Claritev Corporation (CTEV) Earnings Call Transcript & Summary

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Thank you, Shawna, and thanks, everyone, for joining us today and at the conference broadly. I'd say, our first presentation today is the team from MultiPlan, Dale White, President and CEO; and Jim Head, Executive Vice President and Chief Financial Officer; and Lucas [ Gabriel ], Senior Vice President of Finance and Head of Investor Relations for the company is joining us as well. Again, thank you to the team for joining us at the conference. Dale, I will just talk a little bit, but I thought the place to kick off kind of maybe the level set is to, if you will, is just discussion you had at the Investor Day, the pivot and your growth initiatives that you've laid out kind of the four growth initiatives, maybe you could just, like I said, level set us on that message and then we can kind of dig in a little bit from there.

Sounds good. Thank you, Larry, and thank you, everyone, for being here today. I think it's important, and I think it's a great place to start. But at the same time, I think it's important that we put this last year in the proper context because this time last year, we were in a different position. We fell short of our own expectations. The line of sight into the business was less visible. And most importantly, when you think about it, it's what a difference a year makes because we are in a much, much, much different place than where we were last year. We reset the -- we've stabilized our revenues. We've reset financial expectations. We launched a growth plan. We launched a growth strategy, and we took all the actions that we needed to take to initiate that growth strategy and begin the process of transformation. And so we're really pleased. I couldn't be more happier than with the way the company has performed over the past 12 months. We pivoted, and we pivoted hard into 2023. And so when you think about where we are with 2023, we're performing as we expected. There's been no surprises. The headwinds are dissipating. The tailwinds continue to grow. We have a lot of momentum behind the business. We've achieved critical milestones on our growth plan, and we'll talk about those here in a second. We made an acquisition, an important acquisition of Benefits Science Technologies in May. We think it's a real game changer for the company. We're really pleased with where we are. The reception from our client base has been very positive. The integration is going well, and our pipeline continues to grow. We partnered with ECHO Health, which put us in the payments business over the summer. As we said on our last call, we secured our first customer in Q3. And our pipeline continues to grow there as well. Most importantly, into Larry's point, at Investor Day, we highlighted all of our growth initiatives. And for 2023, there are four and that we launched and expect to have -- expect to be significant contributors to our 2024 growth plan. And our 2024, and as you heard Jim and I say on the call last time, we expect to resume growth in 2024. So when you think about the four initiatives, we said that all of them are on time. We're ahead of schedule. You have -- we launched -- in July, we launched our balance, what we call our Balance Bill Protection initiative on our HST platform. We're pleased that at that time we had about 11,000 lives already presold on the program. And then -- since then, just in Q3, we doubled that number where we expect to have close to 21,000 lives on that program come January 1 of 2024 with expected incremental revenue of about $5 million annualized next year. Our Pro Pricer initiative, which is the second of the four we launched in October. This initiative is where we use machine learning at the front end of our -- what we call our savings funnel to dynamically and intelligently route the claim to the solution that maximizes the savings opportunity for the customer and revenue -- of course, revenue for the company. And we launched that with one of our larger customers in October. Again, when fully ramped next year, on an annualized basis, just with that one larger customer, we expect close to $6 million in revenue from that going into 2024. Obviously, it's just one customer we have work to do. We have -- we expect next year to spend additional resources and continuing to enhance and evolve that product and roll it out across the rest of our business. The third growth initiative was one of our product -- one of our payment integrity initiatives where we refreshed what is called IBR, or Itemized Bill Review. It's a module within our Payment Integrity suite. We launched that on time in the third quarter, and we signed a handful of customers in Q3 to the new program. So we're pleased with where we are and that too will be a contributor to our growth in 2024. And the last of the four, is NSA, right? Everybody knows the No Surprises Act. And we continue -- again, it's complex. The complexity continues to grow. There's a lot of movement. There's a lot of ground moving for both payers and providers as that landscape settles, as the litigation continues to evolve and the rules change. So we're continuing to make investments in supporting our customers' efforts to comply with that changing regulatory environment. And so we're creating portals where, on a real-time basis, our customers can see at any point in the process where their claims stand relative to the IBR process. We're creating flexibility across the claims repricing platform to give our payers the opportunity to tailor their strategies to what their goals are under the program. So we continue to see an opportunity to support our payers' efforts and help them solve the complexity of that as NSA settles in. But that -- we're not stopping there, right? We've said there is time and time again, that there's a set of initiatives that we're working on in 2024, that we've already set in motion that will become the foundation for our growth going into '25 and beyond.

