Healthcare Nirvana: Fewer Insurance Coverage Hassles

When Kelvin Chan went looking for a therapist a few years ago, he was prepared for a convoluted process. Finding a provider who was accepting new patients was hard enough, but he was also unsure whether his insurance would cover his visits.

Chan pulled up his insurance company’s summary of benefits, a lengthy legal document chock-full of jargon and caveats.

Kelvin Chan

“My first resource was finding that document, reading it, and realizing I didn’t understand it,” he recalls.

His therapist was likewise unable to clarify whether and how his insurance would cover the visits. Chan had to do what he had been putting off: calling his insurance company and attempting to ask all the right questions.

Chan points to that experience as a turning point. It would eventually lead him and co-founders Urvish Parikh and Akshay Venkitasubramanian to launch Nirvana, a technology company that aims to streamline insurance verification, in 2020.

Like Chan, Parikh and Venkitasubramanian each had stories of insurance frustration, and all three had extensive experience in the healthcare and financial technology sectors.

“Ultimately, we were all brought together by our shared values around making healthcare more transparent,” Chan says.

The trio developed a product that leverages artificial intelligence (AI) and machine learning to automate insurance verification. The company started focusing on mental and behavioral health but is now expanding to other specialties and partnerships, including with electronic health record firms.

They market their product to providers as offering the ability to more confidently seek upfront payments based on AI-derived insurance coverage estimates. Their pitch: Nirvana can cut the risk of claim denials and errors, reducing back-and-forth disputes among providers, insurers and patients. In a new release, Nirvana also claims it can help patients seek care without fear of surprise bills.

Late in 2024, the company announced it had raised $24.2 million in series A funding, led by Northzone, a venture capital firm that has invested in big-name companies such as Spotify, Klarna, and Trustpilot. Wendy Xiao, a partner at Northzone, said in a statement that her firm believes Nirvana could be a “category-defining company” within the healthcare sector. Xiao is also a board member at Nirvana.

Andy Swanson

If Nirvana is creating a new category, it might be best defined as insurance clarity. Andy Swanson, M.P.A., the chief revenue officer for the Medical Group Management Association, says there is clearly an opportunity in this area of healthcare. “The challenge is multifaceted, beginning with the seemingly endless plans provided by large and small insurance carriers,” he tells Managed Healthcare Executive.

Chan, who became Nirvana’s chief executive in January, notes that details such as copays, networks, and even terminology can vary widely among insurance carriers and even from plan to plan sold by the same insurer. That complexity is why many practices hire verification specialists trained to understand insurers’ rules and interpret edge cases. “But it’s hard because benefits are growing in complexity,” Chan says. “And these verification specialists are often tasked with 100 other things to do.”

Leveraging technology

Nirvana uses relationships with payers and clearinghouses to access health plan information that its high-brainpower AI models analyze to predict how an insurer will handle a claim. Its AI models are not just built to engorge insurance plan documents: They are also AI-smart enough to adapt, recognize and respond to patterns within specialties and transactions to improve their accuracy.

The technology can be deployed in a variety of workflows, from a patient-facing online registration form to the check-in desk at a clinic. The company’s Discover product allows providers to retrieve patient insurance information using only a patient’s name, date of birth and ZIP code.

“A lot of people will show up to hospitals and providers without their insurance card in hand,” Chan says. “Or they might think they have a United Health[care]-based plan, but really, they switched to Aetna three months ago. So, we’ve actually built a system where you don’t even have to collect the card.”

Nirvana recently announced a collaboration with Clear, the identity verification company known for offering fast-track airport security services for travelers. The Nirvana partnership will allow providers to use Clear’s biometric verification technology to confirm patients’ identities and access biographical data that would typically be done manually by patients completing intake forms. From a patient’s perspective, the process involves taking a selfie to prove their identity and then granting the practice permission to access their information.

Customer expectations

Chan believes part of his company’s growth is attributable to a change in consumer expectations. As consumers increasingly order products and services through their smartphones, they are becoming more and more frustrated with a healthcare system in which they often have to undergo a treatment without knowing how much it will ultimately cost.

“There’s a cap to how much Americans are willing to bear in their healthcare experience,” he says.

Swanson says medical practices are also reaching their limits.

“In today’s climate of high-deductible plans and growing patient medical debt, most medical groups have growing bad debt and increasing write-offs for care provided,” he says.

Swanson used the analogy of leaving a restaurant without paying the check. If enough customers did that, the restaurant would go out of business. The same is true of medical practices.

“When patients are unable or unwilling to pay, or insurance carriers refuse to pay, medical groups are left carrying a financial burden they simply can’t afford,” he says.

Upfront payment can help solve the problem, but Swanson says inaccurate payment estimates can be frustrating.

“Collecting estimated patient payments upfront are, by definition, estimates, which must be adjusted down the line after insurance billing is completed,” he notes. “This elongates the payment process and can frustrate and confuse patients.”

Expanding its footprint

With its new funding, Chan says Nirvana is expanding beyond its mental health roots to other specialties, including physical therapy, intensive outpatient care and digital health. One reason they started with mental health, he says, is the sharp turn toward remote care during the COVID-19 pandemic.

“We follow [specialties] where I would say consumer access and choice are really important because that’s oftentimes when insurance coverage is a more determinant factor in whether you’ll see a provider,” he says.

One area of growth, he says, is weight management, as more patients use online telehealth platforms to access glucagon-like peptide 1 therapies. Given the high price tags associated with those drugs, the ability to quickly understand out-of-pocket costs can make a big difference in whether a patient seeks care.

Finding trust

Although the complexity of the insurance industry has created a business opportunity, Chan says he hopes insurers will find ways to simplify the consumer experience, even if that lessens the need for companies like his.

In the meantime, though, he says companies that can facilitate more transparency can have an impact that goes beyond just simplifying the payment process.

“I think the fundamental issue in healthcare that I see today is there’s a pure lack of trust in the system,” Chan says. “Patients don’t trust the provider when the provider says, ‘Hey, we take your insurance.’ The provider doesn’t trust the insurance company when they file a claim. And the patient doesn’t trust their own insurance company. So, you have this three-way system of distrust.” The opportunity then, he says, is to find ways to reestablish trust. “And if Nirvana can do that, I think a significant root cause of healthcare inefficiency and fear of seeking care would be eliminated.”