Private equity firm New Mountain Capital merged three health tech companies in a multi-billion dollar deal to be a top player in the payment integrity market.
New Mountain is forming the new company by combining The Rawlings Group, Apixio’s Payment Integrity business and Varis to tackle the challenge of health plan payment accuracy using technology and artificial intelligence.
The companies did not disclose financial details. Bloomberg reported that the deal values the combination at more than $3 billion, citing people familiar with the matter.
The new company, as yet unnamed, will have an expansive set of capabilities, including subrogation, coordination of benefits, pharmacy payment integrity, and complex claim solutions and will serve many of the largest health plans in the U.S., according to the company in a press release.
The Rawlings Group is a 40-year-old company with a large industry footprint working with health insurance companies to identify third parties responsible for paying medical claims. It has more than 1,600 employees.
Insurance giant Centene sold Apixio's to New Mountain Capital a year ago. Apixio's technology improves administrative, clinical and financial programs for health plans across the country,
The merger doesn't include all of Apixio, as its connected care platform and value-based care services will now become part of Datavant, as part of the deal.
And, Varis specializes in overpayment identification solutions including diagnosis related groups (DRG) and ambulatory payment classification (APC) prospective payment system.
The combined entity, which will have close to 2,000 employees, sees an opportunity to leverage its size and scale to compete in the fast-growing payment integrity market.
"The status quo for payment accuracy and payment integrity has been the same way for a long time, and New Mountain Capital really saw this an opportunity, with three different companies that were in the market that were best-in-class on their own, to come in and really disrupt the marketplace with real scale and to use advanced technology and AI to really perform accuracy that makes payers save more money, but also process payments and claims faster," said David Pierre, who was tapped the lead the combined entity, in an interview with Fierce Healthcare.
"This can be a real win for the payers in this marketplace, as well as providers too, if you're doing things accurately the first time, without all the administrative waste that goes into the system today," he added.
Pierre previously served as chief operating officer of Signify Health, where he led over $1 billion in revenue and oversaw the company’s initial public offering in 2021 and subsequent $8 billion sale to CVS Health in 2023. He also spent 10 years at health IT company Cerner, which is now owned by Oracle.
The combination of the three health tech companies introduces a "next level of payment accuracy and proactive identification of errors" to create a comprehensive platform well-positioned to drive meaningful savings for health plans, company executives said in a press release.
The combined companies claim to impact 160 million lives across more than 60 health plan clients, including many of the top 20 plans.
Payment errors and administrative complexity, or all the administrative layers involved for providers to get payment from health plans, are top drivers of excess spending in U.S. healthcare.
It's estimated that administrative complexity accounts for $267 billion in annual costs.
One study pegged the cost of healthcare administrative spending at approximately $1 trillion annually, but interventions to make healthcare payments more efficient can reduce annual expenditures by as much as $40 to $60 billion.
"The real pain point is just the complexity and the back and forth that occurs between providers and payers and trying to get a medical claim verified and paid accurately and on time," Pierre said. "There's so much administrative waste that goes into the process today and back and forth that when done correctly with technology and expertise, it can be much more streamlined."
He added, "We're trying to solve specifically on the payment accuracy side of the house right now. We have experts from AI, we have experts from clinical and we write the subrogation manual for the subrogation industry. So we have real expertise in terms of talent. Combining that with a lot of technology, we're going to be able to solve some of these challenges that have been out there for years."
The combined company sees the potential to use advancements in AI and other technologies to make medical payments more efficient.
"We've been leveraging AI across these companies in various forms and fashion. When you just look at the sheer number of algorithms that we run, the natural language processing models that we have in place today, we have close to 500,000 of these models that have been built and put into place. But I see it as, number one, you have to do it safely and responsibly, and the way to do that is with experts. Starting out with just an AI solution is not the way to go. We have combined decades of experience with lawyers, clinicians and others who have written these rules and other algorithms to make sure that's done in a responsible manner, and everything that we do is actually verified by humans so we're not doing things without a human intervention at this point," Pierre said.
The combined entity is already using AI to tackle the claim selection process, of what Pierre refers to as "pre-pay" or "pre-adjudication" of the claim.
"You're looking at what the payer sends you and sifting through it and seeing if there's an opportunity to really find errors and make sure that the payments are done accurately and in real time, versus having to go back and forth between the provider and the payer," he said.
The power of analytics, AI and other technologies enables the company to intervene earlier in the claims cycle to drive maximum return on investment for clients, executives said.
Private equity firms and investors are placing big bets on healthcare payment companies. Earlier this year, KKR & Co. agreed to buy a stake in health tech firm Cotiviti from Veritas Capital. Cotiviti provides payment accuracy and analytics services to health insurers and other healthcare companies.
R1 RCM, a company that provides revenue cycle and billing services to hospitals, is set to go private in a $8.9 billion deal led by TowerBrook Capital Partners and Clayton, Dubilier & Rice. UnitedHealth's Optum also is a big player in this market.
McKinsey & Company estimates the market for healthcare payment integrity services at around $9 billion.
Pierre contends that the size of the market is notably larger — at about $18 billion in terms of annual spend. "We can play in a much larger pool than some of our competitors, just based off of the breadth of the offerings that we provide," he noted.