Can I just dig in, just in terms of scaling Pro Pricer, for example, maybe we talked about kind of the near-term contract and so forth, how do we think about the ability to scale that business? Like what could that look like, if you will, if it plays out as anticipated?

I think it continues to -- what we start with, right? We've launched it with one of our larger customers. And now we're building up the process for the rest of the market segment. So as you go downstream in market where we want to take the product is to the regional health plans and the third-party administrators and tailor that program for their needs, right? So there's additional developmental work that has to be done. And we expect to launch what we'll call Pro Pricer for the downstream market in Q2 of next year.

Okay. And that's where it starts to emerges.

In the end, this is transforming all of our -- the suite of products we have into a much more dynamic offering and maybe kind of wrapping it all into one bundle. We had built this business by starting out in a network 40 years ago, getting inside the claims environment at the payers and then adding solutions, but it was very much a routing, call it a routing algorithm, start with the network, go to data eyesight, go to clinical negotiation, go to financial negotiation but this is basically putting all that intelligence at the front end and dynamically picking the best solution that MultiPlan has to offer. And that's where it gets -- it's optimizing our solutions for the customer. And so it's going to take time, but the downstream effects are pretty profound. If you can say we've got a solution that in a box.

Right. And the opportunity being you can -- the portfolio of products that you said you're moving it downstream away for -- I don't go away from, but expanding into kind of the region all the smaller players.

Correct.

Away from kind of your large just...

Just moving through our customer list.

Right, to your customer. Okay. And where does -- can you also speak to say BST, the acquisition it's -- I believe you've referenced $20 million annualized revenues today as we on a kind of pro forma basis...

Yes, I think we...

How do you think about that in the context?

Yes, at the time -- well, let me just give you the bookends here. So we're -- we talked about '16, '17, I think, in 2023, annualized is we owned it from January 1. That might come in a little bit soft in terms of where we're at, but that's not why we bought the company. Down the other bookend is as we say, we think this going to be $100 million business down the road. And I think we feel very good about that and where that's -- what the opportunity is, and here's why. BST is basically an analytical layer on top of our platform, and it's just a series of solutions and products around four main areas that are pretty important to our customers. The BenInsights platform is really important to employers because it helps them analyze their own book of business. I'm a CFO. I have a book of medical risk because we are a self-funded plan, and we use those tools to make really good decisions. So that's one suite. The other suite is PlanOptix, which is new. We feel really good about that. PlanOptix is the price transparency solutions that -- the entire market wants, the providers, payers, CPAs, brokers, stop-loss carriers, et cetera. That's another suite, Then risk analytics, which is ported on top of our platform, where we can go in and help manage risk for a Medicare Advantage Plan from the beginning and from enrollment and onboarding all the way through kind of the day to day. So all these things are huge opportunities on a relatively small platform today. We brought the customers to the table. They have the analytics solutions. And so this could be a pretty big -- that's why Dale calls it a game changer.

Right. It really is a game changer for us, right? When I think about the history of MultiPlan, we've been focused on out-of-network claims, right. That's where we built this business. It's the claims that fall outside of the payers network, the smaller percentage. The opportunity with BST, and this is why Jim and I liked it so much, is it's really the gateway to in-network, right? It's that other 85% to 90% claims today where we have one product called Payment Integrity to apply against it. Now we have risk models. We've BenInsights. We've other BST products that can take us. It's really the bridge to in-network, deepening our penetration in Medicare Advantage, open the door to Medicaid and other government programs. It starts to unlock value of all the claims that we had inside the four walls of the company.

