Navin Nagiah and Prateesh Maheshwari on Cutting Out-of-Network Costs by 80%

Health plans spend millions every year paying middlemen a cut of "savings" on out-of-network claims, savings calculated from a rack rate nobody ever expects to be paid. Daffodil Health is automating that process end to end and cutting out-of-network repricing costs by about 80%.In this episode of Care Shift, Navin Nagiah (Co-Founder and CEO, Daffodil Health) and Prateesh Maheshwari (Managing Director, Maverick Ventures) break down how out-of-network claims really get paid, who ends up bearing the middleman fee, and why Daffodil walked away from the percent-of-savings model even though it means giving up 50 to 60% of potential revenue. Navin draws on his years at MultiPlan to explain why incumbents can't make this shift themselves, and Prateesh shares what he learned running finance at Oscar Health and why Maverick backed Daffodil at seed and again at Series A. We also cover the No Surprises Act, where AI fits in claims pricing, and who ultimately captures the value.CHAPTERS00:00 Welcome Navin and Prateesh00:06 What Daffodil Health does02:42 Following a $30K out-of-network claim03:52 Who really pays the middleman fee05:52 Out-of-network costs at Oscar Health07:34 What is a rental network?09:16 How middleman fees squeeze health plan margins11:07 The $10M margin opportunity for mid-sized plans12:13 Why cost containment startups never broke out15:29 Choosing trust over short-term revenue16:48 Why MultiPlan can't build this in-house19:53 How incumbents fight back22:01 The problem with percent-of-savings pricing24:03 Pricing shifts and backing spinout founders27:25 Maverick's seed diligence29:39 Giving up revenue by design31:23 Will percent of savings die?33:29 Landing the first design partners38:35 Vendor selection lessons from Oscar40:15 Regulation, press, and the No Surprises Act43:32 How the No Surprises Act works45:57 Where AI fits and where humans stay in the loop50:37 Making pricing decisions auditable52:55 What stays defensible in 3 to 5 years54:55 What Maverick looked for at Series A56:46 Why Navin chose Maverick58:17 Health plans in 3 to 5 years1:01:55 Who captures the value1:03:55 Best advice they didn't takeLISTEN TO CARE SHIFTSpotify: https://open.spotify.com/show/6JghxsuNbQ7hWIHuLjaoJzApple Podcasts: https://podcasts.apple.com/podcast/id1858302821#CareShift #HealthTech #HealthInsurance #OutOfNetwork #NoSurprisesAct #AIinHealthcare #VentureCapital

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Health plans pay middlemen millions to "save" money on out-of-network claims, but those savings are calculated from a bill nobody expects to be paid. Navin Nagiah, Co-Founder and CEO of Daffodil Health, and Prateesh Maheshwari, Managing Director at Maverick Ventures, explain how Daffodil is automating out-of-network repricing and cutting those costs by about 80%.We cover:- How an out-of-network claim actually gets paid, and who bears the fee- Why Daffodil rejected the percent-of-savings model- Why incumbents like MultiPlan struggle to change- Lessons from Oscar Health on vendor costs and margins- The No Surprises Act and independent dispute resolution- Where AI helps in claims pricing and where humans stay in the loop- What Maverick looked for at seed and Series A

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LinkedIn: https://www.linkedin.com/in/navin-nagiah-8ab16

LEARN MORE ABOUT DAFFODIL HEALTH

Website: https://daffodilhealth.com

LinkedIn: https://www.linkedin.com/company/daffodilhealth

LEARN MORE ABOUT MAVERICK VENTURES

Website: https://www.maverickventures.com

LinkedIn: https://www.linkedin.com/company/maverick-ventures-sf

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LinkedIn: https://www.linkedin.com/in/prateesh-maheshwari/?isSelfProfile=false

HOSTED BY VIK BILAKANTI

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