[INTRO MUSIC]
[On-screen text: Health Trend Talks with UnitedHealthcare]
[Video preview of the upcoming conversation]
BECKY PARADISE: We have to continue to be focused on how we help members navigate and so they understand upfront the decisions they're making. More transparency in the system is going to help them understand the care they need, the best avenue to obtain that care, and doing that at the best cost.
[On-screen text: Health Trend Talks with UnitedHealthcare]
[Animation, frequency waves moving]
[Craig Kurtzweil speaking on screen]
[On-screen text: Craig Kurtzweil, Chief Data & Analytics Officer, UnitedHealthcare Employer & Individual]
CRAIG KURTZEIL: Welcome to Health Trend Talks with UnitedHealthcare, a video podcast series where I sit down with leading minds to unpack the trends shaping employer benefit strategies. I'm Craig Kurtzweil, Chief Data and Analytics Officer for UnitedHealthcare's commercial business. And I'm joined by Becky Paradise, a leader in our affordability team who focuses on out-of-network management among other initiatives. Becky, thanks for joining me.
BECKY PARADISE: Thanks for having me.
CRAIG KURTZEIL: Well, to start with, you and I have worked together for a while, but the audience might not know you as well. So do you mind just kind of introducing yourself and your role within United Healthcare?
[Craig Kurtzweil and Becky Paradise sitting in a recording studio set, speaking into microphones, having a conversation]
[On-screen text: Becky Paradise, CEO, Out-of-Network Management, UnitedHealthcare Employer & Individual]
BECKY PARADISE: Sure. Becky Paradise. I sit on the E&I affordability team where I lead our out-of-network management team. So we're focused on providing out-of-network reimbursement solutions for our customers, as well as supporting any of the state or federal surprise bill regulations.
CRAIG KURTZEIL: And you are a busy, busy person these days. So let's maybe start by kind of breaking that down into some components. So we use the term total cost of care and affordability. How do you and your team kind of delineate between those two efforts?
BECKY PARADISE: Sure. Total cost of care is basically the financial outcome that we measure and those are things like what we're paying for services, how much of the services are used, and then where that care is delivered. All those things influence the cost. Affordability is the strategy, operating model, or actions we're taking to influence that. So that's going to be all the levers like network, out-of-network strategy, pharmacy management, clinical programs, payment integrity, and such.
CRAIG KURTZEIL: And we're all constantly monitoring the affordability issue that employers are facing today. Well, we know fraud, waste, and abuse is a key topic, and sometimes the cost associated with that can be hidden from employers. How do you focus on fraud, waste, and abuse, and what do you see as the key drivers in that area?
BECKY PARADISE: So, I think when you're looking at fraud, waste, and abuse, we have to make sure that we're sort of firing on all cylinders when it comes to those programs. You need to have a comprehensive payment integrity program, preventing, detecting, and recovering improper payments, leveraging advanced analytics and AI to help identify unusual billing patterns or outlier trends. Provider credentialing ensures that you get the right providers in your network. Prepayment review controls also help reduce any improper payments before they even occur. And lastly, routine audits will help verify billing accuracy and contractual compliance. And every dollar that we remove via fraud, waste, and abuse is a direct reduction in the total cost of care.
CRAIG KURTZEIL: You mentioned network. So network is obviously in the headlines these days when it comes to the No Surprises Act. So let's talk about that a little bit. So before we jump into some of the details and what we're doing about it, just explain for the audience what is the No Surprises Act and then we'll take it from there.
BECKY PARADISE: Sure. So the No Surprises Act is a federal regulation that's major intent was to protect members from balance billing situations. And for that, the regulation has been doing what it set out to do. It is protecting members from receiving unexpected bills from providers in those certain surprise billing situations. That being said, it also created a dispute process that we are seeing emerging trends that that dispute process is being used as a revenue strategy and that is creating some unintended consequences and costs related to that process.
CRAIG KURTZEIL: What's the biggest piece that's kind of driving some of those unintended consequences?
BECKY PARADISE: So, we see certain providers and NSA dispute mills driving a significant amount of volume into the process. Their demands are way above market-based rates. And then we also see quite a bit of ineligible dispute activity, which also just adds administrative burden to the system since we have to review and evaluate every single one of those disputes.
CRAIG KURTZEIL: So, I'm in particular interested in the ineligible claims that come through. So, give a little bit of detail there. What type of claims are ineligible and why are they trying to come through the system?
BECKY PARADISE: Sure. So, ineligible claims can be things like we're seeing Medicare claims being submitted to the process. It could be a situation where a state surprise bill regulation applies, or it could be things like the bundling of the disputes isn't accurate. So, those are just a couple of the examples.
CRAIG KURTZEIL: Well, speaking of those ineligible claims, why do providers keep submitting them?
BECKY PARADISE: So, it's unclear why. Generally, those ineligible claims, again, we see quite frequently there's about a 40% rate of ineligible claims across the system. And it will require some extra diligence by CMS to ensure that we've got the right disputes coming into the process.
[On-screen text: Craig Kurtzweil, Chief Data & Analytics Officer, UnitedHealthcare Employer & Individual]
CRAIG KURTZEIL: Speaking of employers, what can they do in this space? What can they do to help with the No Surprises Act issues that you're facing?
[On-screen text: Becky Paradise, CEO, Out-of-Network Management, UnitedHealthcare Employer & Individual]
BECKY PARADISE: Sure. Employers, first of all, can help by staying informed. They need to be aware of what's happening with their experience with the IDR, asking for data. And then I would say, most importantly, they need to lend their voice to the policy discussions about affordability in the system and the unintended consequences the IDR process is having on them.
