clients' needs.

And what's also happened is because we've grown out a lot of states where we are easily, you know, one of the largest options out there, just with some of the great relationships I've had with building companies or consultants or IPAs, is now a lot of our brokers are going out and selling in markets where they may never have. So it's really encouraging them to, you know, focus in on certain areas. You know, we have the provider directory, we have every specialty you need, we have the hospitals, we have the behavioral health.

And, you know, now you should just start focusing on some of these states. Let us go to the areas you already have members, we'll focus on that. But now how do you now spread your brand across the country? And, you know, a good example of this is we have a client that just went live this year, um, you know, based predominantly on the East Coast and is owned by one of the large BUCA um uh BUCA networks, but yet in all the other states outside the one that they reside in, we're gonna be their primary options.

So it's great to show them really where the directory is, where they can now start selling, and then just, of course, you know, fill the gaps of where uh they already have the members existing outside of where they want to go sell now. You know, one of the things you mentioned is letting members nominate providers and using claims data to shape the network. How does that actually work in practice? So we are looking at, again, the historical claims data.

We're seeing the hierarchy of where utilization is for particular providers, and we're doing that outreach directly to the provider. And so it's uh really listening to the members, but also taking our own initiative to make sure that we secure those contracts with the providers. The members now have access. And the great thing about it is our members are um our, I should say, our health plans are putting our logo on the ID card.

So now the provider is not just searching as if we were just a rap network for that little tiny fine print on the EOB that says Unity. They're actually seeing it up front. They're realizing the contract that we uh just established is already immediately generating revenue to that practice, and members are having no issues with access. And so it's a way different approach compared to the other networks that I built before because that was something that I always preached that we should transition to do.

But I think there was that either, I don't know, hesitation, or you know, we we probably couldn't get ahead of a multi-plan or a zealous because they were always sitting first tier. So we were always happy, you know, just being second place. And of course, we still do have some larger uh health plans that, again, are still using us in a secondary manner. But really, I'd say our focus is only in the self-funded side, regardless if it's uh 10,000 or 20,000, up to a couple hundred thousand lives, but where we can actually sit in that primary role and again, you know, handle any issues, uh, continue to customize the network, but ultimately bring value across the board to all parties that we service.

You mentioned earlier that you've sat on the provider side as well. So how does that experience influence how you contract and engage providers today? Yeah, no, great question. I I think I have an advantage over every competitor or anybody in this space because of how I know how that whole process um of verifying eligibility and and of course submitting claims and going through that bill review process and denials and everything else that comes with it and negotiating directly with uh, you know, my competitors or even the the BUCA networks themselves.

So I don't think that anyone has that experience. And if they do, like I said, it's not, I think, as uh well versed as I have being the different specialties and states that I manage provider practices in. So I do take that knowledge and I try to translate it into how that provider wants to be treated and also how they want to be explained and how we customize the contract to fit those needs. So I think a lot of our competitors, you know, they'll have very long, huge contract that can be confusing, that could have a lot of different language in there that you know is not always advantageous to the provider or even the member.

And so um when we're able to really customize and provide to them a very clear, honest, fair, open agreement, then it really I think increases our chances of securing that provider. Um and again, making it so that this provider never leaves our panel. You did something unusual for somebody who's uh you know at a startup. You you decided not to grow with private equity, even though you got some offers, which is not surprising.

Yeah. Why was that important to you and how does that shape your strategy? Well, I I, you know, I luckily picked two of the best partners I could ever pick. Um we're very uh different.

I'm I'm in the the middle of both of them when it comes to the age groups, uh, even though the younger one is, of course, closer to my age, but I have a very um respected, trusted partner in Charlie Hildebrand and Morgan Smith. Charlie's done this uh many times over. He's had already two uh nine-figure exits that he's been a part of and grown. So I think this time around, it was very important for us to stay independent.

Um, you know, Morgan's been a part of Coral, which is a great company that's grown year after year and been a part of the uh bundled surgery network. So, you know, he had the still experience of the network side, definitely understood the financing side because that's all they do is pay claims. And so I think it was uh important for us to stay as independent as possible until we got it to the level of where it needed to be now if we were ever going to, you know, sell or or bring on investors.