Does one of the [BenInsights ], call it the in-network structure, if you all, what -- I don't call, barriers, but what barriers competitive landscape, how challenging is that to penetrate, if you will?

Sure. I think if you look at it through two lenses. One is we already have the pipes inside the payers. So over the past 20-plus years, we've invested over $500 million to get that valuable real estate, right? Where we're embedded inside the four walls of the payers, and we're linked to each of their claims platforms. So that gives us the data today. In many cases already, we see a payer's [ whole ] view right, 360 degrees of claims, meaning they're in-network and out-of-network. We only had payment integrity to apply against it. So when you go out there, just talking about in meetings, who is our biggest competitor on BST, it's the payers -- the payers, their own captive. And our goal is to not replace what they do, but to supplement, complement, be a safety net for them. And that's what we've done, and that's what our plan is, and that's how we're executing on that.

Is it more applicable to -- maybe a more relevant product with smaller payers versus a larger payer given that you're competing in a way against the captive?

I think as you go downstream in market, of course, those -- the smaller regional health plans or the provider-sponsored delivery systems don't have the resources that a larger payer may have to throw against it. At the same time, our opportunity is with the larger payers. We're not -- it's not just with that tail. It's with the larger payers. We fully expect that many of the risk models that we're developing for Medicare, many of the opportunities through the risk models for the commercial health population or BenInsights, which helps employers manage their and optimize their benefit plan or their medical spend are all applicable to larger and small payers.

Okay. Within more -- within your -- I guess, I know you've kind of got guidance of the $200 million to $275 million that you've laid out kind of over several years in terms of revenue opportunity. And Jim you've referenced BST being -- I assume that, that's obviously, about you how you're referencing to $100 million of that $200 million to $275 million, right? Is that the way we're thinking about it?

Yes. And we've been kind of -- as we go through each quarter, we've been updating on the growth plan and each quarter, we still kind of have the same long-term point of view. And what we're trying to do is give you a sense of what we're accomplishing. But it's -- again, we're starting from a year ago where it was a one-product company. And we're evolving this into multiple products, and we had to acquire some capability with BST to do that, but we're starting to launch products. It doesn't just happen overnight. Now Pro Pricer, some of the stuff we're doing with HST is going to be near term, more immediate. So that fills in some of that gap. But it's going to take some time to get there, but we feel like with all these products and the platform that we have, we're going to get there. And importantly, investors are very focused on, okay, let's talk about 2024. So we'll be a little bit more explicit when we come out with guidance in terms of what the components of our growth are and how this all fits in.

And the guide is -- in terms of the guide early in '24?

Well, we -- as per the goal, and I guess, in February after our Q4 -- we announced our Q4 earnings and then provide guidance for 2024.

Okay. Could you touch PlanOptix's functionality and potentials within the kind of the whole provider segment, in particular?

Sure. So plan -- or what we call PlanOptix is built on the price transparency data. So a year ago in the summer of 2022 CMS required, both payers and providers, but payers specifically to post their contracted rates in machine-readable files. And so all -- if you're a payer, you had an obligation to post that to data site and machine-readable formats. We've ingested that data. We ingested 400 billion records, and we've created a set of software solutions that enable -- will enable payers to benchmark themselves against their competitors. And for them to use throughout their provider negotiation strategies. And so what do I mean by that? We now have over 70 health plans, the contracted rate data that we've ingested onto our system, 400 billion records and a payer will have an opportunity to benchmark themselves against their competition in a given market. So they'll know whether they're using that data, whether they're above or below or on par with their competition, and they can do that at a specific provider. They can do it for a specific clinical service within a provider, or we can do it at an MSA level and understand so they could go until they can take our data on our software and look at Dallas-Fort Worth. And if I'm payer woman, I can compare myself to payer 2, 3 and 4 in that market space or a point-of-service program, for an HMO program, and understand how I compare against my competition and where my deficiencies are within my contracted rates. So it's an incredible competitive intelligence for a payer, and you can do that at a specific hospital. So as their hospital contracts renew, what they can determine where do they sit at that hospital against their competition and that they're deficient which clinical specialties, is it orthopedics, is it surgeries or cardiology? Where do I need to focus my attention to improve my contractual -- my competitive position against my peers? And so it's incredible intelligence at both at market level and at a provider level for the payers to use.

