About Rob Stuart, CEO
Rob Stuart is the founder and president of Claim.MD, a leading electronic data interchange (EDI) clearinghouse dedicated to streamlining the billing and collection process for providers, payers, and software vendors. Raised in a medical clinic, Rob has devoted the last 40 years to passionately serving healthcare providers. With a background in programming from the early years of IBM, he continues to stay at the forefront of technology. As an advocate, Rob is devoted to helping others understand and navigate the healthcare space, ensuring they achieve stability and receive better access to care. Outside of his professional life, Rob enjoys gardening and is a proud pet owner of a cat and a macaw.
About Claim.MD
Claim.MD, is a leading EDI clearinghouse, processing tens of millions of transactions every month. Many of the company’s first providers are still customers to this day, as its products and services are – and continue to be – designed with the provider in mind. Claim.MD is affordable and powerful – a system of tools to send simply clean claims the first time. The company’s first systems were developed as custom solutions for doctors who were pioneers with electronic claims. Since then, Claim.MD has continued to build new and enhanced services as it serves a vast array of providers and payers. The company’s extensive insurance network links providers to Medicare, Medicaid, Blue, and thousands of commercial insurance companies across the country.
Medical Travel & Digital Health News (MTDHN): Please tell us about yourself and how you got started with Claim.MD.
Rob Stuart (RS): Back in the early 1980s, I was living in the oil fields of West Texas during a severe recession, with no work available. I was just starting college and the PC had just hit the market. I connected with some people developing software for oil and gas that fascinated me with potential for broader applications.
Shortly after, the director of the Information Systems Department at my university received a call from a physician who needed someone to make his computer communicate with Medicare over the phone. The director thought of me since I was already experimenting with technology that was still new to the school. as I do now, but it was a straightforward application. I was able to successfully make the computer talk to Medicare over the phone.
Throughout my entire career, my approach to taking on new projects has remained the same. When I approach a project for a stakeholder, my first question always is, “Where does it hurt? Tell me your problems.” If there is a problem, my goal is to understand that problem and find a way to solve it. That’s what I did with our very first provider and we are still doing that today.
MTDHN: Can you explain a little bit more about your services and who you serve?
RS: Yes. I want to preface by mentioning that I grew up in a med-surg clinic my grandmother ran. My first professional medical work experience was in answering a distress call from a physician. Because of this, my heart has always been with providers. If you met me at a cocktail party, you’d think I only work for physicians and hospitals!
However, what’s good for the goose is good for the gander. So, if we’ve written a great system for providers, it naturally benefits payers as well – the coin has two sides. Likewise, TPAs need copies of data to build up their records and we’ve worked for TPAs in the past to automatically send data when serving their members.
Anywhere that medical electronic data interchange (EDI) needs to be communicated, we can work for either the sender or receiver. Medical data now comes in consistent ANSI formats, which we’re all very proud of. But before that, we had local formats and eventually, the National Standard Format.
As a clearinghouse, our job is to take data in the format that is most relevant to the sender and convert it to the format that’s most reasonable for the receiver to read it in. There’s no one-size-fits-all solution so our goal is to bridge that gap in the most efficient way possible.
MTDHN: Would you say there are opportunities for more claims to go electronically, particularly on an international level? Could you talk a little bit about the international market?
RS: Absolutely. While we’ve made a lot of progress in our EDI market in the last 35 years, that work is only limited to the U.S. The ANSI standard formats are American formats – they don’t mean anything once you get past our fifty states.
Therefore, when it comes to the international market, we’re dealing with different systems and standards. I don’t like to use words like “ANSI,” “4010” or “5010” when talking to providers because it doesn’t resonate with anyone outside of the U.S. People are befuddled when we start discussing loops and segments.
MTDHN: When you say providers, do you mean hospitals and physicians?
RS: Yes, we work with hospitals, physicians, outpatient surgical centers and even surgical dentists who bill medical plans. We also work with insurance companies because we operate front-end portals. For instance, when a provider goes to the insurance company’s website, they can login and the payer gives the provider the chance to enter the claim directly on their website.
Claim.MD has developed a wonderful, user-friendly interface. We offer packages as a standalone product that we will sell to insurance companies that want us to operate their claim-entry portals.
MTDHN: What countries do you typically see claims coming from?
RS: Most of the claims we process are domestic, typically from patients with coverage from group or marketplace plans, Medicare, Medicaid, etc.