CRAIG KURTZEIL: Good, good. So now for the solution. We've identified the problem. What is UnitedHealthcare doing to combat this issue? And broadly, what does a more sustainable approach look like?
BECKY PARADISE: Sure. We are working on multiple levers to help improve the process. First of all, we are using AI-enabled insights to help us understand our briefing arguments, where we can improve them, why we're winning and losing. We're also working with our network partners. We're evaluating our negotiation approaches. We also have litigation approaches we're taking where appropriate, as well as we're continuing our advocacy to ensure again that we maintain the protections of this bill but address these unintended consequences of that IDR process being used as a revenue strategy.
CRAIG KURTZEIL: A bit of a provocative question for you. When you think about the affordability drivers in America, where do you think the responsibility really lies?
BECKY PARADISE: Well, I think it's a shared responsibility across a number of constituents because everyone has a role to play. Providers influence the utilization, clinical decisioning, and site of care that's used. Pharmaceutical manufacturers influence drug pricing and access to medications. Employers are shaping benefit designs and incentives for their members. Health plans will help manage total cost of care and payment accuracy and navigation. And then policymakers are the ones that are establishing the rules that govern the market. All of these stakeholders ultimately need to work together to be able to ensure we can provide affordable access and encourage members to effectively use their benefits.
CRAIG KURTZEIL: And what do you think sets UnitedHealthcare apart in the ability to influence those factors?
BECKY PARADISE: UnitedHealthcare with its scale and data, has a unique ability to look across the system and across all the levers, network strategy, out-of-network, payment integrity, clinical programs, pharmacy strategy, and really help identify patterns across all of those disciplines and really work with employers to ensure that we can create the right type of benefit plan offering to make best use of their plan dollars.
CRAIG KURTZEIL: You mentioned employers. What role can employers play right now in helping drive that affordability agenda?
BECKY PARADISE: So employers are the ones that are going to be asking the questions about what care should we provide, what are the cost trends, how do I make benefits more accessible for my members? So they need to continue to ask us to help them understand their cost trends, how they can continue to provide affordable benefits for their members.
CRAIG KURTZEIL: When you think through those issues, what's one uncomfortable area that our brokers, consultants, and clients really need to pay attention to when it comes to our affordability agenda?
BECKY PARADISE: I think one of the uncomfortable truths is given the current cost trajectory, we cannot assume that we can continue to provide the current state of affairs ongoing. We really have to challenge everything we're doing, evaluate if it's truly providing value, and ensure that, again, we're keeping the member in mind. This is all about providing them access to care in the right setting at the right price.
CRAIG KURTZEIL: As you think through all the various trends, what's one trend that you think people should be focused on today that maybe they haven't been in the past? And maybe what's another trend that we've historically focused a lot of time and attention on but maybe is dropping from a prioritization perspective?
BECKY PARADISE: One of the main trends is just the convergence of all of these challenges, high-cost claimants, specialty drug spend escalation, the NSA, and the provider consolidation and coding intensity. All of those things are sort of happening at the same time, which is unlike prior years. So we have to be keenly focused on pressure testing what's really driving value in the system, and again, how we can help our employers and employees find the best benefit arrangement and incentive for themselves so they can continue to provide that cost-effective care.
CRAIG KURTZEIL: And it's a balancing act, right? For the employers, they want affordability, they want affordable care, but at the same time want to reduce abrasion points in the system. So as you drive the affordability agenda, how do you juggle those competing priorities?
BECKY PARADISE: That's a great question. We have to continue to be focused on how we help members navigate and so they understand up front the decisions they're making. I think more transparency in the system is going to help them understand the care they need, the best avenue to obtain that care, and doing that at the best cost.
CRAIG KURTZEIL: And Becky, let's end on a fun one. So, when you think through your personal life, what's one trend that you're adopting right now that you're excited about, and maybe what's another trend that you used to be excited about that maybe you're letting go of?
BECKY PARADISE: Sure. I’m embracing anything that makes my life simpler, whether that's better routines, less clutter, using technology, anything that's giving me time back to make most use of my free time, my personal life. And one trend I'm happy to be leaving behind is the concept of just because we're busy, we're being effective. I'm really focused and interested in focusing, both in my personal and my professional life, on things that really matter and making sure I'm putting my time and energy in that place.
[OUTRO MUSIC]
CRAIG KURTZEIL: Good advice for everybody. Well, speaking of time, I know your time is very important, so thank you for spending a little bit with me today.
BECKY PARADISE: Thank you, Craig. I enjoyed it.
CRAIG KURTZEIL: And thank you for joining me on Health Trend Talks with United Healthcare. I'm Craig Kurzweil, and we'll see you again next time.
[On-screen text: Health Trend Talks with UnitedHealthcare]
[Animation, frequency waves moving]
I'm Craig Kurzweil with UnitedHealthcare, and we'll see you again next time.
[On-screen text: Avery is an AI companion that uses generative artificial intelligence to provide general information and educational assistance. Avery’s responses may be incomplete or inaccurate and should not be relied upon as error-free. Averay is provided for informational purposes only and does not constitute medical advice, professional advice, a benefit determination, a guarantee of coverage, a referral, or an authorization for health care services. Avery is not a substitute for the advice or judgement of your health care provider or other qualified professionals. Coverage and benefits are subject to the terms, conditions, limitations, and exclusions of your applicable health plan. Employee benefits including group health plan benefits may be taxable benefits unless they fit into specific exception categories. Please consult with your tax specialist to determine taxability of these offerings. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. B2B E1266467550 7/26 ©2026 United HealthCare Services Inc., All Rights Reserve. 26-22449908]
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