So it -- maybe sound like maybe an ignorant question, but the customer ultimately the payer or the provider or both? Or is it...

The customer. It's a great question. The customer, at least initially for us because we had 700 targets, is the payer community.

It is payer.

It's the payer community. We do believe that the provider community and based on feedback that we've gotten initially from some provider partners that they, too, will have an interest and understanding how now I'm in a major metropolitan area, and how do I, add my system, how do I compare against my peers with that same provider -- with that same peer group.

So we actually could service that...

Yes, it could -- it was exciting because we think it will open up for the first time a new channel for us. right? It has the potential to open up a new channel, right? We're a very payer-centric company, 700-plus payers as customers. Now we think our provider base has always been our product through our network. We think we can unlock that as a potential target for customers now.

Okay. Just kind of a sidebar tool, two quick things. Acquisitions, maybe the BST acquisition, are there other opportunities? Are you still looking at strategic opportunities that could fit within the same kind of landscape and...

So I would say, let's think about the strategic lens that we're looking at things is very different than a year ago. We are now looking at a bunch of different areas. We've got our Head of Corporate Development here who is now thinking about buying, building and partnering in a bunch of new areas. So I think our aperture is much wider now. We're not looking at in-network stuff. Dale just talked about a data and insights offering that we could sell to basically anybody in the market. We'll focus on the payers first, but it's available to the market. So I think we're going to continue to -- we're going to open up the architecture a little bit. Our platform is very valuable to a lot of startups who can add products and value to us so we can partner, like we did with ECHO on the payment side, and then we can make acquisitions. Now importantly, for our debt investors, we've made it clear, and we've been very consistent each quarter telling you that retirement is the first priority. But acquisitions aren't off the table. It's just they're probably not going to be big, right? They're not going to be game changers. And one of the reasons why is we think with all this new product getting unleashed, the demand side is there, our delivery of product is kind of our #1 thing that Dale and I are focused on in terms of execution, getting it done, getting it done right, getting it done on time and delivering to the market. And we're bandwidth constrained to kind of do 20 products. But what we're doing is sequencing, lining them up so we have one coming after the next and getting it distributed into the market and building out a product-oriented company. So it's going to take time, but acquisitions and partnerships will be part of that, but it's probably going to be small.

Right. Okay. As it relates to -- most don't even know I'll ask this question because to No Surprises Act is -- it's all over the place. Obviously, it's in the courts now. It seems like it's moved past Congress and it's now at CMS and courts. How are we to look at that opportunity and the way you see it today? And where can it be, given the messages, portals open, portals close, all sorts of different -- how do you think about it as an opportunity given that the landscape is evolving, I guess, is the best way to put it?

Look, I think everybody would acknowledge both even CMS and -- that the rollout of this regulation and law has not been stellar, right? And so there's been a lot of stop and start. There's been a lot of litigation in Texas. There is -- I think there were four lawsuits. CMS didn't lose on all four, but it lost on the major points within those four lawsuits. And that creates change. It creates complexity for the payers. And so, for us, we continue to invest in that -- in NSA, invest in supporting our payers' efforts to comply with an ever-changing regulatory landscape. The most recent ruling added, if it holds, and I don't think CMS has indicated whether it's appealing that yet, but it's -- it will change, it will make that process even more complex than it is today. And that plays to our sweet spot. We've built this out in anticipation of the complexity. We built our systems out, allowing for this pendulum to go in either direction and we're ready to -- we're already ready to respond if it moves in one direction or another. We're investing in the platform now. And in anticipation of the regs finally settling in, right? The federal government, I think, last month issued -- finally issued a set of regulations to help make the process more efficient for both the provider and the payer. And -- but it's in -- at this point, it's in the comment period, comments are due back to the Feds by January and ideally sometime in the spring, summer, we'll have a set of final regulations that will hopefully bring clarity and more efficiency to the process that will allow it to start to settle in.