When it comes to international claims, we often work with sovereign nations that are unable to provide certain healthcare services within their realm. These countries send their patients to the United States for care.
It’s a bit different than medical tourism where someone might travel to Thailand for an elective procedure like a breast reduction. In these cases, these are medically necessary care where the patient is sent by their Ministry of Health because their country is unable to provide the treatment they need.
MTDHN: And which countries are they primarily coming from?
RS: We have serviced sovereign nations overseas for many years. They send their citizens to the U.S. to receive the best care possible for their citizens. The challenge for them is understanding and managing the payment process – how do they pay for it? How do they know how much to pay? How do they know what’s reasonable and customary?
When they came to us for help, again, our first question was, “Where does it hurt?” We were soon able to see their pain point and we realized that international delivery of healthcare is similar to handling workers’ compensation claims. Workers’ comp payers operate differently from traditional health insurance; they are not covered by HIPAA and they don’t always have computer systems for reading ANSI formats or adjudicating bills. Instead, decisions are often made manually by an adjudicator looking at a paper claim and progress notes from the encounter, which can be inefficient.
When we first started with workers’ compensation, about 15 years ago, the process involved requesting old claim data from state archives weeks in advance, which was time-consuming. Texas was one of the first states to mandate EDI for workers’ compensation claims so we expanded into that market because we worked with a significant amount of providers in Texas.
Every medical billing department, whether it is a hospital or an outpatient physician practice, has their standard billing pathway. But they often have different people handling workers’ comp and auto accident claims because of their unique requirements. These claims may be submitted electronically. However, their claims are often delayed by outdated faxes of progress notes that then delay payment by up to two weeks to allow for documents to be matched up.
So, when we saw that problem, we worked to streamline the process. For instance, if you sent workers’ comp claims through a typical clearinghouse, they would handle the claim and return rejections if necessary, leading to a time-consuming, manual process of resubmitting claims with additional documentation.
To improve this, we developed a system where documents are embedded directly within the claim file. This approach ensures that all necessary information is included from the start. For international healthcare delivery, we tailor our approach to meet the specific needs of foreign Ministries of Health. We have tons of inbound and outbound formats such as CSV files, XML, JSON, etc. – whatever format is most relevant to them. We store the claims in ANSI format while maintaining HIPAA compliance for the provider and payer.
MTDHN: Are there any barriers with language?
RS: Language has not been a significant barrier yet because there are tools like Google Translate to help bridge those communication gaps.
However, there is a barrier with translating the technical details. Google Translate can’t translate ANSI formats and codes used in the U.S. healthcare system into something readable for anyone outside the country.
Thanks to our wonderful team, we translate these technical formats (that most people can’t read) into more readable formats such as English documents, CSV files or XML. When we translate the medical codes and formats into readable English formats, our international clients can then translate it to their local language.
MTDHN: How can you prepare providers for the next stage? Do you anticipate any changes to the claims process for healthcare and workers’ compensation?
RS: Yes – in healthcare, workers’ comp, auto insurance, international delivery and plain old health insurance, changes are inevitable.
In terms of what comes next, there will be ANSI 6010, and other format revisions. Right now, we are in a time where things feel stable. But the reality is that as soon as healthcare delivery exceeds the data formats that we’ve devised in the industry so far, we will go back to a similar situation. We’ll then have to bring it all down to the ground and develop a new standard that incorporates that architecture.
Providers don’t realize that they are depending on their clearinghouse to keep their financial operations running smoothly and uninterrupted. Any clearinghouse must fully test any new standard changes with every single connection they have. Unfortunately, the world is not perfect. Insurance companies may reject claims that are fully HIPAA compliant because, at times, technically correct data gets rejected by the payer, and we have to account for that to ensure claims continue to move through the system smoothly.
So, when these format quirks happen, it’s important for your clearinghouse to be ahead of the curve and minimize disruption to your billing process.
A hypothetical example might be the next big format revision focusing on billing criteria for air ambulance and hyperbaric oxygen chambers. These revisions wouldn’t be initiated by Claim.MD but by the industry and we would have to comply. In these times, Claim.MD is able to quickly adapt and offer the best service to our providers. By following our consistent approach of asking “Where does it hurt?”, we can preemptively address any issues before they affect our providers. Our philosophy at Claim.MD. is that we always remain fully backwards compatible with our providers sending data. By allowing them to stay compatible with older systems while gradually adopting new formats, we help them avoid the risks associated with sudden changes.