And um, again, it was important for me to, you know, keep the positions that we all held and be able to make decisions equally because you know, we all three align very well, but we all bring a very unique and different skill set to the table. So, you know, with bringing more uh, you know, more folks on board and and you know, having them have a say. And and I think a lot of people investing in the space don't really understand the space. You know, they see the dollars and cents associated with it and the ROI, and we just weren't at that level yet.

We wanted to really build something different. Um, and I think now that we're at that level, I think of course the offers are even coming more than ever. Um, but yeah, we we had to bootstrap a little bit. I had to, you know, wear a lot of different hats.

Um, but luckily I'm addicted to what I do. So a lot of times this is doesn't feel like a job to me. Uh you know, of course I I love my family and I love traveling and you know, seeing my friends, but ultimately I I uh enjoy working these, you know, 15, 16 hour days um and on the weekends, and just because again, I've this is what I've been doing since I was 17 years old. So I know you're already naked, you're already nationwide, and and I know you're getting traction with some TPAs, some tribes, and maybe even potentially some Taft Hartley plans.

Where are you seeing the strongest adoption and why do you think that is? So I think, you know, we're we're growing everywhere. Um I think that we've had our states that yes, we are extremely dominant in, where again, if we don't add another provider, not that we won't, but that we would be pretty sitting pretty well. And funny enough, the toughest the one of the toughest states to contract in is the state of Wisconsin.

And that was actually our first client was based in Wisconsin. And so we've done a really good job. Um, I know that there's some legacy networks there that have controlled those state that state. Um, but yeah, no, we've done a great job of building out Wisconsin, um, as well as the rest of, you know, I call it original Big Ten country before the merger of all the now Big Ten's a nationwide brand, but uh so we've done good in Illinois.

Uh we've done good in uh Michigan, Ohio, Pennsylvania. We're really strong in Arizona. We have some really big opportunities um in the state of Nevada, and we're growing out the state of Nevada right now with just some new clients and new structures that we have. Uh we're of course always gonna have a great presence in California, Florida, Texas, and uh New York just based on population.

But yeah, I mean I think that um, you know, it's every state's been a victim of RBP. So it's not like, hey, let's just only focus on the Midwest, um, you know, or just the East Coast. And of course, I know that uh the RBP vendors, just because I know some of them personally and I talk to them, um, that they've expressed certain markets that I know they've struggled in now and are having to, you know, roll up their sleeves and do the hard work of actually getting contracts. But, you know, as mentioned, you know, a lot of these folks have, I think, tarnished um, you know, I don't want to say their trust or reputation, but um ultimately that's how we provide our value across the board is educating people that, hey, we're here before RBP.

And again, we're not telling our TPAs you can't use RBP, but there is no reason why anybody should be using RBP before a legitimate contract that provides the same, if not larger, savings signed off by the provider. Um, yeah, I mean, that's you know, we we definitely have some target states. Colorado's another state we've been great at. Um, you know, Georgia, the Carolinas.

But yeah, I mean, there's definitely some pockets. Uh, maybe we need to focus in on, you know, maybe a little more love to the Dakotas or Wyoming. But again, until we get more members in that state, that's when we'll actually put more emphasis. But we do have providers in every single state and hospital system.

So it's it's been great. So if Unity succeeds at scale, what does the healthcare network of the future look like? And what should advisors and employers be thinking about right now? I think you should be looking at how do you incentivize the member and structure a plan that can cover uh member deductibles or co-insurance levels if they use the provider directory appropriately.

And that's where we have some of, again, our most innovative health plans and brokers. One of our first clients, um, company called a Virgin. We love a virgin. Drew Leatherberry is doing some amazing, impressive things in the industry.

And I think that it's gonna take brokers and health plans like that that are gonna actually shift the change and get folks to not really rely on uh a BUCA plan. And again, I'm not trying to go to war with any BUCA network. Um, you know, I am not writing insurance myself. I'm just customizing a plan that can be used appropriately and still cover all the needs uh without having that big fancy logo on your ID card that everybody thinks they need, but really they don't.

And that's a great place to end our conversation for today, Jared Pierce, CEO and co founder of Unity Preferred Network. Jared, thanks so much for a fascinating conversation. Appreciate it. Thank you for having me.

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