And where is potentially the opportunity for you in that complexity? You talked about the QPA and now you have different factors in your QPA. Does that present opportunity?

Yes. All of it presents opportunity. I think we're spending our time on making sure that we can bring flexibility and rules-based protocols to a payer, so they can tailor their own strategies, how they want to approach the compliance, to give them the flexibility they need to do that, so that's one. Two, we're bringing machine learning to the process. How do we -- how can we make the process smarter? How can we make the process more efficient for both the payer and the provider and bring in an element of automation to it. Most of what we do in this process, remember, if you think about a surprise bill, continuum, it's identify the supplies bill. It's then, reprice the surprise bill to the payers QPA or to some using -- or using one of MultiPlan's other solutions. It's returning it to the payer, allowing the payer to pay the provider and then the process gets clunky. That part of it highly efficient, highly automated and then for a relatively small percentage of the claims, with providers unhappy with that initial payment, the provider has the right to raise their hand and request a negotiation first and if the parties are unable to reach an agreement it goes to IBR. And that's where we are focused our efforts on bringing machine learning and AI to that part of the process to achieve the best possible outcome on behalf of the payer and to bring more efficiency to it.

That's where the opportunity lies in that kind of arbitration process if you will.

Or making smart choices upfront to eliminate that -- the chance that it goes to the IBR.

Before I turn it over to audience. Just your thoughts on -- I think you have a little bit of a maybe more insight than maybe, but we've heard from the providers over the past, particularly couple of years that the payers have become far more aggressive in their tactics. You hear this. And what do you see, what do you observe in terms of how payers and their behaviors are towards filling into claims activity and things of that nature? Do you see their behavior, has it evolved over the last kind of 3 to 5 years, if you will?

I think on the largest part of the claims, I mean if you think about the -- one aspect of it is the NSA, right? So now that's governed by rules and regulations, right? It says you have to calculate your QPA, and now they've gone as far as to define how do you do that? And the court said it will make sure that payers can use Ghosted Rates and other things. So the process is very specific. And in terms of how does the payer offer it allow the payment and then what happens if the provider doesn't accept the payment or doesn't agree to it and what happens then. So it's been very regulated for a good part of it. I think as the market evolves, the payer, the provider and the consumer, right, I think that's where the biggest change is the consumers are starting to have more say in the process. And so I think there's an effort on both the payers part and the providers part to find that balance. And there's always give and take. Over period -- I mean I have enough gray here. I've seen that give and take over 40 years. But I think they're focused on the consumer now and finding ways to enrich that number's consumer because the consumer wants to be an informed stakeholder. They want more say in the process? And how does that balance happen.

But there's a fundamental issue in the market, which is just pricing in general. And I just want to remind folks that -- and this is public data, but if you think about three rates in the market, the first one is Medicare. And then the second one is, call it, commercial in-network, okay? And then the last one is out-of-network. And let's think about -- if you go to a hospital system, you could pull filings, [indiscernible] filings and look up at a hospital system and probably 20% to 25% of their volume is Medicare or Medicaid. And that's a [ quite ] the rate is 100% of Medicare -- that rate. And it will give you a relative expense. So if you go into the commercial realm, it's probably 3x as higher, okay? So the rate is 3x higher for a commercial in-network. And that's probably another 70% more volume. So you're already getting to 90% of a hospital's volume is split that way. And then the last fit is uninsured or out of network. And the rates there in a hospital are probably 6 -- 5 to 7x, maybe 8x Medicare's rate. So what you see here is the out-of-network realm is the last fashion for a hospital. They're contracted on the first 90% of their business. The last fashion to get any yield off the book. So think of it -- I was probably like -- it's like airline can -- one like I go to a seat and I looked to 27 -- the row 27 and 27a is the Medicare, and I'm like, what they paid for the seat, they're 100. And I look to the right, and it's the commercial in-network. And what do you pay for your seat, and they said, well, $300. And they asked me what I paid for my seat, it's like $750. Does that make sense? The same -- essentially the same seats in a way. And so where you're seeing all this tension is one of the reasons why is Medicare, Medicare is probably under market. It's in the hospital.

But is the hospital today -- I mean, I should say it's a [indiscernible] payer today, the priority of that 10% has that become more aggressive than you've seen in past years?

I think it's because the pricing continues to go through the roof. The really interesting Wall Street Journal article, maybe two months ago, where the Indiana Employers Association looked up [ RAND ] Corporation Study about hospital rates. And they found out that they were paying something like 700% to 800% of Medicare for commercial in-network rates in Indiana and the Indiana employees want to [ resort ] . And they had no idea. So this price transparency is actually bringing this to light. And I think that's why there's a lot of tension. Cost is always a fundamental tension between payer and care provider.

Yes. It's always -- is it more so now of inflation, right? So now you're battling the inflation executed and costs. So I'd say, yes, there's always -- there always has been and there always will be a healthy tension around.

And I apologize. I don't do a more job of watching the time quite frankly. Are there any questions in the audience? I apologize. I ran a little long here. Janegail's question over here.

So just with regard to the transition to the Medicare Advantage revenues, I understand the pipes are the same, but are the sales teams the same in terms of does this require an additional SG&A component in terms of sales to address them? Or is there one kind of technology review that buys both commercial and Medicare Advantage?

I think it's a great question. I think it's the internal buyers are sometimes different, right? So in the larger payers, in particular, where they may have a dedicated unit that focus because the numbers are so big on out of dollar claims when you cross over into -- either into in-network or into Medicare Advantage, you may be moving into different parts of the organization of a larger payer. And -- but we're comfortable doing that today, right, with the same sales team. What we -- what -- for us, what we do is we bring a different set of solution experts behind the sales team. So we have solution experts for payment integrity. We have solution experts for data and decision sciences, and those solution experts would be -- will support the sales team. Same relationship managers with the bigger companies, same sales team for the bigger companies. As you go downstream in market and you become -- it's the provider-sponsored delivery plans or the TPAs, typically the buyers are the same. It's either -- it's a network operator, it's the operations, it's the Chief Financial Officer, who are the two of the internal buyers at those organizations. And those are the same buyers of what I'd call our core products.

And one more quick one for me as [ PlanOptix's ] and insights being inroads into the provider market. Are there any limitations on your use of data, all those zillions of megabits of data that you have from all of the Aetna's, the Cigna's, the United's space?

Yes. And it's an excellent question. And if you think about like we talked about in the claims environment. If we're inside the claims environment, in-network, out-of-network, there is limitations on it, but with a lot of our promoters, there's plenty of data that we can -- from their own systems that we can tell them insights. But to your point, the PlanOptix's data and insights is actually data that's available, but it's really jumbled. And so our value add is we're cleaning that up, unscrambling it, enriching it with our own data, but it's not primary data from our network contracts and things like that and claims data and giving insights back. So the good news is, this is available to all and not really restricted in that sense. And that's the beauty. And what -- I think what is valuable on the data and insights world is there's lots of databases out there that could give a piece of the picture. And if you can enrich them or aggregate them into something more valuable, that's -- and give insights, that's where everybody is going to want that.

Thank you. Thanks, everyone. Thank you, Dale. Thank you Jim, Lucas, Shawna and the team. I appreciate you taking the time to come down and I also appreciate the meetings we do in New York. So thanks for the support.

Thank you.

Thank you.